Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
The lessons that America teaches the world
- Mark Struthers (31 December 2004)
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Kicking the doctors out of medical profession
- Mansur ilahi (1 January 2005)
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Re: The lessons that America teaches the world
- Nicholas Bennett (1 January 2005)
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Is the GMC really the one to blame?
- Rameen. M Shakur (2 January 2005)
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Validating 'REVALIDATION'
- A.A.W. Amarasinghe,M.D., (4 January 2005)
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Is one death from regulation failure important?
- Nigel Dudley (7 January 2005)
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Forget Shipman
- Pablo Martin (7 January 2005)
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Re: Is one death from regulation failure important?
- susanne mccabe (7 January 2005)
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Evaluating Dame Janet's Reforms-what did we learn from Wanless ?
- Philip JR Taylor (12 January 2005)
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Mark Struthers, GP Bedfordshire, UK. mark.struthers@which.net
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Finding fault with the British system of medical regulation is not difficult. Correcting the faults is more complicated as Kamran Abbasi so rightly indicates. There may well be lessons from other countries. Indeed, the USA has much to teach us. However, what Britain can learn from America is how things should not be done. Finding fault with America is all too easy too. American society does not have the answers to complexities, has a chaotic value system and is in a bigger mess than we are. Disaster lies in adopting those faults and those empty solutions. The American way is wrong. We must learn to go another way. That bit should be simple. Competing interests: None declared |
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Mansur ilahi, Consultant Overseas
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Medical profession is losing control of its own regulatory bodies such as the GMC and the respective Royal colleges. Increasingly they are being run by so-called Executives (non-medical) and experts, not surprisingly therefore the decisions of these bodies are hurting the medical profession. The other day I was reviewing some of the GMC guidance booklets, I was struck by a sentence in one of the guide booklets that the GMC will help through it’s own lawyers to file a case for the complaining patient against the doctor accused of malpractice. That is truly an abuse of the institution funded by the medical profession. If GMC wants a change in its charter and wishes to prosecute doctors directly it better arrange it’s own finances too!!. One of the great anomalies of the medical profession in the UK is that regulatory bodies which perform essential function in the health care delivery such as the GMC and the Royal Colleges are left to largely fund themselves. This approach has devastating consequences as decisions made are increasingly done for financing these institutions . For example The main reason that examinations as PLAB, MRCP, FRCP (former) etc had been broken into components was not that medical material to be tested has increased twice or thrice or that the examiners are dumber and cannot spot the right candidate , but it mostly owes itself to need for examination fees needed by the Royal colleges and the GMC. Once successful in that entry into these medical regulatory bodies this hotch potch of so called medical administrators got numerous non medical people, inducted inside . But lately they have come to the most bizarre decision, the medical registration to be increasingly delinked from license to practice. An other money earner spanner is being thrown to the detriment of the profession . When I was new doctor, I was asked to make a few recommendations for bringing up a school health service for a small city in third world country, I reflexely advised recruiting of some doctors and nurses but it was frowned upon as it did not involve the induction of numerous secretaries and a host of numerous other non medical facilitators and conferences and workshops. Most health funds in developing countries get spent on conferences in five star hotels , non medical presenters posing as health workers on powerpoint presentations . Some times there is no distinction between doctors and others . Most international donor bodies are already plagued by this amateur businessman mafia hence even seriously funded programs as HIV hardly have a presence on ground in hospitals in third world countries . No doubt after creating posts as Nurse Practitoners , chief executives of royal colleges and head of medical examination boards , this non medical mafia is now bent upon taking full control , we have learnt lately that doctors shall be termed in future as merely “health care workers” . Only the invasion of herbalists , masseurs and oriental Hakims is left , rest of this mafia already deeply infiltrated the medical setup of the UK under Blair like in other countries . Competing interests: None declared |
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Nicholas Bennett, Infectious Disease Postdoc/Clinician Department of Pediatrics, University Hospital, Syracuse NY
