Letters
The aftermath of the Bristol case
Case arose through a failure of action, not of detectionDoctors should not have to fail before they are given supportSociety of Clinical Psychiatrists supports doctors who have been
suspendedBenefits of openness and teamwork must be emphasisedArmed forces need independent civilian adviser who can be
approached in confidenceDeaths are acceptable in some specialties but not allSeries of operations with low mortality may exhibit high average
mortality by chanceConcept of collective responsibility is importantGeneral Medical Council's disciplinary hearings should be
confidentialReturning contracts to regional level might prevent such casesAirline pilots are assessed every six months, so why shouldn't
doctors be?Supraregional neonatal cardiac surgery works in Western AustraliaTechniques for measuring quality of care need to be assessedStudents must be taught more about ethicsBristol case highlights potential weaknesses of Calman systemPrivate practice has similar problemsFormal mentoring might have helpedRoles of GMC, royal colleges, and Department of Health remain
unclearRoutine monitoring of mishaps would be valuable way of improving
careDoctors have surely forfeited privilege of self
regulationPoor performers will need remedial trainingCase arose through a failure of action, not of detection
EDITOR This is a strange stance for the editor of a scientific journal
committed to encouraging rational ideas in medicine. Dramas like this
(even dramas that occur more often than once in a lifetime) are
certainly "powerful levers for change." But that is not a reason
for senior medical journals to seize on them and use them to promote
pre-existing agendas of change that have only a tangential bearing.
The lesson of the Bristol tragedy, when the dust and the shouting
outside the General Medical Council have subsided, is that there was an
inexcusable failure of existing mechanisms of control. The tragedy
provides no rational support for the wholesale imposition of systems of
monitoring and control on doctors in general. Such systems may or may
not be necessary, and the BMJ should be arguing that if
they are introduced it should be only with proper testing, so that ill
effects (which I2 and others have predicted) can be
determined and weighed against the benefits predicted by Smith among
others. But that has little to do with the Bristol case. Here the
problem was not a failure of detection; it was a failure by those in
authority to take any action on the warnings that they repeatedly
received. What purpose will all the monitoring in the world serve if
society cannot respond to the shouts of warning it is already
receiving?
I have not found that the level of trust in my practice has "all
changed, changed utterly." This is partly due to patients' well
known capacity for exempting their own doctors from the strictures they
apply to the profession in general. Of course we must look for careful
progress, but this is not the time for responsible journals to indulge
in emotive polemic.
Doctors should not have to fail before they are given support
EDITOR Poor undergraduate or postgraduate training, communication
difficulties, and family or personal problems may be the basis for some
poor performance,1 but many good doctors break under the
strain of patient demand in impossible circumstances. In my specialty,
general practice, some poorly performing doctors are identified in the
leafy suburban practices, but most seem to be from the most deprived
parts of Britain, often facing a difficult task in single handed
practice. I wonder how many of us might become poorly performing
doctors if faced with a consultation rate twice the national average, a
daily diet of violent drug addicted patients, and constantly vandalised
premises.
Doctors working in these circumstances have a choice. They can try
hard It is a tribute to our profession that most doctors facing such
difficulties belong to the former group. My practice population has a
rate of chronic illness twice the national average, high standardised
mortality ratios, and a high unemployment rate, but we receive no
deprivation payments. Since the inception of the NHS no partner in my
practice has remained until retirement. Some have paid a high personal
price for their devotion to their patients. We are fortunate in being
well supported by our nursing and clerical staff, but we can see how
easy it is to be overwhelmed by workload.
I support the General Medical Council's work in detecting poorly
performing doctors at an early stage, but prevention is better than
cure. Why should we allow good doctors to be damaged by permitting the
sort of working conditions prevalent in many deprived areas? These
doctors should not have to fail before they are given support.
Society of Clinical Psychiatrists supports doctors who have been
suspended
EDITOR Thirty eight suspensions were the result of whistleblowing by
colleagues or other staff alleging professional incompetence. Ten cases
are still outstanding. Fault was proved in only two of the remaining
28. This was despite the odds being heavily against the accused doctor.
The prosecution selects and pays most of the members of the
disciplinary panel, and the burden of proof is the balance of
probabilities rather than the more rigorous "beyond reasonable
doubt."
