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The BMJ Interview: Sir Liam Donaldson

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Interview

British Medical Journal

Interview : Sue McGregor

 SUE MACGREGOR (SM) - Sir Liam has been England’s Chief Medical Officer since 1998, in fact he is the 15^th person in the post since it was established in 1847. He is also the UK government’s chief medical adviser holding critical responsibilities across the whole field of health and health care, advising the Secretary of State for Health and the Prime Minister. His tough and straight talking approach has allowed him to push through some radical changes in medical training and CPD, Continuing Professional Development. He has not been afraid to take on some of the sacred cows of medicine—how doctors are regulated and how patients are protected. He has been involved in some of the highest profile and most uncomfortable moments for the medical profession recently. He was, for instance, at the heart of the audits into Harold Shipman’s practice, the Bristol children’s heart surgery enquiry, and the retention of children’s organs at Alder Hey. He has brought a diverse mix of experience to the role; he has practiced as a GP, a surgeon and a public health physician. Add to this his work as a manager and a medical academic, and you have a pretty wide spectrum of interest for a Chief Medical Officer. He might even feel more than qualified to take on the job, it is rumoured his heart’s really set on, managing his beloved Newcastle United. Sir Liam Donaldson, welcome to the BMJ Interview.

LIAM DONALDSON (LD) - Thank you.

SM - Can you make any comparisons between managing a top football team and managing health for the UK?

LD - Well I think they are both very very stressful jobs. Both require somebody to maintain a positive outlook because there are so many negatives around. I think it is important when you are trying to persuade people about some of the lost causes that public health people have to pursue to remain positive, so there are some similarities. But I guess being serious about it, the job I have got is a dream job really in that I am responsible for the health of a very large population and I have the opportunity to do something that, when I was in clinical medicine I never thought I’d be able to do, which is to influence not just the health of a series of patients coming to see me one by one, but potentially hundreds of thousands or millions of people.

SM - But like a top football manager you have always got people on the side line sort of shouting advice to you, and I hope that’s not quite what we are going to be putting you through on this podcast, but we have got various people who would like to talk to you, and the first person to put a question to you, and we’ve had a huge response by the way via our website bmj.com, from around the UK and indeed other parts of the world. The first person on the line is Josef Milerad who is Scientific Editor in Chief of the Journal of the Swedish Medical Association. Hello Josef.

JOSEF MILERAD (JM) - Hi.

SM - Hello, you’ve got a question for Sir Liam.

 

JM - Yes I do. In Sweden, like in most other European countries, we do not have a position of Chief Medical Officer. What is the main benefit of having one?

LD- Well I think Sweden has a similar post of chief medical adviser within government. I agree that it is not structured exactly as in the UK, but essentially I think it is very important that somebody with a medical qualification and with an outlook on the population’s health sits at the centre of government. As was said in the introduction, it is a post that’s been in existence now for more than 150 years and it is unique in the sense that it isn’t a political appointment, and so I transcend party politics, but at the same time I have to work corporately with the government policies of the day and most of the time that works very very satisfactorily. But there are occasions, and they are not very common, when I actually have to disagree with my employers in quite a public way. And I have always said that I try to, there are three Constituencies that I respond to, one is the government whom I am working for, the other is the medical profession and I try to reflect their views within government and the third is the public, but if there is ever a conflict of interest then it is the public that has to win.

SM - Josef Milerad, was lying behind your question maybe the rather cheeky thought that Sweden can do perfectly well without a chief medical officer?

JM - I guess we have been doing fine so far but Professor Donaldson’s argument had convinced me that maybe we should consider having such a position.

SM - Alright Josef Milerad, thanks very much. Sir Liam, you have made a pretty good case for the retention of a CMO and that he or she obviously has plenty to do and plenty of responsibilities. But we have had a lot of doctors e-mailing into the BMJ website saying that the NHS is in chaos. I mean one reads about that every day in the press here; the NHS IT programme, called Connecting for Health, is in real difficulties and has swallowed up quite a lot of money; and that morale amongst doctors has never been lower. How much of those problems is it your responsibility to solve?

