Chief Medical Officer's Annual Report 2014-15

Chapter 4 Doctors and the Management of Clinical Risk

This section looks at doctors' management of clinical risk, its challenges and ways we can improve.

What is Clinical Risk?

A clinical risk is the chance of an adverse outcome resulting from clinical investigation, treatment or patient care. (National Patient Safety Agency: May 2007 report www.npsa.nhs.uk)

Weighing Up Risk in Decision-making

Managing risk in healthcare is a universal challenge for doctors and other professionals. This is because it is inherent in every clinical decision and because no risk assessment tool or process can ever be 100% accurate. Expectations can be very high, believing that if a perfect outcome is not achieved then blame should be apportioned. Doctors tread a difficult path, with the expectation that they will make decisions balanced against criticisms of being overly paternalistic.

In the stressful environment of illness and suffering it can be comforting to project an omnipotent and benevolent identity on a doctor who can then be counted upon "to make it alright". However, regardless of the skills, wisdom and abilities of any doctor there are situations where the outcome is bad. This could be side effects or failure of a procedure or treatment or advancement of disease. The effect of this is seldom acceptance that it is not possible to mitigate against all bad outcomes but instead to apportion blame. Mistakes and incompetence, of course, do occur and these do need systems to mitigate them. At the point of decision, a patient has to trust the doctor to be working to their benefit and have confidence in their ability, knowledge and experience.

Standards of behaviour and sanctions for breaching these exist, whether they are through the professional regulation of doctors by the General Medical Council or other bodies such as the Colleges. (GMC: Good Medical Practice 2013 - Duties of a doctor)

Managing risk is an inherent part of a doctor's role. The breadth of their training and knowledge allows the management of complexity required to best plot the course of a patient's care and treatment through assessment, investigation and treatment. This can be rewarding when things go well for the patient but can also be stressful when the doctor realises that they are often making "judgement calls" where a decision is based not just on following an algorithm with a clear evidence base but also on "gut feeling" resulting from the application of wisdom rather than knowledge. An early sign in burn out of doctors is their reduced ability to tolerate the anxiety of making risky decisions.

The Importance of Positive Risk Taking

Everyone understands that everyday life contains risk and we all make positive decisions to expose ourselves to it. Our recreational lives are full of this. We choose to pursue certain sports with a degree of danger like skiing. We choose to travel on holiday to exotic and potentially risky destinations where gastrointestinal upsets, insect bites or other more serious risks await. The reason we take these risks is because the potential benefits of the choice outweigh, in our minds, the potential adverse consequences. Just as in healthcare decisions, our risk assessment is based on a combination of factual knowledge, experience and expectation. Avoidance raises anxiety rather than reduces it and it is psychologically healthy to stimulate and empower ourselves by taking some risks.

There are situations in healthcare where risk taking can be positive too. The decision to not admit to hospital or to a care home may be perceived as a risk, especially when there is a different expectation or pressure from patients and their carers. However, if we are to support more people to remain independent for longer at home or in the community we have to admit to hospital only those for whom there will be benefit and where there is no appropriate community alternative.

Similarly, the decision to discharge carries a degree of risk and again may be resisted by some patients and their carers. However, the advantages of keeping a patient in an inpatient bed have to be weighed up against the risks to that patient. The risks associated with being in hospital need to be recognised. Some are obvious and measurable like hospital acquired infections. Some are less obvious like increasing dependency or dislocation from home, family and society. Older people experience functional decline as early as 72 hours after admission and are more likely to have an episode of delirium or infection.

There is also a wider service and societal impact from using resources inappropriately, preventing their use by others when they need it or driving an inappropriate increase in acute capacity at the expense of chronic care and support.

There is risk associated with every clinical decision whether it is to do something, or do nothing. Apparent therapeutic inaction may be frustrating or confusing for patients unless clear explanation is given. It can be tempting as a doctor to manage a patient's expectations and anxieties by prescribing or ordering an investigation when a better course of action is to do nothing beyond simple support and waiting.

