Editor's Choice

Performance matters

BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7506.0-g (Published 23 June 2005) Cite this as: BMJ 2005;330:0-g
  1. Fiona Godlee (fgodlee{at}bmj.com), editor

    It must be one of the worst nightmares of any clinician or parent—the failure to recognise or adequately treat a child with meningococcal infection. Death rates from meningococcal sepsis have not changed much over the past 20 to 30 years, despite growing appreciation of the benefits of aggressive management in intensive care. Perhaps this is because most children with meningococcal sepsis present to their local hospital and many die before they can be transferred to specialist intensive care units.

    This is a disease where the quality of care really does mean the difference between life and death, as Nelly Ninis and colleagues show in their careful case control study (p 1475). The authors looked at the care given in the first 24 hours of admission to hospital, comparing children who died and children who survived, correcting for how sick the children were at presentation. Three factors were independently associated with an increased risk of death: not being looked after by a paediatrician, inadequate supervision of junior staff, and inadequate use of inotropes. A child with two of these factors was nearly 10 times more likely to die from the disease than one with none.

    Expertise, or lack of it, is confirmed in this study as contributing to poor quality of care. Age and experience by themselves are no guarantee of performance, according to a recent systematic review. The review finds that older doctors and those in practice for more years performed less well than their younger, newer colleagues. It's another argument for revalidation, John Norcini (p 1458) says, along with patients' expectations and the individual and collective responsibilities of professionals to ensure they are able to provide high quality care.

    No author in the series has argued against revalidation—it would be a hard case to make. But exactly how the system might work remains highly contentious. In the final article in our series on revalidation, Kieran Walsh and Lawrence Benson (p 1504) call for radical reform in place of the collection of reactive and short term solutions that make up the current system in the United Kingdom. We need “a strategic and fundamental reassessment of the place of professional regulation in modern health services.”

    Finally Mike Pringle (p 1515) makes a passionate appeal for a system that is more than just another bureaucracy based around the GMC's fitness to practise procedures. This would combine the ability to find doctors who are underperforming, which, he says, appraisal and clinical governance between them have so far failed to do, with clear standards of professionalism against which doctors can be judged. After so much back tracking, loss of public confidence, and defensiveness, the chief medical officer's review of the medical revalidation is a real opportunity to get things right. We should seize it.


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