The motives behind the whistleblowing varied. In some cases the motive
was intellectual arrogance, particularly in inbred departments. Some
colleagues regard a different style of clinical practice as
incompetence. Occasionally the morbidity and mortality of patients of
the accusers were marginally higher than those of patients of the
accused doctor. Other motives included minority intolerance,
professional jealousy, and power struggles over control of a hospital
department. Such cases are contrary to the Geneva declaration, the
United Nations declaration of human rights,1 and the
General Medical Council's ethical rules. The suspensions are contrary
to European Union law on civil rights.2 But it is easy to
dress up allegations so that an administrator suspends the doctor first
and investigates afterwards.
Suspensions and the accompanying professional isolation are damaging,
and clinical reactive depression may result; the rate of suspensions
has doubled in the past year. The Society of Clinical Psychiatrists has
established an informal service whereby a consultant psychiatrist
provides therapeutic care and if necessary a place of sanctuary
(outside the NHS, because the accused doctors do not trust patient
confidentiality under these circumstances). The society plans to
arrange this scheme more formally, involving over 200 consultant
psychiatrists. But why should such a service be necessary? The chief
executive of the NHS has said that doctors wrongly suspended should
receive financial compensation for the harm done despite his claim that
suspension is a neutral act.3
Chief executives should be aware that whistleblowing may have hidden
motives. Donaldson has shown that there is a more humane and less
wasteful way of dealing with so called difficult doctors, which does
not automatically lead to suspension.4
Benefits of openness and teamwork must be emphasised
EDITOR I feel ashamed to be a member of such a profession. The autonomy
of the individual seems to be so important that suspicious fellow
professionals have to take draconian steps with obvious damaging
effects to the whole of the medical profession before something can be
done. I would opt for the "less punishment but less crime"
option Through initial and continuing medical education, universities and
professional bodies should teach professionals the benefits of openness
and teamwork. Emphasis should not be put on the ability to cope on
one's own without recourse to colleagues. How often have anaesthetists
like me had to intervene by sending for a more senior surgeon because
the junior surgeon performing the operation thought that he or she
would lose face in doing so? In an atmosphere where teamwork was the
accepted norm, perhaps Drs Wisheart and Dhasmana would have considered
that they could ask for the help and additional training (or careers
advice) that they so desperately needed.
So where were the professional bodies of the surgeons and
anaesthetists? We who elect their officers may wish to ask where they
will be for us. Would we wish them to ignore our minor problems as they
grow and speak only when the General Medical Council has pronounced on
our case? Of course it is terrible to be falsely accused, especially
when there seems to be little difference between absolute denial of the
problem and formal proceedings. Discreet inquiries and perhaps an
invitation for Drs Wisheart and Dhasmana to go on sabbatical to a
centre with higher survival figures (if comparable), long before the
problem got out of hand, would have been the best answer for both
sinned against and sinners.
Doctors must stop the "I can cope on my own" routine and start a
new era of openness.
a
rachael_dawson{at}mcmail.com
Armed forces need independent civilian adviser who can be
approached in confidence
EDITOR A few years ago I was a junior in the armed forces. One of the
consultants had a high complication rate for one procedure, and I was
seriously concerned for the safety of his patients. My own consultant
was aware of the problem and even joked about it. The consultant
outranked me both professionally and militarily. Challenging the
conduct of a superior is fraught with danger; as well as jeopardising
one's career, one faces a real risk of being charged with
insubordination. There was no mechanism by which I could safely express
my concerns. Had I done so I am sure that the consequences for me would
have been serious.
Had there been an independent civilian adviser who could be approached
in complete confidence I would certainly have blown the whistle on this
consultant.
Deaths are acceptable in some specialties but not all
EDITOR A tenth of people with major depression and schizophrenia commit
suicide. Do we really believe that all these deaths are avoidable? Many
people have struggled bravely with distressing symptoms, a restricted
life, and stigma from society over many years before choosing to die.
Does major mental illness have a core mortality that cannot be
decreased even in the best resourced and best run service? Are we
holding people responsible, and even driving them out of their chosen
specialty,2 for adverse events that they can do little to
influence? I suspect so.
Series of operations with low mortality may exhibit high average
mortality by chance
EDITOR
When an individual surgeon's performance of a particular operation is
being assessed a series extending over several (or perhaps many) years,
beginning at consultant appointment, would be needed if the assessment
is not to be distorted merely by chance. If, as Poloniecki suggests, a
second assessment period might be required (maybe after a complaint to
the General Medical Council) the delay before professional conduct
could be properly assessed would be absurdly long. Little seems to have
been done to collect any data (complete or even estimated by sampling)
on national average mortality for specific major operative procedures
except in cardiothoracic surgery.