LD - Well not all of them I hope and to a certain extent I wouldn’t express the problems as darkly as that. I think when I’ve been out and about in the NHS I still find that doctors working in the front line are very, very positive about the things that they do. I certainly recognise their concerns, they have a very heavy workload; they have many targets that they have to meet; and increasingly they have to spend time on non-clinical activities. But on the other hand, I think we are still very fortunate in this country that we have doctors who are very very committed. They come into medicine with values which are laudable really to help patients and give public service. They are not motivated by money particularly, as in some other countries where there’s much more of a private practice domination in the system. So I think we are building on a bedrock of great commitment and good will. And yes, from time to time there, are problems of poor morale, at times of reorganisation particularly. But when you talk to doctors individually, as I do on visits to hospital and to primary care centres, I still find that most of them look forward to coming to work and enjoy their job, even though at times there are many frustrations.

SM - Well let me put to you some of the frustrations, because we have had e-mails from quite a lot of junior doctors in particular who are concerned about the new training system and about the bottlenecks that it creates in their career paths. A lot of them have told us that they don’t know whether they are actually going to have jobs for them after the Foundation Programme, and some of them therefore are applying for jobs outside this country. Australia is very popular, and some of them are even considering leaving medicine altogether. Now that can’t be a situation that you can’t be worried about.

LD - No, that isn’t a situation that we want to see.  The whole programme of reform to the training and Modernising Medical Careers programme was set up to try and get away from two main difficulties. I think one that doctors were, too many doctors were in bottlenecks or were languishing for many many years in SHO, senior house officer posts and, secondly, that in those early years there was no structured education. So we had excellent undergraduate programmes where doctors were getting superb teaching, modern teaching, and then they were coming off the production line and just going into service jobs, where there was no educational content until much later on when they started their specialist training. So the programmes have been designed to address those problems and I think largely it will. 

SM - Why are they still unhappy about them? They are looking at sort of glass ceilings above them and they can’t see where they are going in the profession.

LD - Well it is very early on with this programme and we have tried very hard to deal with the balance of numbers between those in the earlier stages of training and those in the later stages of training. We made an announcement a couple of weeks ago that we’ve actually identified around 20,000 training posts, which should be able to absorb most of the people who want to go into specialist training or general practice training. It may not let everybody have their first choice. But one of the slightly frustrating things about any initiative on medical training is that there is virtually no corporate memory that many of the junior doctors are coming in facing a situation as they find it, and they haven’t had to experience some of the problems and frustrations of the old system. So there were big problems with the old system. We think there are going to be many fewer problems with the new system, it won’t be perfect but it is attempting to iron out very longstanding difficulties with what was becoming a very outmoded way of training and education.

SM - We have got another doctor on the line now. you, yourself Sir Liam have talked openly about, I think the word you used was  “the awful experience” some people have had when things have gone wrong in their NHS treatment, and it is obviously something you care very deeply about. Our next question comes from Michael Carter who is Consultant Anaesthetist at Luton & Dunstable Hospital. Hello to you Michael.

MICHAEL CARTER (MC) - Hello Sue.

SM - You have got a question for Sir Liam?

MC - Yes please. Sir Liam, you have been a strong advocate for increasing awareness about patient safety in all areas of health care, not only nationally but on the world stage. Is there one particular incident that you were involved in clinically that adds to the fervour with which you pursue this avenue internationally?

LD - Well, it is good to talk to you and I visited your hospital I think last year, and you are doing some excellent work as a hospital trust on patient safety. I think I have been most moved really by the victims’ families that I have spoken to, and as Chief Medical Officer I receive letters from patients and families often about aspects of their care. And I have met some of the families who have lost relatives, often mothers who have lost children, and I have been very moved first of all by the circumstances, the potential avoidability of those deaths. But also the way in which people have almost risen above the tragedy after the initial anger and bitterness. They have often said: “Well look, we can’t go back, we can’t bring our dead child back. But what we do call on you to do as a health service is to learn, and if you want to honour the memory of our family who has died, our child. Don’t plant a tree in the hospital grounds, don’t unveil a plaque. Just demonstrate to us that you can stop this happening to another mother’s child.”

