Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
And why not Ofdoc?
- nicola J brooker (14 December 2004)
-
Helplines and complaints
- ronald anderson (14 December 2004)
-
proceed with caution
- Stephen F Hayes (14 December 2004)
-
The hunt is on
- William E. Osmun (14 December 2004)
-
Separate self-regulation and patient protection
- Makani HEMADRI (15 December 2004)
-
A good enough revalidation system
- richard rosin (16 December 2004)
-
Why Panic?
- Dhirendra Singh (16 December 2004)
-
A small illustration of the flawed culture of the GMC
- Richard Smith (20 December 2004)
-
Re: A small illustration of the flawed culture of the GMC
- susanne mccabe (20 December 2004)
-
“Small illustrations” of a flawed culture (continued)
- Michael O'Donnell (22 December 2004)
-
Dame Janet's critique of regulation of professions
- Adrian K midgley (22 December 2004)
-
Re: Dame Janet's critique of regulation of professions
- Rita Pal (25 December 2004)
-
Expediency? Length of Training?
- Patrick L Xavier (1 January 2005)
-
The GMC: expediency before principle
- Terry J Hamblin (1 January 2005)
-
The cost of expediency
- Mark Struthers (2 January 2005)
-
The fallout from the Shipman enquiry.
- Simon J. Ellis (3 January 2005)
-
The GMC: principle not expediency
- Graeme Catto (3 January 2005)
-
Re: The GMC: principle not expediency
- Stevie M Gamble (4 January 2005)
-
Re: The GMC: principle not expediency
- John Stone (4 January 2005)
-
The Profession and the GMC should reject the Shipman report
- David H Marjot (4 January 2005)
-
A contradiction in terms
- Justin A B Robbins (4 January 2005)
-
Re: The fallout from the Shipman enquiry.
- Penny Mellor (4 January 2005)
-
Re: Re: Dame Janet's critique of regulation of professions
- Dr John Rumbold (4 January 2005)
-
£84000 K and Whistleblower Rights
- Pal Rita (4 January 2005)
-
Re: The fallout from the Shipman enquiry.
- Davina Hollisey-Mclean (5 January 2005)
-
"First, do no harm".
- Alex M Grieve (5 January 2005)
-
Re: The fallout from the Shipman enquiry.
- Mark Struthers (5 January 2005)
-
Failing doctors or failing system?
- Mark I Burgin (5 January 2005)
-
Two Bites of the Cherry
- Brian D Keighley (6 January 2005)
-
Expediency before principle is common
- Neville W Goodman (6 January 2005)
-
the future of the GMC
- stephen mccabe (6 January 2005)
-
The GMC : expediency before principle
- Alan Leaman (6 January 2005)
-
The GMC: the wrong target in the Shipman report
- Arthur Rushton (6 January 2005)
-
GMC Reforms may damage the NHS
- John J Turner (6 January 2005)
-
BMA Chairman responds to GMC Editorial
- James Johnson (6 January 2005)
-
Re: The fallout from the Shipman enquiry.
- deborah m henshall (7 January 2005)
-
Response to "The GMC: expediency before principle"
- Sir Alexander W Macara (7 January 2005)
-
Be aware of the political subtext
- D Michael Davies (7 January 2005)
-
CLUB CULTURE
- Rita Pal (7 January 2005)
-
Clinical accountability.
- William G. Pickering (8 January 2005)
-
Re: BMA Chairman responds to GMC Editorial
- Stevie M Gamble (8 January 2005)
-
Re: Clinical accountability.
- Deborah M Henshall (8 January 2005)
-
Re: BMA Chairman responds to GMC Editorial
- Nigel Dudley (10 January 2005)
-
Doctors and patients: shared interests
- Anita M Houghton (10 January 2005)
-
Re: Re: Clinical accountability.
- C Kevin Connolly (10 January 2005)
-
The GMC: do we want it anyway?
- Kiaran Asthana (10 January 2005)
-
Re: Re: Clinical accountability.
- Rita Pal (10 January 2005)
-
Re: Re: Re: Clinical accountability.
- Dr John Rumbold (10 January 2005)
-
Seal up the mouth of outrage for a while, Till we can clear these ambiguities
- susanne mccabe (11 January 2005)
-
Why self-regulate?
- lucy k cogswell (12 January 2005)
-
CONFORM OR BE BANISHED
- Rita Pal (15 January 2005)
-
British GPs are accountable to 14 systems
- John D Holden (15 January 2005)
-
GMC: Political correctness before principle
- Robert D France (15 January 2005)
-
Re: The GMC: the wrong target in the Shipman report
- Charles A. West (19 January 2005)
-
Re: Re: The GMC: the right target in the Shipman report
- Rita Pal (20 January 2005)
-
Shipman-aberrant man-aberrant reaction
- Terence GOULD (8 February 2005)
-
Re: Shipman-aberrant man-aberrant reaction
- Stevie M Gamble (9 February 2005)
-
GMC pre-emptively wash their hands of responsibility for poor practice and clinical errors.
- William G. Pickering (12 March 2005)
-
Professional performance, transparency and the GMC
- Huw Llewelyn, Azar Chaudhry, Honorary Medical SHO, Vanda McGibbon, Senior Ward Sister, Luton & Dunstable Hospital, Lewsey Road, Luton LU1 4OZ (7 April 2005)
-
Re: Professional performance, transparency and the GMC
- susanne mccabe soostevens@hotmail.com (8 April 2005)
-
Re: Re: Professional performance, transparency and the GMC
- Huw Llewelyn (14 April 2005)
|
|
|||
|
nicola J brooker, senior house officer Australia
Send response to journal:
|
Sir - why not have an Ofdoc and forget the GMC? The medical profession AND the general public need a fresh pair of eyes; a regulating body that meets the challenge of delivering trust, transparency and accountability to them. I don't see why a regulatory body needs to be solely staffed by doctors either. They should be hired (and fired)independently of the medical profession. And why is it so difficult to decide what minimum standards, criteria and thresholds should be? (Yes - alas the NHS workplace can be a difficult place to meet minimal standards). Ofdoc may not be such a bad idea after all. Competing interests: None declared |
|||
|
|
|||
|
ronald anderson, Emeritus Professor, Faculty of Veterinary Science,University of Liverpool Retired,current address. The Coach House, Quarry Rd Neston CH64 7UA
Send response to journal:
|
Against the background of the latest Shipman Report, now is not a good time to be facing real, imagined or vexatious complaints. The likely consequence is that, to that accompaniment of widespread publicity, a Helpline will be set up to invite others, who 'might have been affected',to make contact. The track record of such helplines is that they reap a substantial harvest of new complainants, some acquainted with, or even related to, each other and some recollecting for the first time, and in detail, events which may have occurred many years ago, sensing the scent of compensation. If the case comes to trial,the sheer quantity of such complainants is likely to influence the jury (and the judge) more than the quality of the defence, and the burden of the prosecution to prove guilt becomes the burden of the defence to prove innocence. Doctors are in jail as a result of this unjust process. One hopes (vainly, I suspect)that the pendulum, to which Dame Janet Smith has referred, does not overcompensate. Competing interests: None declared |
|||
|
|
|||
|
Stephen F Hayes, freelance GP/GPwSI Southampton
Send response to journal:
|
Sir when a new drug is introduced, there are three questions that must be asked and as far as possible answered before it comes into widespread use 1) does it work for the condition in question? 2) is it safe? (in particular, are there any potential side effects that may be worse than the disease?) 3) can it be afforded? Of course the drug must also be compared with other agents and therapeutic approaches, and there are other supplementary questions to be asked such as who stands to profit from this drug, is the condition self limiting or potentially lethal. Some sould say that 'principle' is all-ie even if a new drug gives only a 30% improvement and costs £10,000 per patient, it must still be given. However, that £10,000 came from somewhere, perhaps an 'unsexy' condition like leg ulcers. Dame Janet's proposals can be compared to a drug. We are not entirely sure what condition is being treated. There is no evidence base or comparative trials. Potential side effects include an exodus from the profession of 50-something doctors who are 'all reformed out' and deterrence of bright teenagers from entering such an over-managed career. Why not be a lawyer like Dame Janet rather than a doctor who can be suspended on an anonymous denunciation or lose her career for one mistake? Shipman and Bristol did happen, and it is self-evident that the performance of doctors matters. Laissez-faire is not an option all are agreed. However, before we mass-medicate, there needs to be more evidence and a thorough analysis of risk and benefit. This is a time for clear heads, not panic measures. And if we are talking about 'principle' then the principle of whether a government that started a bloody war which has made the world less safe on the basis of inadequate evidence badly interpreted and mis-sold should implement costly and potentially harmful vote-winning measures to control the medical profession is one it might be worth going to the barricades over. Competing interests: working doctor |
|||
|
|
|||
|
William E. Osmun, family physician Mount Brydges, ON N0L 1W0
Send response to journal:
|
