Clinical quality should be put at the centre of care

Editor—The multiplicity of recommendations of the non-medical report into the performance failures of the heart surgeons at Bristol Royal Infirmary¹ prompts Coulter to repeat the slogan “put patients at the centre.”² The primary issue—that of poor clinical practice going unchecked—has again been obfuscated. The failure of clinical self regulation caused the serial disasters at Bristol; smothering this uncomfortable truth risks its remedy.

Coulter says that openness and empathy should be shown to patients after medical errors have occurred. Alas, the problem of getting doctors to admit that an error has occurred is more pressing. The notion that all doctors will now openly divulge their error, even if aware of it, is unlikely. Motorists seldom drive to police stations and confess to bad driving, so when their bad driving is seen they are stopped and the transgression brought to their notice. Processions of disasters such as occurred at Bristol show that currently there is no method of preventing them from happening. Until medical errors are promptly identified to the profession, talk of openness afterwards is meaningless.

Coulter floats another flimsy proposal: “improving communication with patients.” Many cases of bad clinical practice have shown that the offender was actually a skilful (or wily) communicator. Patients will tolerate a doctor's social inadequacy or even poor outcome if they believe that reasonable professional competence prevails and clinical rudiments are not neglected. Their only assurance would be a strong system of clinical accountability for all doctors.

Coulter invokes the peculiar view that “by involving patients, doctors could reduce the incidence of medical errors,” as though patients were not already involved, both as patients and with a complaints system. Neither of these, though, is proof against bad practice.

If copies of all complaints and their written medical responses were seen by an independent medical inspector who when necessary could examine medical records, the resulting increased attention by doctors would make them clinically accountable.³ It would also simultaneously solve the unfashionable issue of patient accountability.³,⁴ Poor medicine, the expense of litigation, and the costs of patients' unrealistic expectations would all decline.

Patients would happily vacate a place “at the centre” if instead clinical quality was impartially and effectively enforced. A body devoted to this end that could take their place must be set up.