There is much to be praised in the Berwick report; greater transparency, a no-blame culture, effective systems to improve safety, listening to patients, increasing staffing levels – these are all laudable aims, and while the challenge is to actually make them a reality, the intention is a good place to start. One thing troubles me greatly, however: the headline-grabbing punch line, Zero Harm.
What can be wrong with aiming for zero harm? Is it not, as the report claims, a ‘bold and worthy aspiration’? Haven’t we inherited the words ‘do no harm’ from that earliest version of the GMC Guide to Good Medical Practice, the Hippocratic Oath?
Well, aside from the association with right wing American Zero Tolerance policies, which leaves me slightly squeamish, the report itself concedes that chasing zero harm is an ideal that will never be realised and that ‘continual reduction in harm’ is a better phrase. It certainly is a better phrase, but it is far less catchy, and the word zero is the one people will remember. The fact that we can never achieve zero harm raises the question – are we setting ourselves up to fail? If we raise the expectations that there will be no harm at all, then what response might we expect from patients, families – The Daily Mail – when harm inevitably does happen? We might try to achieve a no-blame culture so that staff can be open about mistakes they make, but patients will only be part of that culture if we are all realistic about what happens when someone is sick enough to need to be in a hospital.
We know that patients, and staff, tend to over-estimate the potential benefits of medical intervention, and underestimate the harms. It is why the BMJ are currently in the middle of a series of articles on the prevalence of overmedicalisation in health services the world over, and calling for recognition of the potential to harm has become a mantra for those of us who are concerned about the fact that there is just too much medicine on offer these days. Everything in medicine is a balance of benefits against harms. When someone is sick, the decision is usually easy, but much of what doctors do is much more finely balanced. Elective surgery, statins in primary prevention, treating hypertension, gliptins in diabetes, screening mammograms – these all require a complex analysis of risk, and while the balance for some will be in favour of treatment, we will always harm some of our patients.
Berwick is right that we should not accept that system errors are inevitable – we should be able to design a system where it is impossible to give an intrathecal injection of vincristine, for example – but we need a grown-up conversation about harms in all areas of medicine if we are to help patients make the best decisions for their own health, and be in the best place to understand when something goes wrong. This report may well prove to be a helpful stepping stone in achieving this aim, but the sooner we can move on from the concept of ‘zero’, the better.
Dr Martin Brunet is a GP in Guildford and programme director of the Guildford GPVTS. You can tweet him @DocMartin68