I can hear the hounds baying over here. The hunt is on to root out all the medical miscreants in the UK. No doubt an entire bureaucracy staffed by lawyers and doctors who never did like dealing with patients is being formed while I write this. So the problem is, how do we define the 'good enough' doctor. And does a gp who only does sports medicine need to know the latest treatment of CHF. And if he doesn't, what do we do? Take away his licence? Retrain him? Who is going to pay for it? Who is going to look after his patients while he is gone? This will all be in the government's hands. Yes, those same folks that have brought us a doctor shortage throughout the western world by their incredible planning and foresight. I agree with Dr. Smith, I too have little faith in GMCs or Colleges, but I have less faith in governments. Competing interests: None declared |
|||
|
|
|||
|
Makani HEMADRI, Staff Grade Surgeon Scunthorpe Hospital, Scunthorpe DN15 7BL
Send response to journal:
|
Dear Sir, It is well known that those who pay the piper call the tune. The doctors pay for the GMC and it is not unreasonable to expect for us to have the authority on how it is run. We expect the GMC to provide guidance and ensure that we are able to practise at a consistent and constantly improving high standard. That is the essence of self-regulation which is the primary function of the GMC. Protection of patients is an extremely important public function but it should not be the job of the GMC. It is the confusion between the roles of self-regulation and patient protection that causes the conflict of interests and is the source of trouble. Hence, parliament should create a separate instituition for the protection of patients, which should have an important medical input but not necessarily controlled by the medical profession. If the GMC's self-regulation is strong there will not be much to fear from any institution set up to protect patients. There will however, be some who will slip through despite the regulation and they obviously need be to prevented from causing harm to the society. Competing interests: None declared |
|||
|
|
|||
|
richard rosin, Consultant Psychiatrist VA Puget Sound , Seattle WA 98108
Send response to journal:
|
The goal of any regulating body should be to ensure that firstly doctors are safe and secondly that they are knowledgeable. The two are not synonymous. Will revalidation-which is meant to ensure fitness to practise - establish that a doctor's knowledge is up to date and that he/she uses that knowledge to make sound, safe decisions. Nobody agrees on the best way to ensure that knowledge is up to date. In the US, recertification exams in all specialties are now the norm. They are a source of great resentment because apart from anything else they seem to be generating large amounts of money for the member boards of the American Board of Medical Specialties ( equivalent of the UK Royal Colleges). Noone has yet provided a convincing argument why a formal MCQ is better than CME which is also a requirement. But even if you know your stuff, how do you ensure that decisions are good? Well there is also anonymous peer review in which random cases are selected and management is followed over time. None of this seems especially unreasonable apart from the gouging of doctors by the specialty boards and it seems appropriate that evaluation by peers should continue since one hopes the blind are not assessing or leading the blind as the old saying goes. How this necessarily entails doctors protecting other doctors is not clear unless the GMC or its equivalent really is as corrupt as the mafia. The question is whether even if these measures were adopted it would be possible to prevent a determined and wiley serial killer such as Shipman. It is likely that an individual such as he would find a way to pass revalidation and continue with his activity. The point about trust made in Richard Smith's quotation by Onora O'Neill is well taken. “The efforts to prevent the abuse of trust are gigantic, relentless, and expensive; their results are always less than perfect.” To this might be added that such efforts are not well-considered and often target the wrong people. It is doubtful that the medical profession has a veritable army of Shipmans waiting for their opportunity to strike. As some others have implied, one has to ensure that the deterrents to professional misconduct are not so pervasive that they become deterrents to people entering medicine. Dame Janet according to Richard Smith, bemoans the fact that “A doctor will fail to be revalidated only if his or her performance is ‘remarkably’ poor”. Well there will have to be a cut-off point. For example if a recertification exam's pass mark is 70% and a doctor scores the minimum as opposed to someone else who scores 80%, then does Dame Janet think that the former doctor needs further training? Is there in fact a huge difference between the doctor who scored 69% and the one who 'passed'? Even if you have an apparently clearcut system like this there are no simple answers. What does 'remarkably poor' actually mean? This is an example of the 'less than perfect' results to which Onora O'Neill refers. There is a concept in psychology recognising the fact that no parent is perfect. Rather, we accept what is called 'The good enough mother'. Perhaps what is needed is a good enough revalidation system which recognises that no matter what you do, not every doctor will be perfect. Competing interests: None declared |
|||
|
|
|||
|
Dhirendra Singh, SpR in Paediatric Neurology Birmingham children's Hospital B15 3RS
Send response to journal:
|
May be because I am not living in this country for a long time or may be because I have never been subjected to a disiciplinary proceeding by the GMC; I really do not understand the distressed undertone of some of the responses on this issue? When we went to medical school, many of us were not even not aware that we will be regulated by the GMC or a body consittuted by the Governmnet led by Lawyers. We are surely more clever than an average Lawyer. Nobody can do us any harm if we could self "regulate" some of our "experts" Competing interests: Being regulated by the GMC. |
|||
|
|
|||
|
Richard Smith, Chief executive UnitedHealth Europe, London SW1P 1SB
Send response to journal:
|
One of the main conclusions of Dame Janet Smith about the GMC is that it has a doctor dominated culture that puts being fair to doctors ahead of protecting patients. This comes about partly because the elected members of the council see themselves as representatives of doctors rather than their regulators. Furthermore, many of the elected members are also prominent in the BMA, which exists primarily to promote the interests of its members, all of whom are doctors. Those BMA doctors who sit on the GMC may understandably fail to understand that they should be acting in a fundamentally different manner when wearing their GMC hat. I experienced some of the doctor dominated culture first hand when in the late 80s I wrote a series of articles in the BMJ that were highly critical of the GMC. In the first draft of my editorial to which this is a response I started by telling the story of what happened, but it took up too much space and was too self indulgent. I thus dropped it, but I'm still keen to get the story onto the record because it illustrates what Dame Janet was criticising--hence this rapid response. What follows is my memory of events, but I'm highly conscious that it may contain both gaps and insertions. If you ask five people for an account of a meeting that happened yesterday you'll get five different accounts, and when the events happened 16 years ago there's even more room for confusion. Hence the difficulties of writing history. The GMC didn't like the articles one bit--although both officers and staff helped me greatly with my research. Their main worry--which now seems ironic--was that my articles would damage the public's view of the council. The instinct of threatened authorities is, I've learnt over the years, not to engage in public debate but rather to find a way to try and shut up the critic. How could the GMC shut me up? The obvious route was through the BMA. It so happened that that year the president of the BMA was also the chairman of one of the main committees of the GMC. He was no fan of the BMJ as we had previously criticised the institution of which he was the head. So the president brought up the issue of the GMC articles at a meeting of the chief officers of the BMA, one of those many meetings where things are fixed but which "don't happen." The meeting in those days comprised in addition to the president the chairman of the council of the BMA, the chairman of the representative body, the treasurer, the secretary, and the editor. By attacking the articles at this meeting the president was undermining a deep tradition of editorial independence. My predecessor was furious, and other members of the meeting were, I think, embarrassed. No motion was passed, but the editor had been "got at" by a powerful figure. The BMJ's response was to reduce the number of articles in the series (which was probably too long anyway) but also to end the series with a blistering critique of the GMC written by the editor. This is a small incident and unimportant in the light of events that were subsequently to overwhelm the GMC, but it does illustrate the culture that Dame Janet identified. The GMC was inclined to try and choke the debate that is always needed for reform to happen. Richard Smith