SM - Michael, do you ask that question because you have had some sort of similar experience?

MC - Yes, I have had a similar experience about 10 years ago and it is one of the things that motivates me in my patient safety work. 

SM - Can you reveal any details of that experience?

MC - Yes, I anaesthetised a six week old baby for an investigation and everything seemed to be fine during the anaesthetic until the end. And then things went awry and we took the patient to the Special Care Unit and handed over, thinking that the baby would make a full recovery. And the baby was transferred out to another hospital, a paediatric centre of excellence and died about five days later. So the first time I had a chance to see the mother was in the inquest. And I didn’t find that at all satisfactory.

SM- We you given any training at that point how to deal with that sort of situation?

MC - No. I had no training at all. I was very much the person looking through the patient’s notes and the mother’s obstetric notes to try and find out causes for the adverse event and the child’s death.

LD - Often when I hear about these stories and I hear about a lot of them, I do see the family as the primary victims of the tragedy. But there is also a secondary victim and that’s often the doctor who has quite genuinely made either an honest mistake or has been, or the system of organisation of services or things of that sort have pressurised them into making an error, where if the system had been different they wouldn’t have made that error. And it is about human beings and legal processes. Whether they are inquests or courts or a way of putting people on two sides of the fence and I think, I am sure that if you’d had the opportunity to sit down quietly in an armchair over a cup of tea with that mother, she would have been able to see things from your point of view, and you wouldn’t have been the person that she saw as having been involved in the death of her child.

SM - Our next question I think is not entirely unrelated to the experience of Michael Carter. One of the areas of great concern is that shortening the training period for young doctors doesn’t allow for enough clinical experience, and that handovers mean that sometimes the patient’s continuity of care is inadequate. Our third caller is Benjamin Dean who is a senior house officer from the John Radcliffe Hospital in Oxford. Benjamin, please put your question to Sir Liam.

BENJAMIN DEAN (BD) - My question was, how can you think that patient safety is improving when there is an overt lack of continuity of care in hospitals, and junior doctors’ training and the experience they are getting is less than ever before. The problem with the shorter shifts, handing over; some of them may come into A&E for example and be seen by one A&E doctor and then handed over to another. They might be seen by four or five doctors within that first 24 hours, all of different teams. It is becoming quite a serious issue that often no-one may take a proper history from that patient because they are all being driven to see the patient quickly and do something quickly rather than one person sorting out properly.

SM - Sir Liam.

LD - Well I agree with you that it is a potential area of increased risk. But I would look at it this way, I suppose there is a bit of a challenge to all of us working in this sort of situation.  If you accept for a moment, and you may challenge things like the European Working Time Directive and other measures which reduce the number of hours worked. If you accept the reality of that, then surely the challenge to us is that if that’s our problem that we recognise such situations could put people at greater risk, can we find a solution that would give us a win win? Because looking at the European hours directive, I know that there are reservations about the length of experience, the amount of experience people get but looked at from another point of view, there is a consumer protection point that we don’t want to have patients exposed to very tired doctors and we don’t want doctors to be tired and lethargic and not fulfilled in their job. So if we accept the reality, surely if we are creative, we can find ways of re-designing what we do to put in the necessary protection so that a change doesn’t necessarily stay as an increased risk but we can actually try and reduce it.

BD - I do agree that if you accept the reality of the European Working Time Directive you have to find a solution, but shortening training, which is a reality with Modernising Medical Careers, I really don’t think is the answer. It looks like a bit of a sticky plaster over a gaping wound to be quite honest.

SM - But you have got your eye on this particular problem Sir Liam.

LD - I have and it I a very fair and reasonable point. But I think we just have to be at our most creative. I must say that in the patient safety field, I find that doctors who apply their minds to some of these problems are actually very creative in coming up with solutions, so I think that some of the clinical leadership we will see will be very helpful.

