|Social Audit Ltd|
|P O Box 111 London NW1 8XG|
|Telephone/Fax 44 (0)171 586 7771|
|Dr Jonathon Boyce|
|Director, Health Studies|
|The Audit Commission|
|1 Vincent Square|
|London SW1P 2PN||
20 July 1998
Dear Dr Boyce,
Many thanks for your letter of 15 July. I was interested to learn more about the Audit Commission's future programme of work. Even if the Commission has no plans for directly addressing the problem of iatrogenic illness, I welcomed your recognition that this is a serious problem that does need to be tackled. This is such a sensitive issue that most authorities shy away from acknowledging this; as a result the problem persists.
I am writing again mainly to acknowledge your letter, but also to comment on some of the points you made. My objective here is not to draw you into correspondence: this letter needs no acknowledgement nor response. But I do hope that the Commission will keep something of a watching brief on this issue, even if it stays on the back burner.
1. I both agree and disagree with your point about the limitations of external audit in this field. I would think the main reason against external audit is to do with, if you like, the problem of policing for a perfect world. Drug prescribing is an inherently risky business, and clinicians are already subject to overwhelming responsibilities, and to seemingly intolerable pressures and stress in work. So I can see that it might well prove unhelpful simply to introduce some sort of centralised discipline, or indicator-led monitoring programme. On the other hand, where is the element of accountability without the expression of some independent point of view? It seems hard to accept that self-regulation is the answer when, 50 years after the founding of the National Health Service, no serious attempt has been made to address a problem of this nature and scale.
2. I am also in two minds about your view that much of the avoidable iatrogenesis results from individual clinical decision-making. Clearly, to some extent it may do, and one would expect to find significant differences in the performance of different individuals. On the other hand, there seem to be numerous features of the medicines utilisation system which positively contribute to risk. Examples include: the nature and scale of drug promotion, lack of rigour in post-marketing drug surveillance, systematic reliance on sloppy science, excessive secrecy, poor warnings and bad communication, and lack of patient participation/representation. What seems to be lacking is any real strategic sense for dealing with the problem, and I honestly cannot see local clinical audit providing it.
3. I agree that some progress might be made if the National Institute for Clinical Excellence lives up to its name. However, it doesn't yet exist and it is not clear how it will perform. As I understand it, this Institute will operate on a rather modest basis, and mainly as a coordinating centre for existing research units. It remains to be seen who will lead and what will follow.
4. I am enclosing for your interest a proposal for research into iatrogenic injury in the North Thames region of the NHS. This includes estimates of the extent of the problem comparable to those I cited, and far greater than any that have ever been officially acknowledged. It also makes the important point that the probable costs of iatrogenic injury dwarf the cost of litigation. I was referred to this study by the Department of Health (which significantly did not mention its expectations of the National Institute for Clinical Excellence). Apart from its apparent uniqueness, this looks like a sound proposal. So it seems all the more disappointing that the organisers of the research are still having to try to secure funding for it.
Thank you for your interest. I do very much hope not to be writing to you in the same vein, a few years from now. I'm sure you do too.