Reconfiguration, and more...

So some busy months, and lots of very busy people! This month, I have had the opportunity to meet members, from lots of different centres in the UK and abroad, at a wide range of events and meetings.

I learn lots from colleagues at these meetings both about the challenges facing the profession broadly, but also about local issues. I also see some great and innovative work. I want to hear more and see more, so I have a made a particular personal goal to visit pathology departments in the UK, and to meet as many of our overseas fellows as possible. I am already shameless about popping in to departments to say hello, and will continue to do so if you will allow me in! 

Road trip aside, what is going on? 

Masses. Pathology networks... still ongoing. Not all network configurations have been agreed yet, but planning for the implementation of some is going ahead. Network business plans have been put together that suggest approximately a 30% reduction in lab staff, mainly senior lab staff. Savings of the magnitude suggested by the NHS Improvement (NHSI) modelling in England were unlikely to be achieved without staff reductions, but the major concerns are not only around the individual staff involved, but also around the stability of patient services that require key expertise, especially in particular areas, for example transfusion. 

There is a real risk that uncertainty over these changes may result in loss of key skills. We know that a previous reconfiguration of pathology services in one region of England resulted in unintended loss of transfusion expertise and risk to service. We continue to press NHSI and to work with devolved nations, also involved in networking, to make sure that workforce plans for the networks are not only as humane as possible, but that enthusiastic prosecution of networks doesn’t disrupt vital services.

NHS England (NHSE) genomic reconfiguration is also underway, and tender submission for new genomic hubs has been pushed back a little at the time of writing. There has been discussion, not only over the test list, which may be revised, but also over the functional relationships in cancer, especially haematological malignancies. We are also keen to make sure that molecular and other training is protected, and that research is enabled. We are told that these issues are expected to be resolved in the bids, and as centres develop their new working relationships. We also want equitable access to the genomic testing, since some labs do not currently offer all the tests, and no additional funding is available. Services will buy tests from the hubs, and we anticipate a flurry of cost pressure business cases that may take a while to be approved, or have patchy uptake. We hope that NHSE will help, and that organisations will work together to bring these key diagnostics to all our patients as soon as possible.

Uncertain times

The major restructuring of cervical cytology services and wholescale move to primary HPV screening has been expected for some while, but the delay has created uncertainty for staff. The reduction in sites from 54 to approximately 12–13 is a major change. This will lead to longer and possibly undesirable journeys between centres for existing staff.

The model of service delivery in new centres may well rely more heavily on advanced practitioners. Few of these are in training at the moment and many of those in practice are over 50, and many may not be prepared to travel to the new hubs. In addition, not many medical staff currently doing cervical cytology are expected to transfer to the new centres. Again, planning for – and with – people is so important! Once the centres are established there will be more stability, but the intervening period is one of concern. The tender is expected in June, with a decision by December, and implementation in 2019. We have raised the risks to service with Public Health England and also alerted Health Education England to this.

Into the future

In all these areas, IT infrastructure, hardware (to replace the nearly 30% of laboratory information management systems [LIMS] that are virtually obsolete), connectivity to link systems, and, for histopathology and haematology, digital imaging will be key to making services more stable and efficient. There have been some great examples of single LIMS roll outs in Wales that has made patients’ test results more accessible, and able to be reported across the principality. Similarly, some regions have good systems that link many hospitals and indeed some acute and primary care systems. These models need to be more widespread. We are pushing hard with NHSI, NHSE, providers and government to invest in this key area. We have had the chance to reinforce this in several fora, and Cancer Research UK are helping us also, since they recognise this as a key need for cancer patients.

What else? The new building has been coming on apace, with little delay, even given the recent weather. We are looking forward to moving in this autumn, and to the new opportunities that the facilities will bring.

The team have been running, and planning further, super expanded programmes of meetings across all specialties that have been really popular. I hope that you will check them out via the website, or keep tabs on the @RCPath twitter feed. On 10 and 11 October, we have a special joint meeting with the Association of Clinical Pathologists on disruptive technology, which will have some amazing state of the art and future art highlights for all specialties and will also host members of the British In Vitro Diagnostics Association. We have Professor Shafi Ahmed on augmented reality, Professor John Pasi talking about gene therapy for haemophilia A and Professor Graham Foster talking about his task to eliminate hepatitis C and a session on AI... so, really amazing speakers, together with a ‘Path Dragon’ spotlight on new tech. There is so much outstanding work going on that it is going to be difficult to work out what can be left out!

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To err is human

 

I have been following, reading and getting briefings about the issues around the conviction for manslaughter of Dr Bawa-Garba, a doctor in training. This series of events has unsettled doctors in a way that I have not seen before. It has unsettled me deeply.

Guilt

We all make mistakes. Despite trying my best, I have made mistakes that I regret, both personally and professionally. I have made mistakes as a trainee, and ones as a consultant. I have also helped, or tried to help, colleagues, at all grades, consultants, staff doctors and trainees who have messed up. 

The thing about making a mistake is guilt. Huge guilt. The stress of finding out you have made a mistake is huge. The worry about what has happened to the patient. None of us go into work to hurt people. The stress can really get to you. It can give you sleepless nights, when you rerun the sequence of events. It can wake you at three in the morning. It can give you a tachycardia even thinking about it. For some people it can be incapacitating or undermine confidence to such a degree that they cannot function normally. However, it is an unusual individual in healthcare who does not make a mistake.