SM - Let’s move on to another tricky and very topical question for you Sir Liam, and that’s the question of revalidation. When the government asks you to toughen up on revalidation when they didn’t like the GMC’s own proposals and your report Good doctors, safer patients, published not very long ago, is really meant to make doctors obviously fit, better fit for practice and better able to protect patients. But at the heart of this is the dismantling of the traditional role of the GMC in regulating doctors. We have had an e-mail from a group representing nearly 700 doctors and patients about replacing the GMC and they want to know why you think a Department of Health appointed body of members will lead to better doctors and safer medical care for patients? Isn’t it just putting doctors in the hands of the politicians?

LD - No it isn’t and it is a big and complex question and there were many recommendations in the report, which is currently out to consultation, so people have the chance to have their say. But this particular issue which is, should the GMC membership be elected by doctors or should it be independently appointed, I think is one on which opinion is very divided. The advantages of election are that it fulfils some doctor’s definition of what professional self regulation is, in other words you are judged by your peers, and you decide who your peers are and nobody else does. The Independent Appointments Procedure has the advantage that you can get a more balanced membership, you can ensure for example, a proper representation of ethnic minority doctors, women doctors and so on, and also that the membership is then above the perception of the public that doctors are looking after their own.

SM - So which way are things going, the doctors are regulation themselves or the politicians are going to have their say?

LD - Well it isn’t political, if the recommendation were accepted—and we are still out to consultation—to have independently appointed members of the GMC, who would be, would still be a large proportion of them would be doctors. The proposal is that it would be an independent appointments commission accountable to parliament which does this. So there is no suggestion of the government trying to control the GMC, and indeed the other aspects that I have proposed just briefly, in fact give a statutory role for the medical royal colleges in medical regulation. So how people can argue that we are doing away with self regulation whereas in fact we are extending it to other aspects of the profession is a bit surprising as a comment.

SM - Well let me try something else on you. Is the business of going before the GMC on a fitness to practice issue? There has been recently a shift in the burden of proof of fault from “beyond all reasonable doubt” to “on the balance of probabilities” and I think a lot of doctors are worried that it is going to make them practice defensive medicine. I mean some of them are already saying they are nervous about prescribing sufficient doses of morphine for instance. Is this sort of “defensive medicine” really in the interest of patients?

LD - Well defensive medicine isn’t but I don’t think that this particular proposal, if it was accepted, would lead to defensive medicine. What we are proposing is, moving to a civil burden of proof. Now that’s very widely used in other jurisdictions, for example, in the whole child protection field. The Civil Burden of Proof rather than the criminal burden of proof is because it has a more precautionary edge for protecting the child when there is a doubt as to whether they are being harmed. But I think there’s quite a lot of misunderstanding about this, that the civil burden of proof is not a simple weighing in the balance of 49 grams of evidence against 51 grams of evidence and then saying well the balance of probability tips one way. It is actually a much more sophisticated and flexible system where essentially a sliding scale operates so that if the potential penalty, the seriousness of the concern and the potential penalty, removal of a doctor’s livelihood say, is at stake, then you go up on a sliding scale to a very high level of civil burden of proof which is pretty close to the criminal burden. If on the other hand the problem is one of a more minor nature where you want the doctor to be rehabilitated and retrained, then the burden of proof required is less because there’s no real threat or serious consequence to them apart from having to go through a retraining programme.

SM - Well let me move on to something that is connected with that. Quite a lot of senior doctors have emailed in to say that they are worried about revalidation and how their performance is going to be measured. In practice will it be an exercise to improve standards of doctors, they say, or just an expensive time consuming way of picking out a few rotten apples? In other words there is a fear that a lot of doctors will lose their jobs if they are not up to scratch.

LD - Well my experience of a longstanding interest in problems of poor performance is that the number of doctors who are bad enough to lose their jobs is very small indeed. Actually most doctors that I know would not want to be treated by such people and they wouldn’t have any doubt about whether they should remain in the profession or not. And I see a lot of clear water between that small group of doctors who’s practice is very poor and the remainder. And I think one of the problems about this whole debate about revalidation is that we have spent too much time talking about the four or five percent of doctors where there are concerns about their practice, and not enough talking about how to help the 95% who are already up to a good standard, to do even better.