The public's interest in the performance of individual surgeons is
understandable. But for politicians and some health economists to have
pretended that an assessment based on a comparison of individual
surgeons' crude mortality with national averages will improve the
public's confidence in the NHS seems about as sensible as proposing to
dispense justice by using the random number generator of the National
Lottery.
Concept of collective responsibility is important
EDITOR Focusing in isolation on individual consultants' performance is a
retrograde step. In contrast, effective communication and collective
responsibility are behaviours that remove divisions and optimise the
quality of an organisation. The absence of barriers within an
organisation engenders a natural openness and confidence in its
dealings with its customers. Each patient should have unequivocal information about the results of an organisation (trust or department) as a whole. The availability of institutional or departmental data
engenders collective responsibility; the availability of data for an
individual does not. If the concept of collective responsibility is
acquired by independent professionals (nurses and doctors in the NHS)
the organisational disaster that occurred in Bristol will be prevented
in the future.
General Medical Council's disciplinary hearings should be
confidential
EDITOR The council may have part of the remedy. There does not seem to
be a good reason for allowing an interval of over two weeks between the announcement by the council of its findings in the cases
brought against the three doctors and the final hearing to decide on
their fitness to practise.
Returning contracts to regional level might prevent such cases
EDITOR A situation in which clinicians and members of the employing
authority work together on a daily basis in a relatively closed community may well lead to problems: the natural tendency of an autonomous organisation is to close ranks when faced with possible adverse publicity. The courage, persistence, and career sacrifice required of a person who is prepared to step out of line in the interest of patients have been clearly shown.2
A return to the system in which our contracts were held at a higher
level, such as the region, would be a simple and inexpensive measure
that would help prevent such situations developing to the point of
disaster. The Bristol case is the most publicised such case, and
rightly so because of the loss of young lives. But there have been
several other places where long and damaging disputes have built up
because the case had become "too local" and personalities were too
important.
Airline pilots are assessed every six months, so why shouldn't
doctors be?
EDITOR My husband is an airline pilot, one of a group of professionals who are
carefully monitored. Every six months he is assessed by a senior
training captain in a flight simulator. The simulator test includes a
variety of technical and managerial problems. Pilots who fail it have
to go through retraining. Those who continue to fail can no longer fly.
This system seems appealing to me. After all, it would be ridiculous to
monitor the number of passengers whom a single pilot had killed in
comparison with his colleagues before action was taken to remedy his
flying skills.
In medicine we need regular assessment of our skills by respected
and senior colleagues. Such a system has been started for public health
doctors in the West Midlands. The quality of the work we do and the
effectiveness and efficiency of the management in our departments are
reviewed annually. I for one would rather be told that my professional
skills were not suitably in line with modern standards, should this
ever be the case, before the population of Shropshire began to die
unnecessarily as a result.
I agree with the BMA that self regulation is
important2 and that our professional skills should be
assessed by other doctors in our specialty. If doctors were unable to
listen and heed advice during such processes, however, then management
would have to act. I cannot believe that an airline would allow pilots
to continue flying its passengers if, after assessment by their
senior professional colleagues, they were considered unfit to fly.
Supraregional neonatal cardiac surgery works in Western Australia
EDITOR The distance between the hospitals is nearly 3000 km, and the trip
lasts six hours. The infant travels in a transport incubator with
inbuilt ventilator and infusion pumps attached. Monitoring is by
electrocardiography and pulse oximetry, with blood pressure and blood
gas tensions being measured. The medical escort is a paediatric
registrar or consultant or a neonatal intensive care nurse, or both.
The infant's parent(s) usually travel on the same flight.
We have recently conducted an audit of 10 years of interstate
transports to assess mortality and morbidity.2 The largest subgroup in this audit comprised 46 patients with transposition of the
great arteries. The first arterial switch operation was performed in
Melbourne in 1983. The unit currently performs an average of 30 switch
operations each year, in a catchment population of 10 million. Between
January 1986 and December 1995, all 46 patients with transposition of
the great arteries had the arterial switch operation. Of these
patients, seven were ventilated and 17 had prostaglandin E1
infusions. The one year survival was 100%, and the current cohort
survival is 98% (45/46). This compares favourably with quoted rates in
Treasure's editorial.1 The youngest patient in this group
is now 21/2 years old and the oldest 12. Initial developmental
follow up data on 43 of the patients shows a 7% incidence of important
problems, three patients having borderline intellectual function or
hemiplegia, or both. Again, such figures compare well with those in
other published reports3 and show that Western Australians
are served well by current management with supraregional
transfer.
