Will the lead clinician please stand up?

Editor—Godlee's comment about the fragmented care described by Gannon in his personal view prompts us to provide additional evidence from our study at a district general hospital.¹,² As part of a research project we persuaded clinical teams to examine the quality of care in their own units.

We found evidence of adverse events or critical incidents in 60/154 medical cases and 27/134 surgical cases. Most of the issues were comparatively minor, commonplace problems that might be found in any hospital ward—for example, venflon cellulitis, over-infusion of intravenous fluids—but in at least 12 medical cases and 16 surgical cases we found evidence of a lack of integrated care, in some cases with serious consequences.

Gannon thinks that we need to revitalise the role of the lead clinician.² Our findings support his contention. However, is that possible and would it be enough? Over the past 20 years, hospital doctors have striven to become specialists rather than consultants. Twenty years ago Sir Christopher Booth, former director of medicine at the Royal Postgraduate Medical School, warned of the effects of technology on the practice of medicine,³ and today we live with such predictions.

In our study we tried to assess causation. Inevitably, superficial appraisals are subjective, but at least half of the problems seemed to arise from a “failure of overall care.” The specialists of today do not have the time to be lead clinicians for all the patients they see. So should we not be training all members of the clinical team to take overlapping responsibility—developed as “total quality care” in the Japanese car industry and subsequently applied to medical care⁴? And should we not nominate individual secondary care doctors to relate to individual patients to ensure the adequacy of integrated care?