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I do wish that Dr Struthers would cease his US-bashing. There is no need to mention his perceived view of US society when the editorial concerns medical regulation. Of course there are things to be learnt from other countries, particularly those who may be "ahead" in certain areas. Others can then cherry-pick the ideas which work and reject those which don't. I see this happening a lot in Ireland, which is learning fast from its European cousins. I wish America could learn from the UK banking and mobile phone systems, in the same way as I wish the UK would learn from the US in terms of customer service, value for money, media bias etc. Americans donate a yearly average of $860 per capita to charity, the British a mere $220 per capita (around 125 quid). If "the American way is wrong" perhaps they should withdraw their dozen ships, twenty cargo planes, 40 helicopters, food, supplies, desalination plants, workers and 350 million dollars enroute to the disaster-struck areas after the Tsunami? Whatever else is wrong with them, their hearts seem to be in the right place. To keep this on topic, I think the UK needs to look at the private healthcare sector in the US for direction, and the US needs to "wake up and smell the coffee" regarding the true value of pharmaceuticals and medical interventions. When it is cheaper to make a product in the US, ship it overseas and then buy it back from a foreign country, you know there's something wrong with pricing regulation. Incidentally I applaud the massive and rapid response from the British people and Government towards the disaster - it was with no small sense of pride that I saw the UK lead the world in the initial relief pledges. I urge all BMJ readers to join me in making a donation towards the relief effort. I also extend my heartfelt condolences to any and all affected. Nick Bennett njb35@cantab.net Competing interests: None declared |
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Rameen. M Shakur, Visiting Research Associate, Brigham and Womens Hospital Brigham and Womens Hospital. 75 Francis St. Boston, Mass. 9761USA
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The majority of the public ~90% trust doctors more than any other professional in the UK. However, this trust was slightly dented with the Shipman enquiry. The enquiry focused on why such a thing was allowed to happen and who was to blame. Yet, are we not missing the woods for the trees? Dr. Shipman was a murderer who happened to be a doctor as well. If Dr. Shipman was a lawyer in the bar, would be blame the entire judicary sytem for his uncondonable acts? I think not. How does any organisational body stop a determined individual member? Blaming the entire body for the misgivings of a minority shows almost disregard and ignorance of the longterm service the GMC has provided the public and the new proposals in view with revalidation. I do agree that the GMC does need to further modernise like the modernisation taking place in medical careers (foundation programmes), however history has shown that merely perpetuating a culture of blame as was the result of the recent Shipman enquiry rather than sincere concern never solved any problem. Competing interests: None declared |
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A.A.W. Amarasinghe,M.D.,, Consultant Psychiatrist 102 Bayberry Hills, McDonough, Georgia 30253-4005 USA.
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At age 70 ( class of 1962 ),if not for the mandated revalidation process, I shudder to guess the kind of service I would be rendering my patients today. According to my records, for the year 2004 I did more than 60 hours of Category 1 continuing medical education although the State of Georgia requires only a third of that. Learning is an exhileration.In the fast dawning vistas of the field of medicine, what an exhileration it is ! Competing interests: None declared |
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Nigel Dudley, Consultant in Elderly Medicine St James's University Hospital LEEDS LS9 7TF
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If the answer to the question is "YES" then it is not only the doctors but also the managers who need to be considering how to further reform regulation to protect the safety of patients. If manager regulation as it existed in Mid-Yorkshire, where there was found by the Healthcare Commission investigation to be year after year of corporate and clinical governance failures, was subjected to the same sort of highly detailed forensic examination it too would be found to have failed to protect the public.