The financial costs of interstate travel and accommodation for the
parents are paid by the state health department. Although the parents
of infants who are transported over ultralong distances suffer
additional emotional costs, they benefit as a group from the excellent
survival rates of their infants.
b
patrick.pemberton{at}health.wa.gov.au
Techniques for measuring quality of care need to be assessed
EDITOR It is disturbing that a failed suggestion from the United
States I applaud and support any research into how quality should be
measured. But it is research and should be subjected to the same rigour
as a new medicine is. Is there evidence that quality is measured? Is
outcome improved? And, as for any new product, what is the cost? At
present, such expensive and time consuming techniques are not developed
enough for general use; as for any medical advance, we should wait for
the evidence base that these procedures do improve quality of care and
are cost effective.
Students must be taught more about ethics
EDITOR It is the sorrow and anger caused by doctors to real, live people
that self regulation must address. Patients with all their emotions
have to be at the centre of self regulation Last week I met a couple who had just been told that it would take the
General Medical Council at least 12 months to decide whether to start
disciplinary proceedings against a doctor. A year or more, that is, not
from the time of their complaint but from delivery of a dossier that
they had assembled at its request. The dossier consists of nearly 1000 pages of evidence supporting their complaint that one of their children
died, and another was left severely brain damaged, as a result of being
used without their consent in a research project.
Nor does the editorial give hope that the General Medical Council will
better fulfil its statutory responsibility for medical education so
that doctors will be trained not to abuse and misuse their patients.
One possible approach is to teach students more of the humanities and,
in particular, about ethics. Recognising this, the council instructed
medical schools to teach medical ethics over a decade ago. Yet it has
not withdrawn approval from those schools that still have no regular
medical ethics teaching, one of which (the Middlesex/University College
London) is right on its own doorstep.
If leaders of the profession are incapable of recognising the
centrality of patients and their experiences to self regulation, this
extraordinary privilege will be taken away from us.
c
Bulletin_of_Medical_Ethics{at}compuserve.com
Bristol case highlights potential weaknesses of Calman system
EDITOR How does the Calman programme of specialist training fit these new
demands?3 In many specialties the time available for training has been reduced. Additionally, on call rotas are being made
less onerous as a result of European Union directives. Although training schemes are becoming better structured, these measures may
lead to young specialists being well trained but less experienced than
young specialists were previously. As a result, training posts have
been set up for doctors who have gained a certificate of completion of
specialist training. Another challenge will be for consultants to
demonstrate their track record to patients and purchasers of care. How
will a newly appointed specialist be able to do this without a
sustained period under the proctorship of a more senior established
colleague? Does this mean that "junior" consultants are inevitable?
The Bristol case highlights a further potential weakness of the
Calman system in that some of the poor results were attributed to one
surgeon having received most of his training under a senior colleague
who himself later came under scrutiny. Previously, specialists spent
time in two or three centres; in the Calman system a specialist's training might well be centred in one region. Therefore rotations are
vital, and exchanges with other centres in different regions and
travelling fellowships overseas will become important.
Close audit of both the trainees' and the trainers' case mix and
outcomes is essential. This might best be supervised by the appropriate
specialist society under the aegis of the royal colleges and
postgraduate deans. This will particularly apply to complex and
subspecialist work, for which the first direct exposure might previously have been as a newly appointed consultant. Supervised training has implications for time, resources, and throughput of
patients. How will established consultants acquire new skills and
techniques safely? Proctorships and sabbatical leave to other centres
followed by close audit may be the only acceptable solution and yet
have many consequences for the provision of services.
The training of specialists presents the medical profession with major
challenges. Failure to meet these will jeopardise the whole ethos of
self regulated postgraduate medical education.
