The Ideal and the Real

In this chapter we first attempt to persuade (or remind) the reader that much healthcare departs from the care envisaged by standards and guidelines. We appreciate that standards and guidelines need considerable interpretation and adaptation for patients with multiple conditions (Tinetti et al. 2004) and that even the simplest conditions require consideration of personal preferences and other factors. However we are concerned primarily with the basic fact that the care provided to patients often does not reach the standard that professionals intend to deliver and which professional consensus would regard as reasonable and achievable. Clinical processes and systems are often unreliable and in fact many patients are harmed by the healthcare intended to help them. All this is to some degree obvious to anyone who works at the frontline or studies healthcare deeply. One of the questions we address in this book is how to manage the gap between the 'real and the ideal' and how best to manage the risks to patients.

Many factors conspire to make optimal care both difficult to define and difficult to achieve (Box 2.1). The vulnerabilities of the system, personal attitudes, team dynamics and a variety of external pressures and restraints combine to produce a 'migration' away from best practice. This in turn means that clinical staff are engaged in constant adaptation, detecting problems and responding to them. Safety is in a very real sense achieved by frontline practitioners rather than imposed by standards. We will develop this further in later chapters to argue that safety strategies to manage these risks need to foster these adaptive capacities both at an individual and organisational level.

Box 2.1 Observation of Patients at Risk of Suicide: When Working Conditions Make It Difficult to Follow Procedures

Over a 1 year period there were on average 18 suicides by in-patients under

observation per year in hospitals in the United Kingdom. Ninety-one percent of deaths occurred when patients were under level 2 (intermittent) observation.

Deaths under observation tended to occur when policies or procedures (including times between observations) were not followed, for example:

• When staff are distracted by other events on the ward

• At busy periods, such as between 7.00 and 9.00

• When there are staff shortages

• When ward design impedes observation.

National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (2015)