Physician Heal Thyself
Peter Carter
Chief Executive Officer
International Society for Quality in Health Care
Agenda
Definitions
 Introduction
 Why Regulate (Self or Imposed)
 Scale of Challenges
 Case Studies
 The Beauty and the Beast of Self
Regulation
 Big Brother (Imposed Regulation)
 Questions for you

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Definitions


Professional Self Regulation: the arrangement by which
practitioners exercise authority and maintain control over the
practice, self discipline, working conditions and professional
affairs as they contribute to the mission of their organisation*
Imposed Regulation: control governed by law and
oversighted by some public official (judge, bureaucrat or
legislator)
Regulation by Private Parties
e.g. Litigation- can be effective if on a large scale, as it has the
power to punish the profession & thereby force changes in
behaviour
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* Aydelotte(1981)

Choice
Self Regulation
OR
 Imposed Regulation
OR
 WHAT??? Hybrid??

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Why Regulate
Market
Failure
Public
Interest
Private
Interest
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Market Failure(Asymmetry of
Information)
Consumer less informed
about nature & quality of
service
 Relies on expertise of the
professional
 Potential for supply induced
demand

So need…
Protection of consumer through regulation
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Public Interest

Cartel like behaviour

Control of supply to ↑prices
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Private Interest
Improve market equilibrium through efforts to
promote greater and evenly distributed social
welfare
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The scale of the challenges
140,000+
different
ways the
human body
can go wrong
6000+
medicines
for
treating
diseases
BNF
ICD10
codes
and we wonder why things go wrong….
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The scale of the challenges

1 in 10 patients admitted experience an adverse event

Half of adverse events are judged to be preventable

5% of deaths in English acute hospitals had at least a 50% chance of
being prevented

Principal problems associated with preventable deaths

poor clinical monitoring (31.3%),

diagnostic errors (29.7%), and

inadequate drug or fluid management (21.1%)

Most preventable deaths (60%) occurred in elderly patients with
multiple comorbidities and less than 1 year of life left

72% of all patient safety incidents are from the acute sector, 13% from
Mental Health, 11% from Community, 2% from Learning Disability,10
0.6% from Community Pharmacy and 0.4% from General Practice.
Case Study 1
Jayant Patel
Who is Dr Patel
 Nature of his appointment
 Under the Radar
 Problems Emerge
 Inquiries
 Criminal Charges
 What went wrong
 Is there a bright side? ( Lessons learned)
 Questions

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Case Study 1(Continued)
1.
2.
3.
Would Self Regulation have prevented this (or
similar episodes)?
Did the existence of a self regulation regime
prevent more effective regulatory practices
being invoked?
Is imposed regulation
alone sufficient or is it
likely to marginalise the
profession?
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Case Study 2
“The Beautiful Hospital”
Chelsmford Hospital
Harry Bailey
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Chelmsford Private Hospital
Facts

Conducted Deep Sleep
Therapy in the 1960s and
1970

Many patients died directly or
indirectly as a result over
many years

Failures of Self Regulation
and Imposed Regulation
allowed this
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Why?
Self Regulation
• Unresponsive
• Lacked
sanctions
• Influenced by
peer
colleagues’
intimidation
• Feared being
sued
Imposed
Regulation
• Unresponsive
• Poor
mechanisms
• Was also
intimidated
And
• Confusion
between the
professional
body & the
government
regulator in
connection to
responsibilities
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Statutory Protection
Protection for quality assurance
activities to encourage their use
 Disclosure of morbidity & mortality
 Information and the disclosure of
information
 Disclosure in peer review meetings
cannot result in legal action against
health professionals
 This has the effect of making Self
Regulation more effective & responsive

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Key arguments for imposed
regulation
Information Asymmetry

The professional services
consumers’ gaps in knowledge

Obligation to fill the consumers’
knowledge gaps
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Hybrid
The DoH(1997) stresses that in order to achieve the
aims of clinical governance: i.e. control,
responsibility, regulation, it expects individual health
professionals to be more responsible for the own
clinical practice and professional self regulation(
individual and organisational).It must remain an
essential element in the delivery of quality patient
services
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The Last Word goes to…..
Professor Avedis Donabedian
Systems awareness and systems design are
important for health professionals, but they are not
enough. They are enabling mechanisms only. It is
the ethical dimensions of individuals that are
essential to a system’s success. Ultimately, the
secret of quality is love
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Questions
Would self regulation alone have presented the
deaths & injuries in the two case studies?
 Would imposed regulation have done so?
 Both were present in both case studies - what
went wrong?
 Is there a system/process that can ensure the
public they will not be injured or killed by those
in whom they put their trust?
 “All you need in Love” is Donabedian right?

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Thank you
Peter Carter
pcarter@isqua.org
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