Private practice has similar problems
EDITOR It was reported in BMA News Review that private
practice could come under scrutiny by the Commons health select
committee during the next parliamentary session, and David Hinchliffe
MP was quoted as saying, "There is serious concern that certain
operations, primarily in the private sector, are not performed by those
sufficiently qualified to do so." I would suggest that unnecessary
operations are a greater problem, some being performed by doctors who
have had only basic training in the techniques while they were passing though a specialty.
The Bristol case has given every chairman of every medical advisory
committee of every private hospital a great responsibility What does one do if a colleague who is not an orthopaedic surgeon
or hand surgeon operates on Dupytren's contractures, or a colleague
who is not a plastic surgeon performs breast reductions, or a colleague
who is not a gynaecologist inappropriately operates on genital
prolapse? What do you do if a colleague always finds something to
operate on no matter what the patient is referred with? And what do you
say to the anaesthetist who always puts in a regional block as well as
giving a general anaesthetic in order to bump up the fee? It astounds
me that the medical insurance companies themselves have not policed
these sorts of activities in order to reduce their own financial
outgoings. All of these examples are observed every week by all of us
who have our eyes open. Worse, they are obvious to our nursing and
paramedical colleagues, who wonder why we are doing nothing to correct
these anomalies.
Smith concluded his editorial with the spectre of micromanagement of
doctors. It is therefore urgent that we put our own house in order and
do not lose the impetus for change that the Bristol case has produced.
Formal mentoring might have helped
EDITOR We need to help doctors by providing a much more structured form
of mentorship or supervision to support them in the work they do.
Otherwise we will continue to use our informal mentors of family and
friends to share this load. If some formal mentoring or supervisory
system had been in place for Mr Wisheart and colleagues, these doctors
might have been able to express their anxieties and concerns about
their surgical work; formal steps might then have been taken to address
these issues. The current system clearly fails and does not allow such
expression.
Roles of GMC, royal colleges, and Department of Health remain
unclear
EDITOR The differing roles of the General Medical Council, the royal colleges,
and the Department of Health in relation to the accountability of
doctors remains unclear. The "rapid response" system being set up
by the Royal College of Surgeons is clearly a step forward, but whether
royal colleges will be able to set up organisational structures robust
enough for rigorous peer review remains to be seen.
Routine monitoring of mishaps would be valuable way of improving
care
EDITOR Death is the easiest outcome to record; other adverse outcomes
such as symptoms and disability are impossible to monitor routinely without a vast increase in resources. The cause of death is often uncertain and may be unrelated to the stated diagnosis. Necropsies are
essential to determine both the cause of death and the accuracy of the
original diagnosis, but rates of necropsy are low2 and, because of the shortage of pathologists, unlikely to increase. Death
rates will be meaningless unless data on both diagnosis and cause of
death are accurate. Moreover, few conditions have sufficiently high
death rates for comparisons to be statistically valid. Collection of
data for comparison between hospitals can thus have only a limited
place. Improved internal audit and external peer review are far better
options, and our royal college could have a strong role in both.
Routine monitoring of mishaps would be a valuable way of improving
care. Many errors occur that are known only to the clinical staff
involved unless a formal complaint is made or an incident form
completed. Doctors may not be informed of their errors because of
shifts, transfer of care to another team, or the problem being discovered after discharge. Mismanagement may be identified by other
units in the same hospital or elsewhere.
3 4
Adverse outcomes may be due to delays,3 problems with
communication and filing, or lack of resources, especially of nurses
and beds. Staff must be encouraged to report untoward events. The
information can be used to identify repeating problems and areas for
audit, to improve organisation, and to enhance education and audit. It would also strengthen the case for more resources.
Doctors have surely forfeited privilege of self
regulation
EDITOR Poor performers will need remedial training
EDITOR Assessment, conducted by trained assessors, comprises interviews with
the doctor, evidence from third parties (complainants and colleagues),
and review of clinical records. A second phase will include objective
tests of knowledge, attitudes, and skills. The assessors may recommend
a period of remedial training. If the doctor is unable to improve or
refuses to cooperate with a process of remedial training, suspension of
his or her registration may occur.2 But the remedial
process is not clear.
Although there is a recognition that the postgraduate system
"is well placed to offer advice and practical
support"3 and an assumption that it will do
so,4 there is no requirement to do so and no clear
guidance.5 How realistic is this assumption? Providing
remedial education is likely to be a highly specialised task but
unfamiliar to most educationalists. Should they accept this role?
The need to provide remedial training will probably occur infrequently.