Competing interests: I am the author of the article to which I'm responding, was formerly the editor of the BMJ, and published a series of articles critical of the GMC in the 80s. I know the present president and his three immediate predecessors and most of the "characters" who have featured in the debate over the GMC over the past 20 years: many of them are friends. |
|||
|
|
|||
|
susanne mccabe, retired cf24 3pf
Send response to journal:
|
Trouble is there were/are far too many 'small illustrations'and it is this as much as the more outrageous scandals that has contributed to lack of trust in the GMC or the BMA. Literally thousands of doctors have 'got away' with breaching GMC guideliness because self interested investigators were so weak in dealing with less than 'serious misconduct' or striking off offences. Over the years there have been improvements, the GMC does now write letters of advice or admonishes doctors to change their practice, rather than arrogantly and unethically let them 'off the hook' - but they have failed to properly prevent even doctors who have been admonished from 'cocking a snook' and continuing the same way once the heat had died down. New procedures include better montoring and keeping a public record about misdemeanours but again they will be those deemed pretty 'serious' and there is no official monitoring....except via what was to be the farce of revalidation. Even the past president of the GMC and the chair of the GP Committee acknowledge this to be inadequate (re article ~ Guardian 18th Decembr 2004). Liam Donaldson has the sense to realise that the procedure suggested is totally flawed. Yet why do even those in such influential positions in the medical world, those who know all too well what goes on behind the scenes, feel unable to speak out until they are free of their organisations...As they say and people who have had reason to move around the country and so experience different quality of health care from different practitioners know without doubt, there are those who should not be practicing at all without re-training. This is not a slight on the profession as a whole. Another 'small illustration' - I contacted the GMC some weks ago to ask whether a doctor was still registered with them I made two follow up requests for this simple information. Currently I am asking whether it is acceptable that a practitioner who was found guilty of breach of GMC guidelines has been appointed as Chair of an Ethics Committee. Again there is the so predictable run around, requests for information they already have on record; requests for dates of cases which they clearly have on record but which many would be hard pushed to remember if they had not kept good records themselves;no one person dealing with the preliminaries; delays, obfiscation. There have been some decent people employed by the GMC over the years but they have been unable to significantly change the culture..it is probably too much to ask that this organisation could tackle both protectiing the public and 'guiding' their friends and colleagues. Competing interests: Have worked on many cases over the past two decades which resulted in referral to GMC |
|||
|
|
|||
|
Michael O'Donnell, FRCGP. Former GP turned journeyman writer Loxhill GU8 4BD
Send response to journal:
|
Forensic investigations are never perfect and there is an irritating flaw in Dame Janet Smith’s investigation of the GMC. She recommends that the GMC constitution be changed “so it has more appointed members who are ‘not beholden to an electorate’ and do not see themselves as representing doctors”. My own observations during the 23 years I spent as the GMC’s Resident Dissident convinced me that the proportion of appointed members who did “not see themselves as representing doctors” was much the same as that of elected members. Just as the proportion of members who, in the eyes of Joyce Robins, co-director of Patient Concern, were guilty of “arrogance, complacency, and an unwillingness to listen and learn from others” was much the same for the appointed as the elected. Appointed members may not have been “beholden to an electorate” but many seemed to be beholden to those who appointed them. Several, for instance, had symptoms of Knight Starvation. I know of only one GMC member who turned down an invitation to join the Honours List and he was an elected member. In 1985 I described in this Journal (20 July) how someone I once admired achieved the honour he so coveted by an act that denied the very qualities for which he'd won my respect. “But then if someone wants to buy your political support,” I wrote, “be it with a free lunch or with a knighthood, you must have something that's worth selling. Often it's your integrity.” When the article appeared three people complained to the BMJ’s editor or to me that I was criticising them. I was in fact writing about someone else but I’ve always wondered what the other three had been up to. Two of them were appointed members of the GMC. Let me add to Richard Smith’s list of “small illustrations”. One event regularly used to belabour the GMC is its failure to take action when the Canadian authorities informed it that Richard Neale had been “struck off” in that country. Members of the GMC secretariat have told me, and others, that a senior appointed member overruled the advice of other members and allowed Neale to continue practising in this country, with disastrous results. Another “illustration”. In my evidence to the Bristol Royal Infirmary Enquiry [1], I described “the concern that I and others had had about two health screeners [charged with overseeing the care of “sick doctors”] who had ‘drinking problems’ yet were allowed to remain in office. I had raised my concern about the first screener with the then President … the problem with the second was so widely known that the Secretariat tried to ensure that alcohol was not available at midday during the meetings of the Health Committee.” Yet no action had been taken by the presidents who had presided over them. Both presidents and both screeners were appointed members. Many well-intentioned doctors, politicians, and lawyers don’t like elections because they can produce “the wrong sort of person”. Yet more than 50 years experience of our hierarchical profession has convinced me that our professional institutions are best organised on democratic lines, for the pragmatic and oft-quoted reason that, though democracy has many flaws and often impedes those who know what is best for the rest of us, it is the least bad and least dangerous system that’s available. The GMC's problem is that it is not a professional institution and its attempts to serve two masters have sent it staggering towards its downfall. I hope our profession will not fall for Dame Janet’s vision of the GMC as a police force detecting and collecting evidence of professional “crime” then handing it on to an “independent” court for arbitration. If the government wants to set up a regulating body – a sort of Offdoc – then it will. It may recruit a few well-chosen medical “appointed members” but if it wants to gain the cooperation of our profession it will have to negotiate with our more democratic professional bodies. It’s the sort of negotiation that governments seek to avoid, often by flattering others into doing their dirty work for them. Politicians know that doctors are dangerous opponents. Those of us, like Richard Smith and myself and the legion of quango sitters, who preach about medicine tend to underestimate the influence of those who practice it. Ever since the first caveman took a thorn out of another caveman’s foot people have recognised the social usefulness of those who can ease pain, alleviate anxiety, and cure disease. On the day Dame Janet delivered her recent report, journalists and politicians spoke of a Crisis in Confidence and Public Loss of Trust in Doctors. Yet only last March a MORI poll found that 92 per cent of people trust doctors to tell them the truth, the highest percentage since the annual survey began in 1983. Only 22 per cent trusted politicians and even fewer, 20 per cent, trusted journalists, with 72 per cent - the highest percentage ever recorded – believing they actively lie. [2] Michael O’Donnell michael@odonnell99.freeserve.co.uk 1. http://www.bristol-inquiry.org.uk/ 2. http://www.hrgateway.co.uk/viewnewsdetail.asp?uniquenumber=4325&loginstatus Competing interests: 23 years hard labour as the GMC’s “house rebel” – elected not appointed |
|||
|
|
|||
|
Adrian K midgley, GP Exeter EX1 2QS
Send response to journal:
|
I found Dame Janet's exploration of what is wrong with the regulation of professions interesting.
