Priority health issues highlighted

In his latest annual report, the Chief Medical Officer Sir Liam Donaldson identified several key areas where he believes the Government and the health service should focus their efforts, including: the use of simulation technologies to enhance patient safety, the need to address increasing antimicrobial resistance, the reduction of alcohol consumption through an increase in prices, the development of effective strategies to treat and screen for prostate cancer, and the advancement of interventions to improve the management of chronic pain. The report highlights the potential contribution of simulation training in improving the safety of surgery – particularly in light of the decreasing “hands on”, surgical experience available to junior doctors as their working hours are reduced. Sir Liam Donaldson pointed out that today’s doctors are exposed to fewer patients than their predecessors and suggested that simulation-based training could hold the key to bridging the skills gap in the future. He added that surgeons trained in this way make fewer errors and carry out technically more advanced procedures, citing research by Imperial College London which showed this to be the case. One study observed surgeons operating on pigs to remove the gallbladder. Surgeons who had completed simulation training were twice as fast at completing the task and twice as accurate as those who had not. A trial in Sweden also demonstrated that junior surgeons who had been given virtual reality training for keyhole surgery made significantly fewer errors than their peers who had not. Their colleagues made, on average, three times as many errors and took 58% longer to carry out an operation. Despite these benefits, access to simulation training is limited in the NHS. Sir Liam Donaldson commented: “While simulations and simulated tasks to develop skills are established in many medical training centres in this country, some other parts of the world are far ahead of us. “Many doctors attending simulation courses (including those for lifesaving resuscitation) are now having to pay for them out of their own pockets and struggle to be released from service commitments to attend. Simulation offers an important route to safer care for patients and needs to be more fully integrated into the health service.” Sir Liam made a number of recommendations, stating that: • Simulation-based training should be integrated and funded within training programmes for clinicians at all stages. • A national centre for simulation should be established to maintain and disseminate leading-edge methods and new developments. • A skilled faculty of expert clinical facilitators should be developed to deliver high-quality simulation training. • Each medical Royal College should identify a lead for simulation training. • National Patient Safety Agency serious incident reports should be made available to simulation centres to embrace learning to prevent such incidents in the future.

Antimicrobial resistance

 Sir Liam Donaldson highlighted the potential problems posed by increasing antibiotic resistance and pointed out that inappropriate and unnecessary use has reduced their effectiveness. “In some diseases, because of resistance, the last line of defence has been reached,” he warned. “Even though these drugs are becoming less effective, fewer pharmaceutical companies are developing new antibiotics because of the low profit yield.” He provided an insight into the “resistance picture” in England. For example, in treating E. coli, resistance levels to the antibiotic cefotaxime have increased from 1% to 12% in the last 10 years. Neisseria gonorrhoeae, a sexually transmitted bacterium, has shown increased resistance to both ciprofloxacin and azithromycin. Increasing, and worrying, levels of resistance are developing in other bacteria, including klebsiella and campylobacter. In some cases, such as some resistant Acinetobacter baumannii and certain extended spectrum beta-lactamase (ESBL) producing bacteria, there are only one or two antibiotics left that work. Sir Liam Donaldson said that, although steps have been taken to control antibiotic usage, recent moves to make certain antibiotics available from pharmacists without prescription should be extended “with caution”. Azithromycin, an antibiotic used to treat chlamydia, can now be purchased without prescription, provided there is a positive test result for the disease. “Although this is an innovative way to deal with the considerable public health implications of chlamydia, further moves to widen access to antibiotics without prescription will need to be balanced carefully against the risks of promoting greater resistance,” he commented. Sir Liam called for: • Existing public education campaigns about responsible use of antibiotics to be raised in profile, in line with practice in some other European countries. • Antibiotic packaging should carry a warning, reminding people of the need to take them responsibly and appropriately. • No further classes of antibiotics should be made available without prescription unless there is careful consideration of the potential public health consequences. • Novel ways to stimulate research and development of new antibiotics should be found. • There should be a ban on the use of certain types of antibiotics (quinolones and cephalosporins) in animals, in order to protect their activity in humans.