But the low numbers envisaged mean that no one is likely to gain enough
experience to provide acceptable remedial training in his or her field.
The issues involved in mentoring, monitoring, and documentation are
vague, and providing protected time for supervision has high
opportunity costs. Poor performers are also likely to have complex
problems, including conflicts within professional relationships.
The General Medical Council's firm lead on professional self
regulation is welcome progress towards the setting of minimum standards. But identification and assessment are only the start. Remedial training has received little attention so far. Although some
debate continues about funding,4 poor performers are
widely expected to be responsible for the costs. Why should the
taxpayer contribute twice to the establishment of a minimum level of
professional competence? The most likely result of facing the
performance procedures will probably be a swift move towards early
retirement. So why bother setting up complex, expensive facilities for
remedial training?
d
elwynG{at}cf.ac.uk
Smith refers to "key protagonists overreacting" in his
editorial on the Bristol case.1 He joins "even the
strongest supporters of the Labour government" in bemoaning "its
excessive concern with media opinion." Yet he tells us (and, from his
privileged platform, the world) that this case is a "once in a
lifetime drama..., Shakespearean in its scale and
structure," which will have the result that "the trust that
patients place in their doctors...will never be the
same again."
Alton Health Centre, Alton, Hampshire GU34 2QX
The Bristol case has highlighted the need for a system of
detecting and rehabilitating doctors not performing to an acceptable
standard.1 The General Medical Council's plans for such a
system combine, comprehensively, fairness in the process while
attempting to secure the safety of the general public.2 Finding these doctors is important, but surely we should ask why we
have poorly performing doctors at all.
and it is hardto provide the same service to their patients as
doctors in more affluent areas provide; they can do this by cutting
their list sizes (and of course their incomes). Alternatively, they can
do the minimum, developing a siege mentality to protect themselves from
patients demanding services they can't provide. This isn't why they
became doctors, and gradually they become demoralised and switch off.
Ashgrove Health Centre, Blackburn, West Lothian EH47 7LL
The Society of Clinical Psychiatrists has data on 171 suspensions of senior hospital doctors. Enough details were obtained on
135 completed cases for us to determine the principle trends. In only
22 were the suspensions proved justified; 110 doctors had been wrongly
suspended and either had to be reinstated (58) or retired (52) as part
of an expensive settlement; and three doctors died as a direct
consequence of the suspension.
Society Clinical Psychiatrists Study Group, Downton, Wiltshire
SP5 3HJ
I believe we must not condemn the actions of "bad doctors"
as if they are isolated felons who take the responsibility entirely for
themselves. Drs Wisheart and Dhasmana and those who chose to ignore the
problem were or are part of the establishment1an establishment that indirectly allows problems to go unchecked.
that is, a climate where small problems can be aired
quickly and easily and no one is allowed to be totally isolated and
autonomous.
Department of Anaesthetics, Queen Elizabeth Hospital, King's
Lynn PE30 4ET
I was interested to read the comments by "the great and the
good" on the dilemma of the junior surgeon with an underperforming consultant.1 The guidance from the General Medical Council and the Senate of Surgery of Great Britain and Ireland is
clear.
2 3
In reality, however, whistleblowing may not be
an option.
Appropriately, we accept a certain failure rate in cardiac
surgery.1 We generally believe that oncologists have done
their best when their patients die. Psychiatrists and mental health
teams, however, are put under tremendous pressure to prevent all deaths
in their patients and receive blame and censure when their patients
die.
Herefordshire Community Health NHS Trust, St Mary's
Hospital, Hereford HR4 7RF
Poloniecki showed some of the difficulties that may seriously
mislead when perioperative mortality statistics are being interpreted.1 He chose an example from cardiac surgery, a
high risk specialty with a national average perioperative mortality of
25%. Those difficulties are much increased and new ones are introduced
when mortality in most other surgical specialties is assessed because
the average mortality for major elective procedures is usually much
less that 4%. In 1988 a colleague and I showed that even large series
of operations with a low mortality may exhibit two or three times the
average mortality by chance alone (table).2
Wynd House, Hutton Rudby, North Yorkshire TS15 0ES
In the wake of the General Medical Council's findings on the
three doctors in the Bristol case, Klein and the media pose the
question whether information regarding the performance of individual
consultants should be available to the public.1 This is at
a time when consultants, particularly cardiothoracic surgeons, feel
isolated, vulnerable, and subject to blame. Focusing excessively on
individual performance promotes risk averse behaviour throughout the
NHS. Risk averse behaviour encompasses views such as "although
professionally capable, I am not going to do this because I might be
blamed for something." Such risk averse behaviour will lead to
barriers within the NHS: doctors versus nurses, doctors versus
managers, doctor versus doctor, and ultimately doctor versus patient.