I look forward to seeing the bar council (150 barristers appointed/chosen by their professional colleagues) response to it, and the subsequent changes that occur in regulation of the legal profession. I expect we have interesting times ahead in our profession, as well. Competing interests: None declared |
|||
|
|
|||
|
Rita Pal, Editor www.nhs-exposed.com
Send response to journal:
|
You should note that the regulation of the legal profession remains an interesting topic. While lawyers are fortunate enough to look down on us minions ( namely doctors), according to the Lord Chancellor, no one can make a formal complaint about the judicial function of a judge. Indeed, public policy dictates that no one can sue a judge. You will therefore note that if Dame Janet Smith's report missed out some important issues such as the regulation of diamorphine - there would be no one who could challenge her. Indeed, even if someone did challenge her, I have my doubts as to whether she would listen. While the legal profession is often extremely quick to make sweeping judgments, I suspect you will find that the legal profession is a closed shop and suffers from the same failings the medical profession is criticised of. In a case I was once involved in, a judge made a decision on the wrong facts and wrong papers of the case. Now, if a consultant had made a decision on the wrong patient notes or even misinterpreted the symptoms, they would be hauled up to the GMC or the court. Judges on the other hand command Godlike respect. One could say that no judge is accountable within the profession. While Dame Janet Smith is commendable in her ability to blame the GMC for just about everything, her aim was to prevent another Dr Shipman. Cases such as Glass v UK were not considered and the importance of prevention of abuse by diamorphine has not been addressed - for instance the regulation of diamorphine is desperately needed in this country. Without it, no matter how much we GMC bash, the central issue remains neglected. Secondly, Dame Janet fails to address the importance of whistleblowing and the safe environment required. In my view, if an inquiry cannot interview medical whistleblowers such as Bolsin to formulate a constructive plan then they cannot expect to come up with a structured suggestion of practical use. Janet Smith's hotline for whistleblowers suggestion is an example of her failure to understand the essence of whistleblowing. A hotline exists at the Department of Health, I rang it. It told three of my colleagues and me to " seek local advice" as they could not do anything. So, we stated that local representations were made and that victimisation was occuring to which they said " consult a lawyer". We then replied " we did not have the money for lawyers and our defence unions did not represent us". Anyhow, there was no constructive solution to the commonest problems faced by whistleblowers. The Shipman Report is useful in certain ways but flawed medically and scientifically. It was afterall written by a lawyers :) who have a limited knowledge of science. It serves to shroud many good doctors with the ghost of Shipman. This cannot be right for the public. In my view a more constructively formatted report with practical suggestions that would be useful in the long run would have been better. As it stands, the Shipman Inquiry is a document with which to hit the GMC on the head with. While that is useful for people like myself, in the long run its suggestions are of limited use in the real world. Dr Rita Pal Competing interests: R Pal v GMC Dragged the GMC into court to answer some important questions on their ability to make secret enquiries. |
|||
|
|
|||
|
Patrick L Xavier, rtd rtd
Send response to journal:
|
Please enlighten me: As I understand it there is a scheme afoot to shorten basic medical training to 4 years. Surely this ultimately does not square with the criticisms being directed at the GMC? Have I missed something? Competing interests: None declared |
|||
|
|
|||
|
Terry J Hamblin, Professor of Immunohaematology University of Southampton SO16 6YD
Send response to journal:
|
The old saying, "He who pays the piper calls the tune" is apt. If the public wants an organisation to protect it from unsatisfactory doctors then the public should pay for it. If doctors want an organisation to protect the standards of the profession then doctors should pay for it. If I am not mistaken the GMC is wholly funded by doctors. Small wonder that it acts in their interest. Competing interests: None declared |
|||
|
|
|||
|
Mark Struthers, General Practitioner Bedfordshire. mark.struthers@which.net
Send response to journal:
|
I currently pay £290 per year to the GMC for the self regulation of my profession. The cost has risen outrageously in recent years. I also pay £4133.60 per annum to the Medical Defence Union (MDU) for self protection insurance. The GMC is expeditious in its affairs and clearly provides value for money in protecting the continuing interests of doctors. When the GMC is abolished the taxpayer will have to stump up a lot to achieve parity in the protection of patients. Competing interests: doctor, father, taxpayer and would be (psychiatric) patient |
|||
|
|
|||
|
Simon J. Ellis, Clinical Director Neurosciences The University Hospital of North Staffordshire, ST4 7LN.
Send response to journal:
|
No one loves the General Medical Council, but being unfair to doctors as proposed by Smith(1) is surely no solution. Reform must be based on logic and fairness. Dame Janet Smith’s recommendations appear to start from the presumption that every doctor is a nascent Shipman(2). If implemented doctors will be subject to such a draconian regimen of oversight that it will be relatively easy to destroy a colleague’s career by starting a few rumours or disaffected patients starting a juggernaut of a quasi-legal process which would make Jarndyce and Jarndyce look like summary justice(3). The current system is bad enough and has been well manipulated, for example against David Southall(4). Of particular concern is her recommendation on standard of proof, “The civil standard of proof is appropriate in a protective jurisdiction. It is arguable that the criminal standard of proof is appropriate in a case where the allegations of misconduct amount to a serious criminal offence.”(5) This means that if there is a 51% chance that a doctor is guilty of serious professional misconduct then he/she will be struck off. For medical scientists used to a standard of p<0.05 as a starting point and not believing that until it has been replicated this seems a remarkably low level of certainty under which a persons livelihood and career can be destroyed. The law needs to come into the 21st Century and give some idea of the probability of a finding being “true” in statistical terms. Is balance of probability (p=0.5), i.e. the toss of a coin adequate? What in statistical terms does beyond reasonable doubt mean? Doctors need to feel that the any system is fair, efficient and proportionate. Dame Janet Smith’s recommendations are not. Her recommendations fail in two other important respects. They will not reassure the public as the process is too complex nor will they protect against a future Shipman. Shipman was an intelligent psychopath. Psychopaths manipulate whatever system you put in place. Short of having a policeman present at every consultation there can be no absolute protection against Shipman happening again. The consequence of practising within a threatening environment is a breakdown of trust. Trust of patients by doctors, which will result in extremely defensive practice. Why bother going the extra mile in securing good care for a patient when they may well destroy your career and livelihood? An adversarial relationship between doctors and patients (the legal model) is in no ones interest. Given the muddled thinking within government, the GMC and our learned friends as represented by Dame Smith might it not be time for the British Medical Association to propose an alternative system and doctors to consider withdrawing their financial support for the GMC. Simon J. Ellis. 1. Smith R.The GMC: expediency before principle. BMJ 2005;330:1-2. 2. Smith J. The Shipman Enquiry. Recommendations. http://www.the- shipman-inquiry.org.uk/5r_page.asp?id=415 (Accessed 12/12/4) 3. Dickens C. Bleak House. 1852-53. 4. Blackhurst D. Southall ruling branded as seriously flawed. The Sentinel. 22 Nov. 2004. 5. Smith J. The Shipman Enquiry. Recommendations: The General Medical Council, Recommendation 81. http://www.the-shipman- inquiry.org.uk/5r_page.asp?id=429 (Accessed 12/12/4) Competing interests: Practising Physician. |
|||
|
|
|||
|
Graeme Catto, President,General Medical Council 350 Euston Road, London,NW1 3JN
Send response to journal:
|
In contrast to the comments from the current editor and his predecessor, the General Medical Council faces the coming years with confidence, recognising the continuing need for the profession and its regulation to adapt to change. The radically restructured Council had agreed to conduct a post implementation review in 2005, halfway through its four-year term of office, and has begun consideration of the Fifth Report from the Shipman Inquiry. The composition of the Council and our fitness to practise arrangements are matters of interest to the public and the profession – as are our policies on registration, education and ethical standards of practice. We welcome the review of the findings of the Shipman Inquiry, and in particular of revalidation, to be led by Sir Liam Donaldson. The whole purpose of revalidation is to create public confidence that all licensed doctors are up to date and fit to practise, and if there are ways of improving the revalidation model we have proposed, we would of course want to include them in our plans. Dame Janet Smith's report raises a number of important questions and we welcome this opportunity to consider them in detail with the Departments of Health and other interested partners. Our continued willingness to refine our proposals through discussions with employers, medical Royal Colleges and others, is not expediency - it is common sense. Competing interests: President, General Medical Council |
|||
|
|
|||
|
Stevie M Gamble, retired EC2Y 8BL
Send response to journal:
|