SM - Well won’t it mean though that the rotten apples are taking up an awful lot of time of good doctors indeed, if there is a new system of revalidation?

LD - Well I think we have, one of the problems is that we have a credibility issue that if we want the public to have confidence in the way that doctors are regulated and in professionally led regulation continuing, which it will under my proposals, we can’t have situations with doctors who nobody would accept as other than a poor doctor, turning up, their practice ignored for four or five years, patients being harmed in the meantime. That’s very damaging to the credibility of the medical profession and self regulation. So we have to deal with the, we have to spend a disproportionate amount of time dealing with the small number of poor doctors in order to retain credibility overall.

SM - One last question for you Sir Liam in this podcast, we have a GP on the line, on her mobile phone I think, Ann Robinson, you are in London, your line is open now to Sir Liam.

ANN ROBINSON (AR) Oh hello Sir Liam.

LD - Hello there.

AR - I just wondered, we as GPs are having our performance assessed and appraised a lot nowadays and I wondered how BMJs readers can find out about the performance of the CMO?

LD - Well isn’t it strange the way the last questions are always the most difficult questions? It is a very good question, I am enrolled in basically two systems, one is because I’ve got my specialist training in public health, although I have done a lot of other things, so I am part of the Faculty of Public Health’s Continuing Assessment Programme, largely based on Continuing Professional Development, and I am also appraised annually as part of the civil service system and on top of that there is a good medical practice element. I went through a pilot scheme for the old revalidation system which the GMC was intending to run, and I got through that. But it is a very good question. These sorts of national jobs which are much of my work is less tangible than clinical work is more difficult to evaluate. But I stand ready to be one of the first through any new revalidation system that arises. And I am very confident, and I think 99% of doctors should be, that whatever system we set up they will get through because I have got tremendous confidence that the vast majority of doctors in this country are well above any sort of minimum standard of medical practice.

SM - Would you welcome lay assessors to assess how you are doing in your job?

LD - Well I will have them because if we introduce, if the idea is acceptable for having an element of 360 degree feedback, then that would involve lay people in my case, probably members of the public or other stakeholders and in clinical doctors’ cases, patients.

SM - Just one topical thought, David Cameron has recently said that his party wants to stop the government micro-managing the NHS and would like to give health managers a degree of independence in setting policy locally in their part of the country—as we know health issues differ around the UK.  What do you make of that?

LD - Well I think that it is something that has been around for a long time. When I was part of the, I was in charge of one of the regions in the mid, early 1990’s and we used to meet with the Department of Health then, that idea was put to Virginia Bottomley as one of the options for changes that then led to an NHS Executive. But the Executive was at arms length rather than independent. But she was given an option of an independent NHS, so I think it is something that needs to continue to be debated. But I do think however you do it that we should try and make the NHS freer of petty political arguing because it is bigger than that, it is a national institution and it is not good for the morale of staff, it is not good for the confidence of the public in the NHS to constantly have squabbling about aspects of the NHS. We all ought to get behind it, give it our full support and try and get our weight behind solving some of the big problems that any health care system has, and I have seen a lot of them around the world, and I am still very proud of what the NHS achieves.

SM - It was widely reported in the press that you would have resigned if the Government hadn’t agreed to ban smoking in public places in England and Wales, so you obviously feel on certain issues that you have a particular passion and responsibility. If you were to stand down as CMO tomorrow— I don’t mean to imply your revalidation would have worked—but if you had suddenly decided that you were going to stop being CMO tomorrow, and there was just one thing you could do before you left the job, what would it be?

LD - Well I think it would be really to ensure that there was a stronger system of patient safety, protecting patients from harm within the National Health Service. I think we have started on a journey there and I would like to see that journey completed.

SM - You have been in the job for 8 years, how much has it changed you?

LD - Well I think I am older and wiser. I hope it hasn’t dimmed any of my idealism because I still get up in the morning feeling very positive about things that needs to be done and I suppose what sustains me is seeing so many committed people out in the NHS doing such an excellent job.

