This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Tony talks to us about making patient safety everyone’s responsibility, the importance of open communication and how his understanding of different global health systems has broadened his perspective on what matters in patient care.
About the Author
Professor Anthony Woolf is Director of the Bone and Joint Research Group at the Royal Cornwall Hospital. He is a consultant rheumatologist and has held honorary chairs in Rheumatology at the University of Exeter Medical School and Plymouth University Peninsula Schools of Medicine and Dentistry. He leads the Bone and Joint Monitor Project, a global health needs assessment of musculoskeletal conditions that identifies the burden through the Global Burden of Disease study. He is the past Chair of the Arthritis and Musculoskeletal Alliance UK and is Co-Chair and a founder member of the Global Alliance for Musculoskeletal Health. Tony has edited Best Practice and Research Clinical Rheumatology for over 20 years as well as serving on the editorial boards of several other journals.
Questions & Answers
Hello Tony. Please can you tell us who you are and what you do?
I’m Professor Tony Woolf and I’m a clinical academic rheumatologist based in Cornwall. I’ve been involved for many decades in advocacy for musculoskeletal health and getting greater recognition of the importance of supporting patients to do what they need and want to do. I’m interested in how we promote musculoskeletal health, prevent injuries and treat and rehabilitate patients effectively.
How did you first become interested in patient safety?
Ensuring that we don’t cause patients harm is ingrained into doctors throughout our medical training and practice, so patient safety is absolutely fundamental. However, sometimes we associate patient safety with risks, registers and reports rather than making sure we are focused on doing the right things for patients in everyday practice. For me, patient safety is a key part of ensuring people have the best outcomes in healthcare. ‘Do no harm’ involves making sure patients get the right level of care at the right time, by clinicians with the appropriate level of skills and knowledge.
Which part of your role do you find the most fulfilling?
I’ve been involved in advocating for musculoskeletal health for a long time and am pleased that its significance is beginning to get some recognition. I’m involved in an organisation called the Global Alliance for Musculoskeletal Health which was created more than two decades ago. We bring together all stakeholders, including patients, to help ensure that we are person-centred in the way we approach our work. I think patients have a crucial role to play in their care and their safety, as they are the most likely to spot risks.
I have also been involved in the Global Burden of Disease Study which demonstrates that musculoskeletal conditions are the greatest cause of disability worldwide, and we’ve been working to help people recognise why this is so significant. We still need action to ensure people get the right care at the right time, as although there are many examples of good practice and models of care, they’re not being implemented. The result is lost opportunities to improve outcomes and people living with avoidable disability.
For example, for most musculoskeletal conditions, we know that early intervention is most effective—for conditions like rheumatoid arthritis, but also for fragility fractures, back pain and many other conditions. If we delay treatment, the condition will progress. Acute back pain can become a chronic pain problem, which places an enormous burden on health systems. Rheumatoid arthritis can progress and cause irreversible joint damage, but with the enormous advances in therapy we have made in recent years, we know that this is often preventable. So we’re trying to make musculoskeletal health and the prevention of avoidable disability a public health priority.
What patient safety challenges does the health system face at the moment?
At the clinical level, individual healthcare professionals need a better understanding of what safety looks like. They operate in a system that has a particular view of safety—risk is often considered something that gets documented, reported and raised at inspections. People aren’t always equipped to consider a root-cause analysis at the individual level. I think staff are also sometimes put off reporting risks and minor things that go wrong because it’s daunting, so we miss picking up on that background noise which signals that the system isn’t safe. We need a broad concept of patient safety that encompasses everyone including patients, and not think of it as being some health and safety issue that will result in a very complex reporting procedure.
When we think about patient safety risks, not being able to provide the right care is just as harmful to people as making an error. At the moment, healthcare professionals are struggling inside the system, knowing they are not able to offer the care they would like. We don’t always think this is something we should consider a major risk, but actually it should be if we know that people are living with prolonged suffering and irreversible deterioration.
New initiatives to promote patient safety such as PSIRF are positive, but if we really want it embedded in normal practice, we need to teach people how to communicate clearly and openly. Communication between clinicians and patients is so important; I always used to say to patients, “If you’re not happy, please let me know.” We want to do everything we can to promote open discussion and usually there is a simple reason why a patient is concerned and they might just need some further explanation. Of course, some issues need to be escalated formally, but issues can be mitigated at an earlier stage if patients are able to talk openly about their concerns.
We really need to make open discussion as part of everyday clinical practice. That’s a concern I have about remote medicine; in some respects it works very well, but we are losing some of that non-verbal communication that can be very important in understanding the patient’s needs and providing the right treatment. In a remote consultation, you don’t have that ‘knowing eye’ on the patient. When assessing someone in person, you might notice that they are a bit unsteady on their feet and realise they are at risk of a fall or that they might be having some challenges with practical tasks. You might pick up that there is something else they want to ask, but they are nervous of doing so. You wouldn’t get that insight from a remote consultation.
What do you think the next few years hold for patient safety?
Patient safety is being increasingly recognised as important and there is a stronger patient voice within healthcare, which we need to encourage. But there are still major disparities within health systems and between countries in terms of patients’ ability to speak up and be listened to. The Global Alliance for Musculoskeletal Health works to promote patient engagement and advocacy, particularly in low- and middle-income countries. There are sometimes cultural barriers to speaking up, and we have to help overcome these.
I hope we will move away from patient safety being a primarily medicolegal issue—we need to be focused on improving the system and preventing the same error from happening again. Of course, there has to be a ‘stick’ that is used when things go wrong, but we want the primary focus to be on improving care.
Going forward, we also need to find ways to help the health system respond more quickly when things go wrong, rather than waiting years for a big report to be written. Often these reports make the news, but they don’t offer practical ways to deal with the issues they raise.
If you could change one thing in the healthcare system right now to improve patient safety, what would it be?
If we want safety to be central to healthcare, we need to get staff thinking about risk in everyday practice and how to reduce the opportunity for error in all the tasks they do. For example, we can put certain processes in place to help prevent falls in hospital, but we also want everyone involved to have open eyes and be attuned to spotting potential hazards. Patient safety needs to be more prominent at all levels of training for healthcare professionals.
Are there things that you do outside of your role which have made you think differently about patient safety?
Getting involved in international initiatives has shown me how much you learn from seeing how other people do things. I have been involved in a number of national and international activities trying to improve musculoskeletal healthcare and because of that, I’ve seen how many different systems work. You can identify simple solutions to universal issues and try to apply them to new systems and settings. The WHO surgical safety checklist is a good example of this knowledge transfer in action.
There are many issues that we see globally. For example, we know that if an older patient falls and breaks their hip, they are at risk of a further fracture. It is well established that they should be assessed for their fracture risk, but it often doesn’t happen. That’s because different healthcare professionals in the system feel it isn’t their role to carry out that bit of the pathway. We need clarity and simple documents that show who is responsible for each task so that people have a good journey and receive the right care, at the right time, without being harmed along the way. We know that if you have a fracture liaison service to coordinate the process, patients have better outcomes and experience, so wherever possible, this approach should be taken. I was involved in setting up the Fragility Fracture Network which is focusing on this issue.
When you’re trying to develop services in completely different settings to the one you’re used to, for example in Sub-Saharan Africa, having a global view also helps you consider what’s really important in a healthcare system. Again, the communication skills of clinicians with patients always come up as one of the most vital considerations.