Graeme Catto, President of the General Medical Council states 'The whole purpose of revalidation is to create public confidence that all licensed doctors are up to date and fit to practise.' No, it isn't. The whole purpose of revalidation is to ensure that all licensed doctors are, in reality, up to date and fit to practise. It is symptomatic of the GMC's continuing inability to grapple with reality that its President hasn't actually realised that... Stevie Gamble Competing interests: None declared |
|||
|
|
|||
|
John Stone, none London N22
Send response to journal:
|
I should have thought that it was a matter of concern that when it comes to the issue of validation everyone should simply defer to the Government executive, as if the Department of Health did not already wield enough power within the medical profession. It is all too easy to see whom this power could be used against and for what purpose. The movements which Sir Graeme Catto welcomes seem to look not towards balancing interests but toward concentrating them even further. The weakness of the GMC ends up being used to political ends, in the same way as the weakness of the BBC. Members of the profession and the public should wonder at our contemporary political illiteracy which allows all this to happen virtually unchallenged. Competing interests: Parent of an autistic child |
|||
|
|
|||
|
David H Marjot, Consultant Psychiatrist Kaleidoscope KT2 5RT
Send response to journal:
|
I have looked at the report of the Shipman inquiry by Dame Janet Smith and have read the editorial commments in the British Medical Journal of 01.01.05. It seems to me that Dame Janet has used her undoubted forensic skills to find someone or something to blame. However I cannot see that her conclusions follow from the evidence she has gathered therefore I cannot accept her report. From her descriptions of the systems that were in place during Dr. Shipman's tenure we must conclude that they served the public and the profession well. It was not the systems that failed but the inability of people to see the enormity of Shipmans's crimes. I recall reading that there are three sorts of problems. The first are 'one offs' where it is very unlikely that the same thing will happen again. There is no need for a vast bureaucratic response to what is often political panic. I would ague that, in spite of its horrors, the Shipman disater falls into this category.The second type of problem is where the case in hand is the first of a new series of events. One can instance HIV ( human immuno-deficiency virus) and AIDS ( acquired immuno-deficiency syndrome) when we then have to set in train appropriate responses to the new state of affairs.The third type of problems are those that are already known and we should have procedures in place to deal with their impact such as MRSA( methicillin resistent Staphylococcus aureus infections). It seems that much of the problem of clinical competence lies when the doctor is in a permanent post. Surely ensuring such clinical competence is a resposibility of the employer, in the UK our monoploly employer is the National Health Service. I can see no reason why doctors should have to pay for this. Competing interests: None declared |
|||
|
|
|||
|
Justin A B Robbins, Freelance GP Plymouth PL8 2LB
Send response to journal:
|
Isn't it now time that we as doctors acknowledged that professional self-regulation is actually a contradiction in terms. Do we trust any other profession to self-regulate,e.g. lawyers, politicians, policemen? I think not, so why should any layman trust us in this regard. If we had the humility and courage to say this publicly we would gain more in public respect than we would lose in self-esteem. Competing interests: None declared |
|||
|
|
|||
|
Penny Mellor, Advocate Home WV9 5HX
Send response to journal:
|
Dr Ellis claims that the current complaints system at the GMC has been well manipulated when it came to bringing Prof David Southall to PCC. I would counter argue that point vigorously on numerous counts. 1) The majority of the complainants whose cases are to be heard at some point (don't know when yet again!) have had their complaints at the GMC since the early 1990's and one case in particular has been with the GMC since 1987. 2) It is totally unnaceptable for anyone involved in child protection to continue making the allegation that he made against Stephen Clark, despite proof to a criminal standard that Mr Clark could not have done what Prof Southall claimed he had. If manipulation equates to complaints being heard years after the complaints have been lodged and proven, then to be frank, Dr Ellis is quite deluded. This process has been so protracted that many parents have almost given up any hope of the justice they deserve and furthermore the justice they have been denied for so long has in turn led to further injustices in their lives. It's interesting that Dr Ellis argues that the proof of wrongdoing at the GMC should remain a criminal standard of proof, a luxury not afforded to parents when their children are permanantly removed from them in the secret family courts based on a false allegation. It implies that a doctors career is far more important than the adoption of a child....quasi logic or self protection? Perhaps Dr Ellis would like half an hour in the company of the Clarks and their surviving child so that he could see for himself the damage the allegation David Southall added to the others did. It isn't rumour or specualtion that has bought David Southall before the GMC, can't be, because they operate to a criminal standard of proof remember... it isn't manipulation of anyone or anything, it is the dogmatic and zealous approach to child protection and lack of "insight", so clearly demonstrated during the hearing into Stephen Clark's complaint that has bought David Southall to this juncture in his life and it is all down to him, nobody else. Why don't the medical profession grow up and stop blaming others for their mistakes, perhaps now is the time for the word "accountability" to be learnt and practised. Competing interests: campaigner against false allegations of MSbP etc |
|||
|
|
|||
|
Dr John Rumbold, n/a West Midlands
Send response to journal:
|
Yes the legal profession have avoided the accountablity that they suggest is vital for doctors. That will probably always be the case since so many MPs are lawyers! Increased regulation of doctors increases their prospects for work so they are bound to think it's a good thing. Rita Pal's case illustrates the hazards of whistle-blowing - I know I would be very reluctant to stick my head above the parapets because of what has happened to people like her. The RCP and GMC can huff and puff all they like but until there are meaningful measures it is a lot of hot air. Competing interests: None declared |
|||
|
|
|||
|
Pal Rita, Editor www.nhs-exposed.com www.nhs-exposed.com
Send response to journal:
|
Dear Professor Catto, I read your BMJ response with interest. I am pleased to see that you welcome the Shipman report findings. Indeed, Dame Janet Smith pointed out that the GMC was not an environment where whistleblowers could report medical failings. You seem to have evaded this is issue entirely. Many doctors and you are aware that without a safe environment for whistleblowers, the next Dr Shipman will not be reported. Indeed, I note that you make no mention of improvements with respect to this. The new GMC procedures are possibly just as flawed as the old ones. In the latest GMC News, you state that the procedures will be “ transparent”. Yet, in my case, the identity of the screener who conducted the discreet inquiries has been refused. Perhaps you would like to clarify whether the purposeful concealment of the identity concurs with your spin of “ transparency”. In my view, the GMC requires an overhaul with new staff. I believe this overhaul should start at the top i.e. with you. In my view, Dr Peter Wilmshurst would make a fairer and more objective president. Indeed, Dr Peter Wilmshurst would have the courtesy of replying to mail sent to him by doctors. The main complaint about you Professor is that you fail to answer your mail. There are a number of doctors who have whistleblown to the General Medical Council. They in turn have been investigated while their concerns have been left by the way side. With respect to my own case - I wrote to you regarding my concerns about the GMC. I also stated that it was a last resort to litigate. You failed to answer my many letters. Despite the fact I simply asked for six sheets to be removed from my files at the GMC, you and Finlay Scott spent in excess of £ 84000 on six sheets of paper. I consider this an abuse of subscriber’s funds. Indeed, the GMC was reported to the Charity Commission for this. Anyhow, money ofcourse cannot buy success in court. I am sure that is a hard lesson learned by the GMC. The GMC forgets that it is the hard work of doctors that pays for all their expenses and legal cases. (www.generalmedicalcouncil.org.uk). You ofcourse are aware of the initial whistle-blowing episode in the year 2000. Letters from the Trust, from the Deanery accessed in 2003 verify that my complaints about substandard support for junior doctors were justified. Indeed, the 2002 CHI report verified this. The BMJ should know that Professor Rod Griffiths was featured in the BMJ not so long ago. The Guardian stated “The conclusions of the Griffiths report were lambasted in the pages of the British Medical Journal by two senior doctors, Sir Iain Chalmers of the Cochrane Centre and the paediatrician Edmund Hay” http://www.guardian.co.uk/uk_news/story/0,3604,1161429,00.html Despite the concerns raised by the BMJ and the Cochrane Centre, the GMC enlisted Professor Griffiths to look into the concerns I had raised. It will be enough to state that at this point, Professor Griffiths’s view did not correlate with the Trust and Deanery letters as well as the CHI report. Indeed, I support the criticisms made of him by the Cochrane Centre. Professor Rod Griffiths is currently within the GMC complaints procedure. I believe the Conchrane Centre should report him in line with their criticisms in the BMJ. It should be noted that the Guardian article points out that Professor Southall was innocent of the charges levied upon him and supported by Professor Griffiths. In my view, no amount of spin will persuade the good doctors of this country that the GMC is about to change. The conduct of the GMC has brought the reputation of the medical profession into disrepute. The GMC is currently falling into the huge black hole it has created for itself over the years. The amount of finances spent on cases against R v GMC Ex Parte Toth, R v GMC Ex Parte McNicolas, Richards and many many more is an example of abuse of doctor’s funds. These doctors work extremely hard in a substandard system. The GMC is certainly not assisting them at present. An example of what the GMC does with its time is featured in the case J Coleman v GMC. Further evidence can be found from the statements made by committee members listed within the article http://www.nhsexposed.com/healthworkers/doctors/gmc/gmc_witchfinder_general.shtml. I hope you Professor Catto will be instrumental in letting us all know when there will be an overhaul at the GMC. Do you not think it is time to change the GMC population as opposed to the procedures? Of the new procedures, Mr Arpad Toth who has fought the GMC for 12 years and is aufais with the GMC rule book said the following – “The new procedures are draconian, disjointed, incompatible, unfair etc”. There is a review from a person who has studied your system the most. Your contribution to the BMJ does not persuade any of us that the GMC is about to change. Better Luck next time. Kind Regards Dr Rita Pal NB I am writing this on behalf of a number of my colleagues and friends. I would be grateful if the BMJ would kindly publish it to represent our views. Competing interests: R Pal v GMC - GMC President allowed 84K of doctors' subscriptions to be wasted on a court case |