Public concern about the steady risk in antidepressant use (www.nhs.uk/news/2013/07July/Pages/Prozac-nation-claim-as-antidepressant-use-soars.aspx) is based on the theory that these medications are being unsuitably prescribed rather than there being a true increase in depression presentations and prevalence. The reality is that antidepressants are an effective treatment for depression and some other conditions. The increase is prescribing mirrors increased awareness and treatment. However, people presenting acutely unhappy to doctors are not best helped by antidepressants. Their prescription may make the patient feel that their suffering has been validated and may fulfil their expectations that the reason for their unhappiness is disease based and therefore treatable. However an inappropriate prescription can cause problematic side effects and imply a diagnosis that is not accurate. The antidepressant "treatment" may then prevent the patient seeking more effective solutions to their mood state such as exercise or socialisation. This also does disservice to the effective use of antidepressants which for some people are lifesaving.

How Can Risk Best be Managed?

Effective clinical risk management requires first and foremost an understanding by public, providers and policy makers that good outcomes are not guaranteed despite the best efforts of people and systems. This does not mean that all bad outcomes should be accepted. Avoidable risks should be identified and when bad outcomes occur in relation to these investigations, learning and action should occur to reduce the probability of such an outcome occurring again. Healthcare providers use clinical governance machinery to manage avoidable risk and Healthcare Improvement Scotland have an important national role in improving service quality and patient safety. The Scottish Patient Safety Programmes have delivered significant improvements in safety across a range of specialities through a collaborative approach to identifying and actioning opportunities for service improvement.

Risk assessment is a challenging skill. Across medicine, efforts have been made to apply a scientific approach to what is often an intuitive process, with varying degrees of success. The Prevention of Falls Programme identified significant risk factors that help predict which falls require additional, more specialist interventions to avoid future poor outcomes like fractures. The simple recognition that identifying and targeting people with poor bone health and cognitive impairment could mitigate future fracture risk is a good example of using scientific evidence base to modify risk assessment.

More contentious has been the management of risk in psychiatry. Creation of psychiatric risk assessment tools for general use has been criticised by clinicians. Significant incident/adverse event reviews have consistently shown that these risk assessments only work when they are translated into dynamic risk management plans effectively communicated between people and agencies. As simple lists of tick boxes they are ineffective. Research by the National Confidential Inquiry into Homicides and Suicides in people with mental illness has identified organisational factors that significantly affect suicide risk. This is an important illustration that the factors affecting risk are often beyond the direct patient - clinician relationship and that consequent outcomes are dependent on systems as well as people. In Scotland, Healthcare Improvement Scotland is taking forward work to translate the understanding of these organisational factors into the "Reducing suicide risk - discussion framework" document for teams to use.

Beyond risk factors identified by statistical analysis there is no substitute for clinical experience. This is best gained by direct exposure to decision-making, initially supported and supervised. Good medical training requires this. Some decision-making that doctors traditionally did, is now being done by other disciplines. It is important that doctors are not de-skilled in this remodelling of service provision. It is also important that the other disciplines doing risk assessment and making decisions on the basis of it are appropriately supervised and supported.

Good risk management is also dependent on communication of risk with other services. Lessons learned from mental health significant incident/ adverse event reviews commonly find failings in the communication of risk between organisations. Issues of patient confidentiality are often cited as being the obstruction to communication, however, this should not be the case. Guidance is given by the GMC. www.gmc-uk.org/15___Risk_Management_Framework.pdf_56300660.pdf.

Doctors should always remain open to seeking the opinion of others in clinical risk assessment. Second opinions can be invaluable, as can discussion with peers. Other disciplines can bring an important alternative view on a situation and decision-making is often best shared through discussion. This is particularly relevant in the delivery of integrated services where social workers have an important insight, especially in relation to vulnerable adult and child protection issues, not to mention housing and employment.