Barriers within an organisation allow blame to be shifted away from the
many on to a few.
North West Lung Centre, Wythenshawe Hospital, Manchester M23
9LT JJGEgan{at}aol.com
The quasi-judicial style of the General Medical Council's
disciplinary proceedings, which were much publicised in the long
running Bristol case,1 seems to have much in common with the procedures followed in the courts. It is therefore a matter of both
surprise and concern that, unlike the embargo on press comment for
court hearings, the media can indulge in speculative comment before a
council's hearing has been completed, the verdict of the disciplinary
committee has been announced, and professional misconduct has been
established or refuted. The General Medical Council needs to retain the
confidence of the profession and the public as it addresses the crucial
issue of self regulation for doctors. If the outcomes of its
proceedings are to be seen as fair and balanced rather than as trials
by the media, this loophole must be closed as a matter of urgency.
National Blood Service Lancaster, PO Box 111, Royal Lancaster
Infirmary, Lancaster LA1 4GT
Much has been written in both the medical and the lay press
about the Bristol cases.1 Proposals have been madesome sensible, some less soto ensure that such a situation does not recur.
I have seen no mention, however, of what I believe to have been an
important contributory factorthe moving of consultant contracts to
hospital level as part of the setting up of trusts.
NHS Consultants' Association, Great Bourton, Banbury,
Oxfordshire OX17 1QH
Seeing the television coverage of the angry crowd's reaction to
James Wisheart and his discredited surgical colleagues1 prompted me to voice my concern about measuring deaths to improve surgery in England. Waiting for a surgeon to kill enough people until,
after standardisation for case mix and severity, the death rate of his
patients is statistically higher than that of colleagues, is like
shutting the stable door after the horse has bolted. At this point many
patients would have died and the surgeon's professional reputation and
probably whole life would have been irreparably destroyed.
Shropshire Health Authority, Shrewsbury, Shropshire SY3 8XL
Having read Treasure's editorial about the lessons to be drawn
from the Bristol case,1 we wish to put the case for supraregional neonatal cardiac surgery despite extreme distances. Western Australia has a population of 1.8 million with an incidence of
congenital heart disease of 7.65/1000 live births. A mean of nine
infants a year require cardiac surgical intervention with cardiopulmonary bypass in the neonatal period. These infants are transported in commercial aircraft by the Western Australian Neonatal Transport Service from Perth to the Royal Children's Hospital,
Melbourne.
Patrick J Pemberton
Jim Ramsay
Princess Margaret Hospital, PO Box D184, Perth, 6001, Western
Australia
I agree that we should be concerned about providing the best
quality care possible, and we should do what we can to improve health
care. But hard questions should be asked about the planned solutions to
the Bristol cases. It is easy to jump on the Bristol
bandwagon1; what happened there was wrong, but will the
suggested solutions improve health care? And would they have prevented
what happened?
publishing hospital mortality league tablesis the prime consideration.2 The concept of a Commission for Health
Improvement is likewise noble, but inspecting hospitals every three or
four years indicates a role similar to that of the Office for Standards in Education in Britain, which has been criticised for expensive and
contradictory outcomes. Attempts in the United States to measure quality of care have foundered, usually because of inability to take
account of severity of illness.
2 3
When attempts to stratify for disease severity are used, major limitations become apparentfor example, the data collected are amenable to manipulation, are unreliable, or ignore important outcome variables.4
Stoke Mandeville Hospital NHS Trust, Aylesbury,
Buckinghamshire HP21 8AL
what is it?
N Engl J Med
1996;
335:
891-894
Taken with his letter in a previous issue,1
Johnson's editorial on self regulation is another nail in its
coffin.2 His concern in "making self regulation
credible" is to make it credible to doctors, not the public. In his
letter he complained that the BMJ's use of a photograph
of a bereaved Bristol parent sensationalised the issue.1
Maybe he saw only the model coffin in the picture. But doctors need to
be reminded of the depth of sorrow and anger in that mother's
eyesthe natural response when your child died unnecessarily.
not some mechanically
performed peer review. Johnson's editorial may read well in the
corridors of medical politics, but it gives no comfort to patients
trying to deal with the General Medical Council.