SM - You are said to be somebody who likes to work on his own in the office. You are not somebody who likes to be surrounded by people giving you advice. Is that right?

LD - No I am a, I think I am a very good listener. In fact my mother always told me that I was. So I do listen to people but I think where I get that reputation from is, I like to write my own reports. So I like to work with groups of people but at the end of the day, I never believe that reports produced by committees have the degree of focus and commitment that they need. And so to that extent when I am writing a report I am usually doing it on my own, after listening to a lot of people and reading a lot of people’s views before I do it.

SM - Can you say now, because you have admitted that there are a lot of teething problems with a lot of programmes, can you say, hand on heart now, that the NHS is in better nick than it was in 1998?

LD - I have got no doubt about that at all. I think things have improved enormously. It has run into problems in the last couple of years particularly on the financial side. But when we look at the, particularly the improved access to service, the increase in staff and equipment, I know these are statistics that are often trotted out, but they are very very important. The infrastructure of the NHS was clapped out. We were very low on some of the basics and those basics have been restored I think. And now we just need to get through this phase of financial difficulty and get more people on board with what we are trying to do, and I think that means engaging clinicians much more. They have been too marginalised over the last few years from the centre of policy making.

Sir Liam, thanks very much for joining us on the BMJ Interview and thank you for listening. Let us know what you think of what you’ve just heard by visiting bmj.com/audio, and tell us who you’d like to hear interviewed on future editions of the BMJ Interview. Meanwhile from me, Sue McGregor. Goodbye.

 

 

Rapid Responses:

Read all Rapid Responses

Hot air

ANDREW MONTGOMERY
bmj.com, 20 Oct 2006 [Full text]

Sir Liam Donaldson

John MS PEARCE
bmj.com, 20 Oct 2006 [Full text]

Operational Definition of Health

Robert J Reynolds
bmj.com, 20 Oct 2006 [Full text]

Anti climax

Radhika Vohra
bmj.com, 21 Oct 2006 [Full text]

The Liam Donaldson Interview

Stuart Sanders
bmj.com, 21 Oct 2006 [Full text]

Editing

benjamin dean
bmj.com, 21 Oct 2006 [Full text]

CMO spot on

Roger M Goss
bmj.com, 21 Oct 2006 [Full text]

Re: CMO spot on

ANDREW MONTGOMERY
bmj.com, 22 Oct 2006 [Full text]

Balance of probablities : Bad news for Doctors!

Charles O Olojugba
bmj.com, 22 Oct 2006 [Full text]

Re: Re: CMO spot on

Paul Brook
bmj.com, 23 Oct 2006 [Full text]

Re: CMO spot on

Robert J Reynolds
bmj.com, 23 Oct 2006 [Full text]

Justice matters

John Hopkins
bmj.com, 24 Oct 2006 [Full text]

Patients at Risk

John A Gilmore
bmj.com, 24 Oct 2006 [Full text]

Re: Re: Re: CMO spot on

ANDREW MONTGOMERY
bmj.com, 24 Oct 2006 [Full text]

The health services and the dream.

William G Pickering
bmj.com, 25 Oct 2006 [Full text]

Avoiding the painful truth and scapegoats

Daniel McQueen
bmj.com, 25 Oct 2006 [Full text]

Response to Dr Dean

Fiona Godlee
bmj.com, 26 Oct 2006 [Full text]

thankyou

benjamin dean
bmj.com, 27 Oct 2006 [Full text]

Softly Softly

Saj Ishaque
bmj.com, 28 Oct 2006 [Full text]

CMO certainly NOT spot on!

Hazel Thornton
bmj.com, 29 Oct 2006 [Full text]

Re: Response to Dr Dean

Robert J Reynolds
bmj.com, 31 Oct 2006 [Full text]

Re: CMO certainly NOT spot on!

Robert J Reynolds
bmj.com, 31 Oct 2006 [Full text]

Sir Liam Donaldson interview

John MS PEARCE
bmj.com, 31 Oct 2006 [Full text]