Support

Systems have generally got better about offering support for staff who make mistakes, but most important is the support of colleagues. I know about this especially in histopathology, where our mistakes are there in the file for all to review. It is rare for a pathologist to get through a career without a serious error, and the help from colleagues when you do make a mistake is really important in being able to carry on. For trainees this support may be from clinical or educational supervisors, but for everyone it is the support of colleagues. Things may ‘go formal’ in terms of educational review, referral to NCAS, an audit of practice or legal action, but the support of peers is key.

To add to the personal reaction, in healthcare our mistakes not only have the potential to harm people, but also to be made very public. Not only are your colleagues likely to hear about it, locally and through any serious incident review process, but when a relative gets angry about what has happened and goes to the press, their story is likely to be published, and to name individuals responsible. You may be referred to a body such as a deanery or regulator. It may not be an albatross around your neck, but the consequences may hang on you for a long while. There are few walks of life where this aspect of making a mistake is quite so stressful. Often you can feel very alone in this, but the positive is that the process may help others to share their stories with you. A culture of openness and sharing is the one thing that helps both alleviate stress, but also to promote learning. This is why reflective practice is so very important.

Approach

I have also spent a great deal of time over the years dealing with patients and relatives who have been harmed in a range of ways by other colleagues. They have suffered the effects of mistakes, or problems in how we dealt with them. I dealt personally with all the hundreds of enquiries at our institution, related to organ retention and consent for post-mortem examination following the events at Alder Hey. I have met patients who have had bad treatment or who have been treated badly.

The thing about telling patients and relatives about mistakes is that you cannot ever predict how they will react. Never assume anything. I believe that I have always tried my best to be open and honest, and firmly and deeply believe in a frank and open apology, human to human. I can never imagine how it feels to be in their shoes, but I can say that I am truly sorry, that it should not have happened and that I am also sorry that there is nothing I can do to put it right. I will say, if there is an appropriate moment, what we will do to help stop it happening again, or what we will try to do to remedy the situation. 

Kindness

Anger and desire for retribution is understandable in the face of injury. The damage of a loved one or the loss of a child is unthinkably awful and you can understand the desire to punish those responsible. Those responsible are also human, and they also suffer. Anger is to be expected, and the astonishing thing for me has been that the vast majority of people have been so very gracious and so very forgiving about what has happened to them. I have even had a thank you card from someone who had had a terrible time over the loss of a baby. We must never forget that this is the majority response and an amazing expression of human kindness to others, even in the face of considerable pain.

The other element of the recent case that has been unsettling has been the context of mistakes. If you prescribe a penicillin to a known penicillin allergic patient and they have a fatal anaphylactic reaction it is completely inexcusable. If it occurs because a senior colleague has told you to do it, in a high-pressure setting where you are covering a ward full of acutely ill patients with no colleagues and having to move rapidly between emergencies, even whilst professionally inexcusable, it seems more understandable. 

Pressure

Particularly at this current time there are staff shortages and enormous pressures across many areas. We have patients as our priority, so we do more, we stay later, we cover shifts that aren’t covered. We do this because we know that there are no doctors to cover the shifts or the work unless we do. And we don’t generally make a fuss. We work with increasing numbers of sick patients with multiple morbidities, with a vast array of therapies, some of which we may never have heard of before, and have to look up, because the medicines field is developing so fast. We are encouraged to concentrate on sepsis, deep vein thrombosis, stroke, smoking, obesity, mental health. 

The pressures have built up. They have built up for everyone in healthcare. They have built up for managers. As an executive on call I have had to make decisions about opening areas of the hospital not designed as wards to patients when we had no beds. If something had happened to a patient in that area, would I have ended up being referred to the General Medical Council (GMC)? 

Guidance

And there is the GMC... Tough words have been said and written, and feelings expressed that ‘fairness’ may have taken a back seat to process and reputation. An incident review would be helpful in the same way that we might review something that has not gone well. The GMC have apologised for the impact their decisions have had. They have acknowledged that they have a lot to do to regain the trust of the profession.

So events have precipitated a general professional wobble, and an undermining of our own confidence in our profession and how it is regulated. But it has brought about some serious discussion about important issues, and discussion that may help bring some light. We generally love our work, we care for our patients and we care about each other. We all make mistakes, and we want to be able to own up to them, learn and move on. We need to be held to account for what we do, and disciplined where appropriate, but we don’t need to be persecuted and vilified for doing our best in difficult circumstances, even if it isn’t good enough, even if it is substandard. Even if we fail.

So what next for this? We anticipate and will look at how best to engage with the GMC review into how gross negligence manslaughter, and culpable homicide, the equivalent offence in Scotland, are applied to medical practice, led by Dame Clare Marx; and the review by Professor Sir Norman Williams into the issues surrounding gross negligence manslaughter in healthcare. We welcome the evidence from Professor Sir Terence Stephenson, GMC Chair, to the Williams Review that doctors’ reflections are ‘so fundamental to their professionalism’ that Parliament and devolved governments should bring forward legislation to protect reflective practice if they saw fit to do so. I have offered our help and support in these reviews. We are working with the Academy of Medical Royal Colleges about systems for reporting unsafe working patterns and best practice in reflection... We are working on sharing learning across our members when something does go wrong also. Pathologists know about mistakes, but we know about learning and we know about support, too.