Bulletin of Medical Ethics, London N5 1LA
The Bristol case has implications for clinical governance,
audit, management, and the provision of services,
1 2
but
what are the implications for specialist training? Having a
rigorous training before acquiring independent contractor status is the
ideal way to ensure high standards, as is acquiring self directed
skills of learning and self criticism. Although this represents the
traditional method of training in the United Kingdom and has generally
led to a fairly high standard, some changes are now inevitable.
Royal Halifax Infirmary, Halifax HX1 2YP
I applaud the sentiments in Smith's editorial, but the focus
seems to be on NHS medicine.1 An equal focus should be
applied to private practice, where the motivation for inappropriate and
excessive treatment is financial.
that of
"policing" his or her colleagues' activity in the private sector. Moral support and advice are readily available from the General Medical
Council, as I have recently found, and the medical director of the
local NHS trust would also be an appropriate person to speak to.
Pinehill Hospital, Hitchin, Hertfordshire SG4 9QZ
One additional point that I think needs to be made after the
Bristol case1 is how we are adequately to support doctors, particularly consultants. Senior doctors and particularly consultants (in all specialties) carry enormous loads; these are not only of basic
clinical care and decision making but also managerial and educational
roles; counselling roles for both patients, their families, and junior
doctors; terminal and palliative care; and many other endless demands.
In many other professions sensible arrangements have been made
about mentorship and supervision of work in order to support people
doing these difficult jobsfor example, in social work and psychology.
Department of Medicine for the Elderly, Brighton General
Hospital, Brighton BN2 3EW
As Treasure and Klein point out, one the main questions arising
from the Bristol inquiry is why so many warning signals went
unheeded.
1 2
In particular, although audit data from the
United Kingdom cardiac surgery register seemed to raise questions about
the performance of the Bristol unit, they were not acted on. In some
ways this is not surprising. When audit was first introduced there was
great reluctance to associate it with policies for professional
accountability. One of the consequences was that royal colleges had no
mechanisms in place to act on the findings of the national and regional
audits they commissioned. Research on the audit programme of the Royal
College of Physicians, undertaken in the early 1990s, found that audit
had the characteristics of a research activityowned by the
individuals undertaking the work, disseminated by them through
publication in journals, and presented at scientific
meetings.3 At that time the Royal College of Physicians
had no organisational mechanisms for dealing with the findings of
audit.
8 Ellesmere Road, London NW10 1JR
Smith states that cardiothoracic surgeons are well ahead
of the pack in providing data on performance and that non-surgical specialties "are going to have to think hard and fast" about how to
follow suit.1 Outcomes in medical specialties relate to diagnoses and treatments that are less clearly defined than operations. An accurate diagnosis based on agreed standard criteria is essential if
valid comparisons are to be made. Comorbidity and other confounding factors must also be recorded. These constraints require both the
diagnostic process and coding to be comprehensive and reliable, which
they are not. Diagnoses may be uncertain and remain so, or provisional
and clarified only after discharge.
King's Mill Centre for Health Care Resources, Sutton in
Ashfield, Nottinghamshire NH17 4JL
The General Medical Council's ruling concerning the paediatric
heart surgeons in Bristol must raise the whole question of the
propriety and effectiveness of self regulation by the medical profession.1 I would suggest that the signal failure by
senior members of the profession to provide support for and ensure the health and welfare of so many of their junior hospital staffoften putting patients' safety at riskmust now result in forfeiture of the
privilege of self regulation.
28 Fitzwarren Gardens, London N19 3TP
Who will help "poor performers" back into practice?
This is a question that, curiously, seems to be skirted. The General Medical Council is now empowered to assess a medical practitioner's performance after valid concerns have been expressed by patients, peers, other clinicians, or health management about a doctor's clinical practice. The advice is clear: a doctor should "act quickly to protect patients from risk."1 Removal from the
medical register for not doing so is possible. The publicity about the
Bristol case does not help matters. Although whistleblowing remains
awkward, attitudes are changing: silent tolerance of poor clinical
practice is no longer considered honourable.
Malcolm Lewis
University of Wales College of Medicine, Cardiff CF4 4XN
© BMJ 1998
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