Planes, flames and corporate greed

and some parallel questions on setting healthcare priorities.

The emergency landing of a Qantas flight in the last 24 hours has triggered Slicer to vent on the veneer of concern for passenger welfare exhibited by the airline industry. That is not to suggest that Qantas has been irresponsible or negligent or lacks concern and, if Rain Man is to be believed, it has been the safest carrier to fly with.  

Slicer observes this incident to be just the latest in a sequence of events – events which you might think could or should be a tad embarrassing to those in senior management in the airline industry who have been so outspoken in recent months.

Each time we board a flight we are asked to watch the safety demo closely, and study the laminated “card in the seat pocket in front” of us. Many don’t bother, and Slicer confesses to being often disinclined to watch the same dull play over and over with different actors. Even with novel approaches which capture the attention for a while,

 

interest is likely to wane as the novelty wears off. What we do not have is the opportunity to inspect the decision to fly or not to fly, or the route to be taken, or the security measures, or the pre-flight checks, or countless other aspects which impact on safety. In many ways Slicer has no problem with that – best leave it to the professionals who are in a better position and whom we trust have the requisite skills to make good objective judgments in the light of the best available information.

The serious question is, ‘are objective professionals making all the judgments pertaining to safety, or are some of these kind of judgments being made by those whose primary concern is the financial performance of their company?‘

Little over a week ago, airline officials complained bitterly about the stringency of American security requirements for planes entering US airspace, and asked for them to be relaxed. The same officials were presumably lying low when only two days later a number of bombs destined for Chicago were discovered – and one on a cargo plane on UK soil. It was almost missed during initial UK searches. One of two bombs destined for the US had travelled part of its route by passenger jet.

During the global disruption to airline travel which followed the eruption of Eyjafjallajoekull in May, passengers were inconvenienced but it is hard to see any stronger motivation in suspending flights other than genuine concern for passenger welfare. What became truly disturbing was that, the longer the disruption continued, the greater the calls from the airlines to move the goalposts of what was considered a safe level of volcanic ash in the atmosphere. Even more worrying, it appears these calls succeeded in getting the goalposts moved, presumably because governments became concerned about the economic impact of ongoing suspension of flights. No good reason for why the original cut-off for a tolerable level (arrived at by those deemed most expert at interpreting the available data) was subsequently raised have ever been presented to air travelers. Steve Ridgway, the Chief Executive of Virgin Atlantic (which lost £30 million during the disruption) is reported as saying:

“We started to just not believe the data that was coming out of the Met Office.”

 As the story of yesterday’s Qantas A380 engine explosion broke, the BBC reported:

“Qantas had no immediate comment on whether the incident might be related to eruptions of Indonesia's Mount Merapi over the past 10 days - which have prompted some flights above the volcano to be suspended.”

Pending further investigation, the putative implication of volcanic ash in the explosion of a Rolls-Royce engine on the Qantas A380 yesterday suggests that concerns remain. The airline industry’s complaints that the evidence base for given thresholds of volcanic ash are not well established cannot be a licence to disregard either whatever data do exist, or informed expert opinion in their interpretation.

Slicer can’t help but see a parallel with government disregarding the view of the scientific committees it appoints eg the view of the government advisory committee on drugs. It seems that, when it comes to setting policy or operational decisions, carefully and expertly assessed balances of risk can be set aside for political expediency or as a result of pressure from industry, motivated by financial concerns. It is unrealistic for there always to be cast-iron evidence on which to base decisions. We do have to live by faith in the skill of others in making a good call on the basis of knowledge, skills or experience – and they must be allowed to make those calls. In healthcare the demand for use of evidence, where it exists, is no bad thing: the demand also motivates good (and bad) research. However, the reality is that many things will continue to require skilled assessment of a clinical situation and clinical judgment by a suitably trained professional, in the absence of evidence. There are many things for which there will never be a robust scientific study conducted. It has been said before but it’s worth repeating: no-one wants to participate in a randomized placebo-controlled trial testing the efficacy of parachutes...