|||
|
|
|||
|
Davina Hollisey-Mclean, Housewife and mother, rebuilding family life and fighting for justice for 15 years ! SA4 3DT
Send response to journal:
|
"No one loves the General Medical Council, but being unfair to doctors as proposed by Smith(1) is surely no solution. Reform must be based on logic and fairness. Dame Janet Smith’s recommendations appear to start from the presumption that every doctor is a nascent Shipman(2). If implemented doctors will be subject to such a draconian regimen of oversight that it will be relatively easy to destroy a colleague’s career by starting a few rumours or disaffected patients starting a juggernaut of a quasi-legal process which would make Jarndyce and Jarndyce look like summary justice(3). The current system is bad enough and has been well manipulated, for example against David Southall(4)" Dr Ellis, welcome to our world ! Not so much appreciated when the shoe is on the other foot, is it? Parents wrongly accused of MSBP have been subject to a " draconian regimen of oversight " in which it has been all too easy to destroy families. We are not talking careers, we are talking about families torn apart by disaffected doctors starting a few rumours, but because it was a doctor who started the rumour it is taken as fact and never questioned. I guess that it's exactly what you are doing too. Have you ever bothered to speak to families who have been wrongly accused of child abuse? Have you ever sat and looked into the eyes of Mr & Mrs Cannings, or Mr & Mrs Clark? If you did would you see the pain and suffering that they have endured reflected within? I dare say not, you are only interested it would appear in the destruction of careers! While you are on the subject of " manipulation " maybe you would like to consider how the system set in place to protect vunerable children appears to have been "manipulated" by some of your fellow professionals! Competing interests: Parents ! |
|||
|
|
|||
|
Alex M Grieve, Chief Medical Officer GKN plc, B98 0TL
Send response to journal:
|
I believe this editorial makes a number of important points, which resonate with views I have been expressing as a "lone voice" for some time. I am an Occupational Physician with several "Fellowships", vocationally trained in 2 disciplines and the Group Medical Adviser of a global engineering company. I have participated in Continuing Medical Education (CME), and more recently Continuous Professional Development (CPD) since its inception in the Faculty of Occupational Medicine in 1996 - that alone makes me one of a rare breed. I am a member of the Faculty's Revalidation Committee, and in 2001-2002 was Registrar of the Faculty. I therefore claim to have an informed personal view. I have watched askance at the ritual dance which the profession has been engaged in over the last few years on the subject of revalidation. I believe it to be bureaucratic and unwieldy. I can not imagine many of my hard pressed colleagues have ever read the full papers, and I believe even fewer of them will do the process much justice in reality. I am particularly apprehensive about the emphasis placed upon Appraisal. I have worked in organisations where appraisal was mandatory (Armed Services, Shell), where the process was clear and where training and protected time were given to enable the practicalities. I am now expected to believe that autonomous (and autocratic) medical practitioners, including NHS Consultants and GPs, are universally and effectively embracing this process! My overall view of the revalidation process is that it is bland, general and qualitative. It is rich in bureaucratic language with numerous internal repetitions of various themes, upon which the whole system depends, but much of which has not yet been defined. I am perplexed by the GMC's view that there has been no revision or improvement in medical training, verifiable medical practice or post graduate training since 1858, and that since then, things have been managed "by exception"! Have they completely ignored the post graduate training process, especially post Calman, and in particular; approval of training posts, trainers, enrolment of trainees, the post graduate curriculum, the SpR process, the RITA process, and after all that, the wealth of work done on CME and now CPD? These various comments lead me to wonder whether it is the GMC that is in need of reform, rather than the rest of us. Once you get beyond these apparent gaps in their thinking, if you can master and repeat "Good Medical Practice", "Revalidation", "Appraisal", "Quality Assured System" - and repeat them ad nauseam, then you have probably captured the spirit of the proposals. Each of these ideas is, from it's own point of view, aspirational at present and, at best, will be qualitative rather than quantitative in future. A "quality assured process" assures us of the quality of the process, not the product. "Good medical practice" states that doctors should have an "appropriate relationship with their patients" and "must work effectively with their colleagues". This tells me nothing. A more sensitive person would find it insulting. One who did not understand it would be no wiser. I am sorry to sound very negative, but the process does appear patronise the majority of excellent, conscientious and effective practitioners, whilst it will never prevent the next Harold Shipman. Poor medical practice is obvious to us all. A more directly targeted and effective way of highlighting it (whistle blowing, clinical audit, pharmacists monitoring prescribing habits) might be more effective and less expensive. There must be better ways to focus and target our energies. Kind regards, Alex Grieve Competing interests: A deep seated anxiety about the effectiveness of "quality assured systems". |
|||
|
|
|||
|
Mark Struthers, GP and prison medical officer Bedfordshire. mark.struthers@which.net
Send response to journal:
|
No one loves the GMC. Simon Ellis’ writing is extraordinary yet bleak, chilling and yet fascinating. Harold Shipman was tried and then convicted to the criminal standard of proof. No one doubted the verdict, the system or the penalty as appropriate. Harold Shipman was a clever psychopath and no one had guessed, not even the GMC. Sally Clark and Angela Cannings were convicted for the murder of their infants and beyond any reasonable doubt. The trials appeared to start from the presumption that two infant deaths were indicative of a nascent killer. They were sent to prison for life. The public thought the system was fair, efficient and proportionate and the doctors did too. Everyone trusted the direction of the judges and the decision of the jury. The adversarial relationship between doctors and lawyers – the legal model – turned out to be a failure. The system was psychopathic: it didn’t care. Beyond any reasonable doubt, Dr Ellis wrings his hands for the doctor guilty of serious professional misconduct and the tipping scales in the balance of justice. Life is so unfair. Shipman was an ‘intelligent psychopath’ and now medical society suffers the fallout from the Dame Janet Smith inquiry. That is life for the doctor today. Psychopaths are a challenge to society: they cause a lot of damage and a lot of expense. They ruin lives. The clever ones are enormously difficult to recognise and to deal with. They manipulate the system, are manipulative of the system and are above the system. The costs to society are fantastic. Is Simon Ellis oblivious to the irony of his words? Expedient, expeditious and value for money, yet the GMC is unloved. Does anyone care? Competing interests: doctor, father, taxpayer and (untreatable) patient |
|||
|
|
|||
|
Mark I Burgin, General Practitioner Rotherham Road Medical Centre 100 Rotherham Road Barnsley S71 1UT
Send response to journal:
|
The GMC suggests that its job is ‘guiding doctors’ but when I wrote a couple of years ago for guidance as to reasonable practice I was told that the GMC cannot offer guidance on specific areas as it was too difficult to get consensus. I instead had to contact a medical defence organisation for advice. I was concerned at the time that the GMC had lost its way. A lawyer friend described to me the GMC as an archaic court who primary interest is to stop doctors from embarrassing each other. Whilst this seems harsh it would explain the near fanatical zeal it tries to stop doctors from falling in love with their patients and the slowness of their response to doctors who deliberately kill their patients. The answer in my opinion is to do away with concept of ‘serious
professional misconduct’ – what does that mean anyway? The GMC should be
interested solely in whether the doctor committed a crime and how that
should affect the doctor’s practice. This work would include ensuring that
doctors who have practiced abroad have not committed criminal offences
whilst there. A separate agency would be invested with the role of helping
doctors with problems. At present some doctors refuse to participate as
