Prof Sir Liam Donaldson, the Chief Medical Officer for England, stands down this week. He’s been in post for 12 years, during the same period as the Labour government. His annual reports provide an interesting snapshot of the evolving health priorities over that period. His final one was released recently with little fanfare. Here’s a summary of the year and ongoing priorities, in his own words:
1. Swine flu
The predominant challenge of 2009 was the emergence of the first influenza pandemic for 40 years. From Mexico, the illness spread fast around the world. England was amongst the first countries to have cases of what was rapidly confirmed as a new flu virus - influenza A/H1N1.
England was well prepared. Initial efforts to slow transmission were maintained for several weeks. Inevitably, the number affected grew. A growing number of people were admitted to hospital. In June 2009, the country sadly saw its first death.
Demonstrating the unusual way in which pandemic flu viruses behave, rates of infection continued to swell into the summer months. General practice felt much of the strain, and handled it well.
When the strain was approaching a critical level, the National Pandemic Flu Service was activated. This was an entirely novel concept for the country, and formed an important part of the pandemic plan. The public had never previously been able to access an internet and telephone based diagnostic and treatment service that provided medication when appropriate. The National Pandemic Flu Service was well used, and relieved significant pressure on the mainstream NHS.
As summer turned to autumn, the picture was mixed. There had been deaths. Hospital capacity had been stretched significantly, particularly in intensive care. But rates of infection had peaked in August 2009 and were falling. For most people, the disease was milder than had been anticipated based on the early information from Mexico.
Some have called the public health response to the pandemic an overreaction. In so doing, they draw attention to the overall costs of antiviral drugs and vaccines. They speak of the relatively small number of deaths compared with previous influenza pandemics and seasonal influenza outbreaks. In describing the number of deaths in the present pandemic, they often use the prefix ‘only’. In response, it is important to ask a number of questions. Would it have been acceptable not to plan as well as we did for a pandemic nor procure countermeasures? Having done so, and in the face of emerging, worrying evidence from the first phase of the pandemic in Mexico, would it have been right not to deploy existing countermeasures and not to strengthen our holdings? Would it have been acceptable to hide and conceal statistical projections provided by statistical modellers of international standing, even though releasing them publicly caused alarm in some quarters? Would it have been right to take the view that it was acceptable to ‘tolerate’ a certain number of deaths, considering them low enough to accept, when a way of preventing them was available?
In the first pandemic of the 21st century, we had the option of fighting the illness to protect children and adults from its adverse consequences. It is vital that we learn from what we have seen in this pandemic, for the sake of those who find themselves tackling - and affected by - the next. It is likely to be worse.
2. Alcohol consumption
I made several recommendations, including the introduction of a minimum price per unit of alcohol. I have been pleased to see public health and medical leaders engaging so widely with this issue. Many of its representative bodies have spoken out in favour of a minimum price policy, including the Royal College of Physicians and the BMA. In July 2009, I gave evidence to the parliamentary Health Select Committee’s inquiry into alcohol. Its report, published in January 2010, also calls for a minimum price per unit. The price of alcohol is a crucial determinant of its consumption. Tackling the substantial harms caused by alcohol in this country requires this decisive action.
I remain concerned about young people’s drinking. The evidence shows that 11 to 17 year olds drink 20 million units of alcohol (the equivalent of 9 million pints of beer or 2 million bottles of wine) every week. Young people who binge drink in adolescence are more likely to be binge drinkers as adults, and have an increased risk of developing alcohol dependence. In December 2009, I published guidance on the consumption of alcohol by children and young people. I advised that an alcohol free childhood is the healthiest and best option.
3. High Quality Care for All
Published in 2008, Lord Darzi’s report High Quality Care for All marked an important milestone. Its central tenet is that quality should be the ‘organising principle’ of the NHS. It aims to set the health service on a path defined by the quality of its care. It seeks to promote quality from being the focus of specific workstreams to being at the heart of how the service operates and thinks.
In 2009, the health service began working on a particularly key means of achieving this. It has been collecting the necessary data to produce ‘Quality Accounts’ for 2009/10. Trusts will report their key measures of quality in the same way in which they report their key measures of financial performance. This is vitally important. Focus shifts to where measurement is made. The act of making and reporting measurements of quality will itself catalyse improvement, helping the NHS to continue developing the quality of the service that it provides to patients.
4. Surgical errors
The 2007 Annual Report, describing surgical safety, highlighted the fact that over 100,000 errors involving surgical patients were reported to the National Patient Safety Agency in that year.
My report recommended that clinical teams should pilot the World Health Organization’s Surgical Safety Checklist. A subsequent pilot study of this checklist involved hospitals in London and seven other locations around the world. It demonstrated that using the checklist could reduce the risk of death and postoperative complications significantly. In 2009, the National Patient Safety Agency started to implement its use nationwide. By late 2009, 80% of hospital trusts in England joined the implementation of this important work.
5. Women in medicine
The proportion of doctors who are women has been climbing rapidly over recent years. It now stands at 41%. In my 2006 Annual Report, I discussed some of the particular issues that this group faces. I formed a National Working Group on Women in Medicine to consider the issues and to develop solutions. I was pleased to receive its report in October 2009. The group proposes a series of steps to enhance opportunities for female doctors. The report makes clear recommendations for a number of bodies, including government departments, universities and NHS employers.
6. Discrimination
On a similar theme, my 2007 Annual Report drew attention to the barriers of racial discrimination that still exist within the medical profession. Substantial improvements have occurred in recent years, but work remains to be done. In 2009, I chaired a series of roundtable meetings on this issue. These brought together high level representatives from the NHS, the GMC and royal colleges. I am pleased by the progress that many of the national bodies are making in this area. I hope that this important issue will continue to receive the attention it deserves.
7. Revalidation
I am also pleased with the progress that is being made to introduce revalidation for doctors. In 2009, the GMC introduced the necessary categories of registration that will allow doctors to obtain and renew their licence to practise. The Department of Health has established a series of pilot sites through which the operational details of revalidation will be tested and refined. I hope that doctors will welcome revalidation. Between qualification and retirement, competence is simply assumed at present. For the vast majority, this assumption is justified. The revalidation process will allow doctors to move from assumption to demonstration. The process will also play an important part in identifying the small number for whom the current assumption is flawed.
Read the full report.
