What was the most significant medical development of 2008 and holds the greatest promise for 2009 and beyond? There is no shortage of candidates – polyclinics, Lord Darzi’s “once in a generation” next steps review, the windpipe transplant, the gene therapy trial for blindness – to name only a few.
But for my money, one development trumps all these, though it has received little notice – the World Health Organization’s surgical checklist launched in Britain and throughout the world last June. It is important not only for what it is designed to achieve – safer operations – but also for what it signifies – a new focus on the quality of health care.
For the first 60 years of the NHS, one issue has dominated all others – waiting lists. We have asked only whether the health service is doing enough and why it is not doing more. Now, we are starting to ask whether it is doing it right and how to help it do what it does better. Access – that is, waiting lists – is no longer the problem. Quality is the new battle cry.
The WHO checklist is an aircraft style safety test which requires surgeons to run through a series of basic checks in the same way as pilots do before take-off – is this the right limb to amputate? Have we counted out all the swabs we counted in – and it has the potential to save thousands of lives.
As I say, extremely basic stuff and while doctors may scoff that the checks are too blindingly obvious to require more rules and bureaucracy, patients I suspect will be astonished that such rules do not already exist. With good reason. More than eight million operations were carried out last year in the UK and there were 129,000 reported incidents in which patients were put at risk (that’s reported incidents – the true number is certain to be far higher).
The National Patient Safety Agency estimates 2000 NHS patients die each year as a result of errors in their treatment and the National Audit Office concluded following an investigation in 2005 that half of all errors could have been avoided if staff had learned the lessons of previous mistakes.
Moreover, checklists do work. In Michigan, a checklist to reduce hospital infections associated with central lines is estimated to have saved 1500 lives and US$175 million in costs in its first 18 months. The results were reported in the New England Journal in 2006 and today Michigan’s hospitals still have among the lowest infection rates in the US.
The beauty of the checklist is that it is simple, virtually cost-free, and likely to save more lives than a whole bunch of miracle cures. It is being tested at St Mary’s Hospital, London – Lord Darzi’s patch, who also played a key role in designing it – and is due to be rolled out across the NHS. Doctors tend to dismiss it as “tick box” medicine which deprives them of their autonomy and threatens to turn them into automatons but it is actually designed to free them to use their skills to treat patients without having to think about tasks that can and ought to be routinised.
It fits, too, with much else that is going on in medicine – the new focus on health outcomes being pioneered by Lord Darzi, the publication of death rates (and other clinical outcome measures) led by Lord Darzi and NHS Medical Director Sir Bruce Keogh, and increased patient involvement in rating doctors and hospitals based on their experience of treatment.
In short, a revolution is under way.
Listen to Jeremy Laurance on the BMJ podcast, taking us through his top medical stories of 2008.
Jeremy Laurance is health editor of the Independent newspaper.