they feel the present system is unhelpful - it is for many. All doctors
should have access to a
Looking after the health care personnel looks very expensive -and it will be - but when compared with the tens of billions that are spent on health care and especially IT and NHS direct is it not time one of the main resources in the health service was properly managed? 50 per cent of doctors will always be below average, it is up to the employer to ensure that they have systems in place to attract the best doctor they can. Problems with competence will then be solved by market forces. The basic principle should be that no doctor should lose their right to practice without a crime. Competing interests: None declared |
|||
|
|
|||
|
Brian D Keighley, GMC elected medical member for Scotland Balfron G63 0TS
Send response to journal:
|
Richard Smith seems to be able to have two bites of the cherry with a highly critical editorial followed by a rapid response recounting his subjective memories of incidents that involved him and the GMC between fifteen and twenty years ago. He describes a "doctor dominated" culture that then obtained, but fails to point out that the proportion of lay members has advanced from tokenism, through 25%, to 40% of the Council and that there is now only one medical member of Council that has survived from the late eighties. He then suggests that the regulatory probity of those with BMA credentials cannot survive the short distance between Tavistock Square and Hallam Street. As someone who has served the BMA in fairly senior roles for many years, I can only surmise that I may be one of those to whom he refers. Richard also knows me as a long-serving director of the BMJ Publications Group, as a Council member of my Royal College and as a former chairman of the Joint Committee for Postgraduate Training on General Practice (one of the other two UK medical regulatory bodies). He may recall that I have never been particularly restrained when criticising any body with which I have been associated and that in these very columns I have argued the case of the GMC in the name of professional regulation and its primary purpose of protecting the public. Richard makes sweeping criticism of many doctors in the past and in the present, but his evidence is anecdotal and not exactly imbued with the same level of objective evidence he demanded from others as Editor a few short months ago. The GMC is not the same body it was in the late eighties; a fact I can not assert with the same level of confidence about the BMA. Brian Keighley Bkeighley@aol.com Competing interests: Competing interests: a non-executive director of BMJPG, who also passionately believes in editorial independence. |
|||
|
|
|||
|
Neville W Goodman, Consultant Anaesthetist Southmead Hospital, BS10 5NB
Send response to journal:
|
The title of Richard Smith's editorial, 'expediency before principle', was a common media soundbite when Dame Janet Smith's report was published. But we put expediency before principle every day, in all sorts of everyday ways. Bad driving kills 3000 people every year, and injures and maims thousands more. We don't insist on retesting drivers; we don't even demand any querying of the ability to drive unless drivers have already had an accident, or have reached the age of 70. By all means, improve medical education, and increase the likelihood that practising doctors are worthy of their licences, but let's not try to pretend that we can ensure that no patient will ever be harmed by a doctor's incompetence. Competing interests: None declared |
|||
|
|
|||
|
stephen mccabe, general practitioner portree, isle of skye
Send response to journal:
|
The "pussycat" GMC as portrayed by Dame Janet Smith is not one that I recognise. Most doctors I know, myself included, are terrified at the prospect of being up in front of the GMC. We do not believe that we will receive a balanced hearing or that the GMC will come down inappropriately in our favour. It is clear that the GMC has lost public and professional confidence and that change is needed. The debate is how much and in what ways? Dame Janet's view seems somewhat retributional and in this way it perhaps reflects the shift in the way that justice is viewed in the UK away from justice towards a more US model of retribution inappropriately promoted as justice. I would suggest the following measures:
I hope that such measures would help the public in seeking justice where they have been wronged while at the same time reassuring doctors that they are not about to become the victims of a turkey shoot! Competing interests: None declared |
|||
|
|
|||
|
Alan Leaman, Consultant in Emergency Medicine West Midlands
Send response to journal:
|
Dear Sir It was a mistake to allow Richard Smith another opportunity to have a go at doctors (1). His loathing for his profession has been apparent for several years, and many will wonder why his hostile views have been given further space in the BMJ. Medicine is a highly demanding profession, requiring sustained commitment and prolonged undergraduate and postgraduate training. The idea that all this might be brought to a premature end by a crude and ruthless system of reaccreditation or re-examination is naturally unacceptable to most doctors. Furthermore it would deter the many talented young people who still seek to join our profession each year. The way forward is not to undermine the professionalism of doctors but to harness it, perhaps by a system of trained, same speciality, mentors. Alan Leaman (1) Smith R. The GMC : expediency before principle BMJ 2005 1-2 (1 January) Competing interests: None declared |
|||
|
|
|||
|
Arthur Rushton, retired pharmaceutical physician Chester CH3 5LZ
Send response to journal:
|
Editor, I was saddened to see that Richard Smith has joined the anti- GMC feeding frenzy initiated by Dame Janet Smith’s final Shipman report. As usual, when journalists are presented with an opportunity of this nature, they ignore most of the facts and attack whatever ‘soft target’ has been identified. The key (ignored) fact in this case is that Dame Janet Smith concluded that the GMC was not at fault in the Shipman saga. Unfortunately she then clouded this conclusion by adopting a very dangerous judicial stance, along the lines that ‘You are not guilty in this case but I’m going to expose all your putative crimes anyway.’ In doing so she has presented the public, the press and the government with a scapegoat for all problems associated with standards of delivery of medical care. Sadly, however, no amount of change to the GMC will prevent another Shipman, because the basic system failures that allowed Dr Shipman to escape detection for so long lay not in the GMC but in the NHS. If adequate management control systems had been in place in the primary care sector of the NHS, then his criminal activities would have been detected much sooner by one of the following measures; i) the excessive use of morphine and other opiates in his practice.
In my opinion it is clear that the NHS Executive failed to apply adequate monitoring systems and processes in primary care, either directly or through the local Family Practitioner Committees(FPCs). They must now ensure that this situation is rectified, ideally through the recently established Primary Care Trusts(PCTs). The GMC’s role should be to work with the PCTs to agree and standardise monitoring processes and criteria, and then to promptly, fairly and openly investigate any suspected cases of incompetence, negligence unprofessional and/or criminal behaviour thus identified or otherwise reported to them. Finally before issuing her fifth report, Dame Janet might have reflected as to how well her own professional body, the Law Society, measures up to the responsibilities and standards that she expects of the GMC. Dr A Rushton Competing interests: None declared |
|||
|
|
|||
|
John J Turner, Consultant Physician University Hospital Aintree, Liverpool L9 7AL
Send response to journal:
|
Richard Smith's editorial expresses doubt about the ability of the GMC to reform. This paves the way for more political overeaction to Dame Janet Smith's Shipman reports. The desire to achieve a culture of strict regulation is resulting in the appointment to the GMC of lay members selected for their anti doctor sentiment by a remarkably anti doctor government administration. Medicine may be justifiably considered a special case but the proposals for accountability and disciplinary procedures are now going far beyond those of the judiciary and civil service. A disproportionate level of punitive action is proposed with procedures taking on a criminal investigation format for suspected departures from standards of professional conduct. Underlying this is often a test of attitude rather than competence with draconian suspensions of excellent caring competent clinicians for being 'off message'with a Department of Health tainted with government spin. This was illustrated in the Alder Hey tissue retention investigation resulting in a Witches of Salem approach, deeply unfair to the medical staff and very damaging to a high standard Children's Hospital. The end result was needless prolonged anxiety to families and unresolved legal action and I wonder if Janet Smith regards this as a desirable outcome. An unhealthy climate of fear has developed across a profession that is in danger of becoming deprofessionalised. This may well be the political objective but it is surely not in the public interest. There is no doubt that this is inhibiting clinical decision making in primary care, hospital emergency departments and elsewhere with defensive clinical practices leading to large hidden costs, and stimulating a paralysing bureaucracy. The legal, risk management and clinical governance departments are becoming the fastest growing areas of the NHS diverting substantial funds from direct patient care. Competing interests: None declared |
|||
|
|
|||
|
James Johnson, Chairman of BMA Council BMA House, London, UK WC1H 9JP
Send response to journal:
|