[1] The Healthcare Commission investigation was precipitated by the death of a single, elderly patient on an acute medical ward where management had suspended a consultant and then failed to provide safe consultant cover and inform junior medical staff of who to contact in an emergency. Managers are under a duty to provide a safe system of care. The 2002 Code of Conduct for managers indicates patient safety to be of paramount importance.That patient safety mantra is frequently repeated by Department of Health civil servants and ministers. A patient died in Mid-Yorkshire yet no manager has been held to account for the failure to provide a safe system of care to protect a patient's right to life. So much for manager regulation protecting the public or warning bells being heard at board level or higher. Strong organisations are said to react to weak alarms; some will not even respond to Big Ben style noises! Dame Janet Smith has indicated that the GMC perpetuates a culture of "mutual self-interest" in the medical profession. I would suggest that in view of the lack of action taken by the Mid-Yorkshire board and the Department of Health against the chief executives and senior managers overseeing a long running failed trust system of clinical and corporate governance that there is an identical managers' culture of "mutual self- interet" that similarly can harm patients.It is not just the actions of individual doctors that can place patients in harms way. Managers who fail to ensure safe systems of care can pose as much danger for patients as any doctor. In a rapid response reply Richard Smith has stated that "The GMC was inclined to try to choke the debate that is always needed for reform to happen." Exactly the same could be said of the Department of Health when it comes to manager regulation. The Bristol Inquiry was a missed opportunity to introduce proper, effective manager regulation and perhaps the current chair of the Healthcare Commission regrets the fact that the Department failed to implement his manager recommendations and just settle for another useless, often ignored code of conduct. Hopefully on this occasion the Department of Health will learn the lesson provided by the Mid-Yorkshire debacle. [1] Eaton L. Commission finds that trust failed to look into high death rates. BMJ 2005;330:8 The views expressed are my own and not those of my employing organisation. Competing interests: Interests in manager regulation and patient safety and knowledge of events in Mid-Yorkshire not covered by the Healthcare Commission's less than adequate, and at times inaccurate report. Detail is as important as the big picture! Consultant at Pinderfields, Wakefield 1993 - 2000. |
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Pablo Martin, GP West Leeds
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Every year it seems doctors have to occupy more space in newspapers and government reports and enquiries. The profession has always been in the spotlight and it will always be. Unfortunately it is not because of the constant efforts of thousands in assisting this ever more hypochondriac society in dealing with the most minute problems to life and death decisions. It is because of the minority, those who take advantage of their position. Somehow people believe the more hazard is created to control the many will help to monitor the few. Difficult to believe if you consider they have been doing so in this imperfect way of current proceedings. As it is commonly said who creates the law creates the trap. And it will continue that way. New Shipmans will come around while law-obeying doctors will be working observed under microscope, following more appraisals, revalidations and whatever is on the horizon to throw over their shoulders. It is nice to improve the general level of performance of doctors, to reduce the number of underperforming doctors, by setting guidelines and implementing some forced study time, but medicine, despite all attempts from lay people is not a mathematical science; it is an art, and the more requisites you put the less likely you will be able to produce a masterpiece. There is an obsession with creating a consumer based service, where rather than improving the general health of the population, you dilute the existing short forces into dealing with more nonsense, where rather than giving power to the doctor to stop vicious circles of ill-defined psychosomatic conditions, you give power to the patients to demand more invasive investigations going nowhere but to disease itself. One cannot forget Shipman but we have more appraisal, revalidations and data of our performance planned to be available to the whole world. Neither can one forget going to an illegal war (as described by Kafu Annan) and other illegalilities and power abuse inundating newspapers and no appraisal/revalidations/... for politicians being set. One cannot forget recurrent cases of paedophilia and abuse among priests and no appraisal and revalidations for clerical people being set. ... We are the lucky ones, the ones who know a little bit about mankind and life and death through disease and everybody is wary of the hidden powers that knowledge can lead to. In consequence nothing like the sense of control you get by interfering with every aspect of medicine. A false sense of security that will bring nothing but take away some of the precious time we do not have to do our job. Competing interests: None declared |
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susanne mccabe, retired cf24 3pf
