Alternative universe

Could the NHS itself be making ‘never events’ more likely, asks Kevin Lewis.

Every so often – though it seems like most days – you come across a story that sounds so ridiculous that it cannot possibly be true. And then you discover that it is (both).

Like the person who took an umbrella back to the shop where they bought it, after one of the seams split open. ‘Did you get it wet?’ asked the assistant, clearly struggling to find an excuse for not exchanging the product or giving a refund. Fortunately, the customer entered into the spirit of things, replying ‘Get it wet? An umbrella? Whatever makes you think that?’ Upon which the assistant helpfully explained that the odd spot of rain would be fine but it is not designed for use in a heavy or prolonged downpour. The customer was on a roll now. ‘I hadn’t realised that. But would it still be OK to use it on a sunny day?’ The assistant thought for a moment before replying: ‘That should be fine, I would think.’

Exasperated and log-jammed early morning commuters on the cross-Pennine M62 have been advised that the best way to ensure that they get to work up to an hour earlier is to delay their journey. I have had a good think about this one, but I am still struggling to make sense of it.

Then there is the bizarre situation whereby UK fishermen are legally prohibited from catching tuna in British coastal waters, while fishermen from France (and Spain, Portugal and several other EU countries) are able to target and catch these fish legally. Speaking as someone who is particularly partial to the occasional scallop, I cannot grasp how and why a UK fisherman is prohibited from dredging for scallops in UK waters, with this ban being actively enforced by our own authorities at UK taxpayers’ expense, while the French authorities turn a blind eye to their own fishermen bringing UK scallops back to their own ports. A clue might be provided by the fact that a recent 20,000 haul of bluefin tuna out of British coastal waters by Normandy fishermen, resulted in all but 500 being pocketed by the French tax authorities. They clearly understand the rules perfectly – élémentaire, mon cher Watson.

It is equally élémentaire that GDPs working in the NHS should not be expected to give up large tranches of their time for no payment. In fact it is of course worse than that, because practice owners/providers have to shell out money for premises, equipment, staff, materials etc and foot the bill for all that themselves, just to prop up the NHS and perpetuate the illusion that the NHS pays dentists for providing NHS treatment. Trying to explain the current situation to anyone who has enough neurones to achieve a synapse, is incredibly difficult. If it wasn’t happening all day, every day in every NHS dental surgery, nobody would believe it.

Enhanced CPD

Indeed, I jumped into the back of a London taxi only last month en route to the BDA, and that destination prompted the driver to tell me that his wife was terrified of dentists and stayed away until she had a real problem. But twice in recent years she had discovered that a practice was no longer accepting new NHS dental patients. The cabbie asked me how that can be right since dentists are obviously being paid a large fortune by the NHS.

My first instinct was naturally to defend my professional colleagues and to correct his misconceptions, but then I realised this was going to be a long conversation. Two complete circuits of the M25 would not be enough to complete his education on the woes of NHS dentistry and the UDA system, so I gave him the ‘lite’ version.

To my surprise and relief, he started laughing. Uncontrollably. ‘That is ******** ridiculous’ he said, and after a further pause to draw breath, ‘Is that really true? It is ******* unbelieveable.’ He then said that because his work took him all over London and he could never be sure where he would be at a particular moment, he liked the convenience of seeing a private dentist at times when it suited him, and remembered – with another outbreak of uncontrollable mirth – that some years ago, he paid his private dentist quite a bit less for his treatment than his wife had paid an NHS dentist for her treatment in the same week.

Although he added that he had always been ‘very lucky’ that ‘strong teeth and gums’ ran in his family and his periodic brushes (excuse the pun) with the dental profession tended to be for check-ups and a visit to the hygienist. His wife was not so ‘lucky’.

His final point was so good that I started to regret not having opted for the M25 circuit. If the London Taxi License worked like the NHS dental contract, he said, he would be spending his day cruising around London bus stops, looking for passengers he could pick up and then transport free of charge to any destination of their choosing. It might be just around the corner, it might be some way down the road, or (on a bad day) it might be a long journey to the other side of London.

I congratulated him on his quick grasp of the essentials of NHS dentistry but in the interests of balance, I pointed out that not all journeys would need to be funded out of his own pocket. ‘I get that’ he said, ‘but if people pay exactly the same for journeys of different lengths, with some taking much more time, it’s not fair is it?’ ‘Not fair for who?’ I enquired. ‘Not fair for anyone – not fair for the passengers who only have short journeys, and not fair for me as I have to pay for my license, my insurance and road tax, £50k for the cab, all its maintenance checks, my annual medical, and all the fuel. That adds up to a lot of money. Why would I bother if it might cost me more than I can make in fares?’ Why indeed, I thought.

As I got out, I thought about asking him if he was paying the fare on my behalf like dentists have to do. But he had the build of a heavyweight boxer so I thought better of that. But then he said that he should be paying me for the journey, adding ‘I have learned something today.’ Always happy to do my bit for the enhanced CPD of London cabbies. You never know who they will tell next.

Never events

You may or may not have been following the discussion taking place recently in the pages of the BDJ regarding ‘never events’, which the NHS has defined as ‘wholly preventable patient safety incidents’. The latest salvo from Mick Horton (who recently completed his term as FGDP dean) and Dave Cottam (vice chair of the BDA’s General Dental Practice Committee) was a minor classic. In addition to making some sensible observations and suggestions, their letter highlighted FGDP(UK)’s efforts to establish an anonymous ‘no blame’ reporting structure for significant events so that shared learning can be facilitated whether or not you have been personally involved in such an event. But their closing suggestion was that wrongly naming ‘significant events’ as ‘never events’, was unhelpful and should itself be a ‘never event’.

Last November, in Jeremy Hunt’s former life as Health Secretary, he asked CQC to review the NHS’s management of ‘never events’. An interim update was published in July and the CQC’s final report is expected next month or thereabouts. Somewhat worrying, the CQC’s recent update states that it has been busy doing lots of ‘engagement’ and some ‘landscape mapping’ and are ‘using never events as a can opener, enabling us to look at wider pieces of safety guidance and safety practice.’ There must surely be some health and safety guidance relating to the use of can openers, and I trust that the CQC will be reviewing that too? You can’t be too careful when using can-openers.

Joking aside, CQC has already puts its finger on one of the key points raised by Mick Horton and Dave Cottam, which is that clinicians are human. Because of this, you can and should raise awareness by sharing experiences and lessons, and put checks and safeguards in place, but is unrealistic to believe that it is possible to legislate every human error out of the equation to produce a genuine ‘never’ event. So full credit to CQC in observing: ‘It may be time that we recognise the fallibility of practice, understand the tension between the concept of never events versus human factors and work to manage risks proactively rather than purely reactively.’

Would it be too cynical to ask the question of whether the NHS itself makes ‘never events’ more likely? Human error is made more likely when people are working in stressful situations, when they are tired from having to work longer than optimal hours to make ends meet (or to keep their businesses afloat), when they are distracted by inherent unfairness and unreasonable pressures in their working environment, and when they are feeling frustrated, unhappy, angry or undervalued. Sounds like the job description for primary dental care, doesn’t it?

Read more from Kevin Lewis:

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