NHS Improvement’s drive to raise clinical standards is prising open the sensitive issue of doctors’ autonomy, and shows how the legal and professional boundaries of medicine are constantly shifting.
The Get It Right First Time programme is uncovering massive and unacceptable differences in performance, such as a 25-fold variation in orthopaedic surgical site infection rates.
Now colorectal surgeon John Abercrombie has used his report into general surgery performance to challenge the high degree of autonomy enjoyed by British surgeons.
He contrasts the demanding training and assessments required to qualify with the laissez-faire approach to subsequent professional development.
The rules are so lax that a surgeon could carry on practising unaware of new operating techniques, care pathways or developments in infection control.
This goes some way to explaining why new approaches to care takes so many years to permeate every part of the NHS.
Abercrombie calls for routine monitoring of performance measures such as infection and readmission rates, and for the surgical Royal Colleges to introduce tougher rules around continuing professional development. This could include visits to units which are delivering the best outcomes.
The report implicitly criticises medical directors for failing to drive through quality improvements such as standardised approaches to care, pointing out how similar roles in Germany and the US govern the way care is delivered.
Surgeons are highly protective of their autonomy. When then chief medical officer Sir Liam Donaldson began his big push around the turn of the century to improve patient safety he came up against surgeons who regarded standardised safe procedures as an infringement of their artistic freedom. The huge variations uncovered by the Right First Time programme demonstrate that many surgeons still don’t trouble themselves to find out the safest way to do their job.
The boundaries of medical behaviour are policed largely by the General Medical Council, the courts and, increasingly, data. Over the last two decades the GMC has been transformed from an organisation dominated by doctors and bearing more than a passing resemblance to a gentlemen’s club to one with an independent voice, strong lay representation and a focus on patient safety and raising standards.
The GMC’s regular checks on doctors’ competence through the revalidation process highlight the importance of constant professional improvement – but Abercrombie’s report shows that aspects of this system lack rigour.
In recent weeks there have been signs that the attitudes of the criminal courts to doctors is shifting again. According to the BMJ four doctors were convicted of gross negligence manslaughter between 2012 and 2015, and three went to prison. But a Court of Appeal ruling in July in the case of an optometrist could have important implications for doctors.
While examining a boy’s eyes the optometrist failed to spot symptoms of a brain condition. The court overturned the conviction for gross negligence manslaughter on the grounds that it undermined the legal test of “foreseeability”, which requires proof of a “serious and obvious risk of death” at the time of the error.
This ruling may go some way to assuaging fears of a creeping criminalisation of healthcare staff who make mistakes.
But increasingly it will be data that makes and breaks professional reputations. The healthcare data revolution driven by pioneers such as Tim Kelsey, Sir Bruce Keogh and Sir Brian Jarman lifted the veil of mystique surrounding medical skill and has exposed individuals and institutions to ever more penetrating analysis of their performance.
The theory has been that transparency would stimulate doctors’ innate competitiveness so they would strive to match the best in their profession. While this is true for many, the data reveals doctors, medical directors and hospitals who seem undisturbed by their poor outcomes for patients.
At some point the next wave of the data revolution will break over the health service, with medical disciplines gradually establishing the limits of variation that will be tolerated. Surgeons and others will have to surrender more of their autonomy and be subjected to more stringent personal development in the interests of raising standards.
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Will the healthcare data revolution spell the end for doctors’ autonomy? | Healthcare Professionals Network