Monday, 29 August 2011


One of the changes that I have seen over my years in the NHS is the increasing encroachment of management into the area of clinical decision making, not just in medicine, but in nursing as well. When I started in the NHS, management steered well clear of the clinical management of individual patients and allowed clinicians to get on with the job.

Increasingly over the years this clinical autonomy has been eroded. We now have a move towards protocol driven care, with increasing restriction on the treatments we can offer and the drugs we can prescribe. This has been justified by the concept of risk management. Since the burden of indemnity has shifted from individual practitioners to Trusts, the Trusts feel they can minimise risk and liability by dictating practice. 

Unfortunately it has not worked. The bill for NHS negligence cases has continued to spiral upwards, and has now exceeded one billion pounds for a year, according to this article. I am not suggesting that the usurping of clinical management by non clinicians has caused this increase, but it certainly has not had the desired effect.

The main point of the article is that this bill is likely to rise as a proposed cut in legal aid will drive dissatisfied patients into the arms of “no win, no fee” lawyers. The article portrays this as wholly undesirable with the implication that these lawyers are taking advantage of the situation. So it was a little ironic to see the adverts that had been placed right next to the article.

1 comment:

  1. I don't know, I don't have a problem with protocol-driven care because it's evidence based and more reliable than just going from experience, given experience is heavily influenced by recall bias.

    It's only an anecdote but recently my consultant told me to ignore the microbiology protocol and prescribe cipro for a patient because that's what his experience said. Unfortunately the guidelines banned cipro for that particular infection because our area has an extensive amount of cipro-resistant organisms and our patient's cultures came back resistant for cipro. If he'd let me prescribe by guideline, she would have been home a week earlier.