Analogies are often drawn between aeroplane safety procedures and healthcare safety procedures, and health professionals (and their patients) have no doubt benefited from the experience and lessons learned by the airline industry. Slicer is strongly supportive of fiscal responsibility and efficiency with the finite public purse in healthcare, but also sees danger in managing a national health service as a business. Emphasis on throughput and performance statistics could all-too-easily be prioritized over safety of individuals. Is same day admission for major surgery a step forward for patients? Is this practice change prompted by professionals who will do the procedures, or by a committee, with/without surgical/anaesthetic representation?

Was there not a good reason why such patients used to be admitted to hospital the day before? What is the main driver for the change? Is it an increase in throughput? Is saving the cash involved in a bed for one night in hospital a suitable justification? Is it both? Is asking the patient to spend part of the night before surgery driving to the hospital, in order to avoid the accommodation cost to the NHS, the equivalent of a budget airline choosing highly inconvenient flight times in order to save a bob or two? Budget airlines often state that, wherever they trim their expenditure, safety is not compromised.  Can that be said for the NHS? Whilst the airline companies might have the potential for corporate greed, the same charge cannot be applied to the NHS since it is a net consumer rather than generator of wealth. However, it is reasonable to ask a few questions...

 

Comments

[Annelies]

Or is someone finally taking the patients' comfort into account? I have had three "major" ops in the past few years. For the first, I was required to be at the hospital for 2.30. I was not "sick" - I had been at work the previous day! I had to get into my pyjamas and get into bed - just so the anaesthetist could come and talk to me. I spent a fairly sleepless night in hospital, so I could have an op around 3pm the following day.
The second time, I was admitted and had already been in for a week before the surgical team took over my care, and the op took place 2 days after that. However, on the third occasion, I did not have to be at the hospital until 8.30 am on the day of the op, I had previously had all the pre-op checks in the pre-op assessment unit. I had met the surgeon on several occasions. On the day of the op, I arrived.met the surgeon and his team again, met the anaesthetist, got into bed, and waitied for an hour before the surgery. I had slept well the night before, in my own bed. 5 days later, I was again back in my own bed. District nurses came and changed my dressings until I was able to make my own way to the GP surgery, where the practice nurse took over the dressing changes, removing the stitches etc.
It may be a cost saving to admit patients on the day of their procedure, but it was also a lot more comfortable for me to sleep in my own bed, in peace and quiet, to get washed in my own bathroom, to relax in my own surroundings. It is worrying enough to have to go into hospital, but I was a lot happier to be in my own home.
In the next year I will have another 2 ops - I hope that in both cases I will be allowed the dignity of wearing my own pyjamas in my own home.

[Slicer]

Sorry to hear you required surgery, but Interested to hear your variety of experience, Annelies. Day surgery has lots of advantages, if patients are properly selected and properly worked up. Slicer's understanding is that it's not appropriate for all types of surgery nor for all patients. The purpose of admission prior to surgery is not just to meet the surgeon and the anaesthetist, but to allow the latter to ensure that risk is minimised. It also allows a discussion regarding various options with the anaesthetist who will be conducting the anaesthetic on the day, rather than a generic one who might be assigned to assess patients in a pre-assessment clinic - if indeed hospitals employ anaesthetists to work in pre-assessment clinics. In many hospitals this is a nurse-led process and tests are performed on that day but results will not be available to be reviewed until some time later. If the tests turn up an abnormality, the anaesthetist may need to assess the patient or have further questions/discussion in order to achieve the best balance of risk and benefit, and ensure the patient is fully informed regarding their choice and their consent. Slicer wants to highlight that it's important that cost does not become a driver which results in admission on the day of surgery for inappropriate patients or procedures. If it's not allowed to then a lack of worry is well-founded.