NHS Managment

Risk management is the process of reducing losses due to accident or misadventure. It is a subject of more than passing interest to the NHS, which is thought to have liabilities for medical malpractice claims of about u1 billion at a cost of u150 million per annum, rising by 25 per cent annually.

The first step in the risk management process is the analysis of claims to find out where accidents are occurring. About 60 per cent of the total liabilities for the NHS arise from obstetrics, particularly claims by people who suffered brain damage at birth that could have been avoided by better obstetric care.

The remaining 40 per cent of liabilities comprise distinct groups of claims that can be analysed, although there are always one-off claims that will be slow to yield to a risk management approach.

Having identified where claims are occurring, the next step is to analyse a series of claims which have common characteristics, to see how they may be prevented.

A number of studies of this type have been carried out in relation to obstetrics (including our own) and the root of the problem is the difficulty of making an accurate diagnosis during the birth that the foetus is short of oxygen and may suffer brain damage.

Sub-optimal diagnosis may be the result of human error, lack of resources (in particular the availability of consultants to supervise the work of midwives or junior doctors), or it may be due to deficiencies in medical knowledge. Frequently, accidents are a combination of all three elements and claims are correspondingly difficult to adjudicate or prevent.

Having identified the causes of claims, the final stage in the risk management process is to work out measures to reduce them and train practitioners in the solutions required.

Whereas the task of analysis can be carried out by a few people, the task of training to improve current practice is enormous and is the area in which most risk management programmes are weak.

As well as the specific measures revealed by this approach, many accidents happen in the NHS for similar reasons to other organisations. High staff turnover hurts quality in any service organisation and is a serious problem for a large number of NHS hospitals.

Another dilemma is the increasing shortage of resources and the underlying issue of whether to treat everyone to a single standard, which results in a high level of claims, or to treat a smaller number of patients to a higher standard. This inevitably involves saying “No” to those for whom resources are insufficient.

In one way or another, this topic is likely to dominate the legal and ethical debate about the availability of medical treatment in this country.