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This an important point.The whole network of involvment in dealing with concerns and complaints needs to be considered even though some changes have already been made. Referral to the GMC usually comes way down the line after dealings with several layers at local level...where there has too often been mismangement, collusion with colleagues when relationships would be difficult if proper investigations or disciplinary procedures were carried out, ignorance of the function of procedures and so on.If concerns had been dealt with appropriately at this stage less distress to practitioners would have occurred by referral to the GMC. It is not the case though that all doctors are in 'fear and trembling' over the possibility of a letter from the GMC.(Re respondent from BMA).Some are, some have known all too well the consequences would be trivial and kept secret. Should though a group of adult professions be 'in fear and trembling' of a regulatory body set up to 'guide' it's members? The medical hierarchy still promotes this attitude in some areas, including in training practice. But it is not healthy.Thee should be a genuine separation of bodies providing guidance and those dealing with disciplinary procedures where if guilty a degree of fear is approriate. In one memorable case, after the usual months into years of dealing with a case at local level had passed all the hurdles necessary to get to the Ombudsman stage, the response from that office was one of the most bizarre...the person was advised to discuss the matter with a religious group who'had a good record of tacklng ethical issues'!but the Ombudsman would take no action. By this stage the person had been put through all the hoops available to obstruct the proper dealing with concerns, they are not always complaints, and case was referred to the GMC - who found the practitioner guilty. In an almost identical case another practitioner was totally let off the hook. It is unjust to colleagues who need a consistent approach, one which does not allow for those in the club or those who may make waves,or those who Trusts think they cannot afford to lose, to be treated differently. And this is one of the reasons it is necessary for people such as Richard Smith to contribute to the historical record of how things have been dealt with by groups in influential positions in the medical profession.(re his letter in rapid responses and critical responses from his ex colleagues to it). Otherwise nothing will change. Those especially who have the long view formed from decades of work in the profession should be listened to - they have access to information which those who have held short term positions are not privvy to. Contrary to 'loathing their profession' they give the impression of being so deeply committed they will speak honestly knowing that this is likely to have unpleasant consequences. Already though,some of the new regulatory bodies include those who have just shifted positions from one committee to another.Some are just directly or by word of mouth, appointed by friends and colleagues. However admirable they are considered,it does not deal with the problem of friends of friends, loyally perhaps ,networking together, as encouraged in most professions but which does not allow for proper transparency and therefore trust. There is a much greater pool of fresh talent to draw from in society and amongst healthworkers themselves. Competing interests: Have dealt with referral of concerns to GMC and other regulatory bodies |
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Philip JR Taylor, GP Clinical Governance Specialist East Devon PCT Axminster Medical Practice Church St Axminster EX13 7RA
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Dame Janet Smith's recommendations for regulation of the medical profession need serious evaluation. Her suggestions could be considered as a health intervention aimed at improving the care of patients.In the same way that we evaluate new drugs and health technologies we should consider the health gains,costs and adverse effects. The aims of her recommendations are to prevent abuse of public trust by doctors and to discover and act on underperformance.Her enquiry discovered evidence of gross underperformance which should have been detected but some form of quantification of the likely scale of any more general problem is required. Some of the costs of her intervention would arise from the time which clinicians spend on any assessment which would otherwise be spent on treating patients, as well as the direct costs of the assessment methods.In addition the costs of either replacing or not being able to replace (because of a lack of available replacements) clinicians "weeded out" by performance review. Potential adverse effects might include defensive medicine ,early retirement of some doctors and possibly a loss of that priceless NHS commodity, the mutual trust between doctors and patients that no interests other than those of the individual patient are being served during a consultation. Derek Wanless was commissioned by The Chancellor of The Exchequer to report on the NHS. He advised that all health professionals should have a half day each week for education,audit and professional development work. If the government is now prepared to embrace and fund this recommendation then individual clinicians may feel that they could cope with a "Dame Janet" regime. Blaming the GMC for being unable to conduct serious and regular performance assessment is unjust.The GMC should confine its role to setting performance standards in consultation with the public.The Government must fund a system in which these can be measured and achieved.It must develop performance review methods which are transparent and fair to the public and to doctors.Where doctors are working in a system which contributes to underperformance there must be a commitment to change the system. We'll then have an NHS which Dame Janet can approve.Will she then turn her scrutiny to regulation of the legal profession? Competing interests: None declared |
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