Social Audit Ltd
P O Box 111 London NW1 8XG
Telephone/Fax 44 (0)171 586 7771
Andrew Foster, Controller,
The Audit Commission
1 Vincent Square
London SW1P 2PN

18 June 1998

Dear Andrew Foster,

I am familiar with some of the Audit Commission's work and value its quality, and this prompts me to ask if you might consider tackling a problem which causes much distress and which must cost the National Health Service several billion per year. The indications are that some good preventive measures might be employed, yet the problem has traditionally been neglected and still is.

The problem is iatrogenic illness, ie ill-health resulting from medical intervention, and my particular interest relates to ill-health resulting from treatment with drugs, used with therapeutic intent. There is not much reliable data on the extent of this problem, but what there is suggests that about half of all cases might be avoided and, therefore, that substantial savings might be made. The best estimates suggest that, each year, drug-induced iatrogenic illness (DIII) accounts for a few tens of thousands of deaths and a few hundred thousand hospital admissions, plus a few million other adverse drug reactions (ADRs) both more and less severe.

I am enclosing some documentation on this, including reference to a recently-published meta-analysis of prospective studies which suggests that DIII would be between the fourth and sixth greatest cause of death in US hospitals. I refer you also to our website, from which you will see that I have little success in raising such concerns with the authorities, including the Secretary of State and the Committee on Safety of Medicines (CSM). You will see, however, that a recent BMJ report on this subject confirms that DIII accounts for something of the order of 3% to 5% of all hospital admissions. I have written to the senior member of the CSM involved in this study, to try to resolve some uncertainties about the figures, but have not yet received a reply. 

Clearly this is a very sensitive issue because it touches on questions of professionalism and legal liability. Still, it does not seem acceptable to do so little to tackle the problem, particularly when much might be done by way of prevention, and when so little is achieved through legal redress. For example, just by way of defining the problem, would it not seem prudent to develop relevant performance indicators for NHS hospitals and trusts?

Many indicators already exist, eg for such matters as patient throughput and length of waiting lists. Might it not be helpful to extend reporting to such things as year-on-year expenditure on insurance premiums, or numbers and value of compensation payments made, with and without admissions of liability? And what of the value of some the preventive measures used here and overseas? I can think of several useful examples, notably schemes that recognise the importance of listening to patients who feel they have been hurt and let down, and then sympathetically investigating their concerns. Having acted as an adviser in many lawsuits relating to alleged drug industry, I have seen, over and over again, cases in which legal action might (and should) have been averted if patients hadn't been confronted with brick walls.

I would be very interested to know whether you and Dr. Boyce might think any of this worth pursuing. I am keen to develop this topic on our website - and would, in due course, want to post this letter there, together with any response from you. I hope this seems acceptable to you, if only in giving you more time and space in which to contemplate a reply than you would ever get with a routine press enquiry. I would like to return to the subject on our website early next month, and would be grateful for some preliminary response in the meantime. Many thanks for your attention and I shall look forward to hearing from you.

Yours sincerely,

Charles Medawar

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