Editor – The BMJ’s rigorously exercised editorial independence is well demonstrated, but lest any readers mistake Editor’s Choice and Richard Smith’s editorial on the GMC for BMA policy (BMJ 1 January 2005), I would like to stress that these were not the Association’s views in the wake of the fifth report of The Shipman Inquiry. In his editorial, Richard Smith, long-term critic of the GMC, says Dame Janet Smith finds deficiencies in the GMC’s new fitness to practice procedures introduced in November 2004. Would it not be sensible to allow the new system a chance to prove itself before condemning its existence? Dame Janet in Chapter 27 of her latest report says broadly speaking the changes are an improvement and states “I do not know how well they will operate in the interests of patient protection” . She believes it would be sensible to allow the new procedures “to develop and settle down before their adequacy and fitness for purpose is judged”. The BMJ editorial does not reflect this. The Inquiry set out to ensure that if ever there was another potential Shipman he would be detected very quickly. The BMA supports the suggested reform of the coronial system, death certification procedures and drug monitoring which will assist this. The Inquiry also set out to enhance the prospect of detecting aberrant behaviour or substandard performance in doctors. I believe the new systems of appraisals and Revalidation do that and hope the current delay to the introduction of Revalidation is as short as possible. Developing Revalidation has been a difficult process for the profession, but doctors worked determinedly with the GMC to produce a system that would work. They deserve credit for that. The third aim of the Shipman Inquiry was to allow scope and opportunity for the continued improvement of “the good quality care provided by the large majority of doctors”. Response to the Shipman Inquiry has to be proportionate and we must not let this last aim suffer in the rush to secure the first two. Doctors in this country already feel more regulated, micro-managed and subject to bureaucracy than colleagues in other countries Richard Smith says that wherever there has been a trade off between protecting the public and being fair to doctors the GMC has taken the side of doctors – is this borne out by the facts? Most doctors still work in fear and trembling of a letter from the GMC and recent events suggest the GMC has been bending over backwards to ensure it is not seen as protecting doctors. Dame Janet Smith recognises that, as well as protecting patients, the GMC has a duty towards doctors and “must be fair in all its dealings with them” but she believes that in the past the balance has been wrong. I don’t regard being fair to doctors as a crime. I would expect any regulator to make absolutely sure it is fair to all parties. The BMA is in favour of professionally led regulation. We backed the need for change within the GMC, now let us allow time for the benefits of those changes to be demonstrated as being fair to doctors and protecting patients. James Johnson
Competing interests: None declared |
|||
|
|
|||
|
deborah m henshall, parent/carer home
Send response to journal:
|
Obvoiously the GMC is not guiding doctors or protecting patients but who gives a damn? For 7 years now we have begged the Police and the goverment to take over our case as soon as it became obvious that the GMC were not capable of protecting anyone not even themselves from harm. To no avail, I feel sorry for the whole country ,including doctors who will ,I`m sure be a patient at some time in their life. Unfortunately you can not mould a doctors personality to make him better than anyone else or to make him care about all of his patients. He will have many different agendas and it wont always be honourable. However we should listen carefully to agrieved parents or patients in order to ensure that there is no danger to others. We should not presume them vexatious just because they feel the need to scream from the rooftops that they have been wronged. Heed the warning or risk further harm. It is not helping a doctor to cover his inadequacies or mistakes even if they are not his fault. Investigate the circumstances immediately do not procrastinate whilst people die or are damaged in the process. If this action highlights a massive problem and knocks public confidence then fix it and restore peace of mind. Simple. Competing interests: dissatisfied complainee to the GMC |
|||
|
|
|||
|
Sir Alexander W Macara, Chairman, National Heart Forum London WC1H 9LG
Send response to journal:
|
Dear Sir, Inexplicable omissions in Richard Smith’s intemperate leading article “The GMC: expediency before principle”(1) prompt me to break an unhappy silence. In late 1994 the British Medical Association organised a “Core Values Conference” for the whole profession (BMA, Royal Colleges, Deans, GMC). It addressed the challenges facing the profession as outlined by an eminent lay member of the GMC which, led by its then President, Lord Kilpatrick, had already formulated performance review procedures and called for action by us all. During the following turbulent years – and intensively during 1997 and early 1998 – discussions in each part of the profession culminated in an historic commitment “Self-regulation and clinical governance at local and national levels” co-signed by the chairmen of all the leading medical organisations, which was sent to the Secretary of State for Health, Frank Dobson and others on 2 July 1998. In a covering letter, Sir Norman Browse, chairman of the Joint Consultants Committee, on behalf of the whole profession, expressed the belief that the document complemented the Government’s contemporaneous clinical governance proposals, and that they would “together solve problems at an early stage and at local level”. The italics are mine, to emphasise that the profession’s united commitment was to deliver accountability through acting proactively at the earliest possible stage in the identification of any problem involving a colleague through its various mechanisms. The “culture change” to which the whole profession thereby committed itself was to delivering early prevention at source, rather than leaving problems to the GMC to resolve when it was already too late. What, one might ask, happened to this initiative, because I believe that, had it been vigorously pursued, much if not all the trauma of the past six years could have been avoided. What I do know is that within days of its release a number of the co-signatories, myself included, had demitted office and Sir Donald Irvine, as President of the GMC, had produced his revalidation proposals. It is difficult to resist the conclusion that the shifting of the focus to these proposals (now seen to be flawed) distracted the profession as a whole from the more promising combined operation on which it had embarked. Sir Alexander W Macara
(1) BMJ 2005; 330; 1-2 Competing interests: None declared |
|||
|
|
|||
|
D Michael Davies, General Practitioner Hereford HR2 8HT
Send response to journal:
|
Dear Sir, Whilst the profession thrashes around seeking an appropriate response to the Shipman Enquiry it would be wise to consider the wider political perspective. Let us not forget that Governments heavily influence the choice of Law Lords for a particular review. The Hutton Enquiry demonstrated how effective and favourable this technique can be for those in government. Clearly, similar considerations regarding the potential eventual conclusions of Dame Janet Smith's enquiry would have been made. There are a great number of recommendations in Dame Janet Smith's report that the profession will wholeheartedly support but we must be careful that their implementation is not used by those in power to restrict the freedom of individual doctors to act in the best interests of their patients. Governments like to control. This Government in particular abhors lack of control and will be keen to restrict our freedom of action. The profession will need to be aware of these potential restrictions when the Government's eventual response is published. Just because we're paranoid doesn't mean that they're not out to get us! Yours faithfully, Mike Davies Competing interests: None declared |
|||
|
|
|||
|
Rita Pal, Editor NHS Exposed www.nhs-exposed.com
Send response to journal:
|
I find the views of Alan Leaman and James Johnson rather disturbing. I would like to examine in more detail Leaman's statement that "Furthermore it would deter the many talented young people who still seek to join our profession each year". In my view, those at the top of the profession do enough to deter young doctors. West Midlands Deanery (the Deanery Leaman works in) has some interesting behavioural traits. Here is how junior doctors were treated there. In 2000, my main complaint to the GMC was the lack of support for junior doctors at West Midlands Hospitals. Professor Temple ( Dean) was interviewed by the Evening Mail in Birmingham His view was presented on the 18th February 2000 ( Expert Defends Quality of Health Service). He said " The world has changed since the times these doctors were left on their own and we're keen to ensure there's a clear chain of command" He went onto say " Over the last five years one of the things which has changed quite dramatically is that doctors are supervised properly". Documents from the hospital stated ( letter dated 2nd December 1998)Reference number CAC/AR/Let Dr Colin Campbell Deputy Clinical Tutor at North Staffordshire NHS Trust said “ They should have proper clinical supervision at all times” and help from a more experienced colleague should always be available. On discussion with several of them they are still working without immediate supervision”. Incase, Professor Temple states he was unaware of the above. Dr Colin Campbell goes onto state in the same letter “ As far as Miss Pal’s education is concerned I am trying to decide in conjunction with John Temple what the best thing to do is" When I first raised these concerns they were ignored by the GMC and the Deanery. The CHI report in 2002 stated the following "CHI’s Clinical Governance Review in 2002. Paragraph 5.34 of the report stated: "CHI was informed that junior doctors working in medicine were often inadequately supervised and often left alone on wards, particularly on the medical assessment unit (MAU). During an evening visit we found only two junior doctors covering MAU, which was full to capacity, with a further junior doctor covering MAU and emergency admissions; one junior doctor covered the medical wards and one covered medical outliers but these patients could be on wards on either site. CHI felt this situation posed a potential clinical risk to patients.” The 2002 report went on to say, in Paragraph 5.78: "There were a number of concerns raised regarding support and supervision for junior doctors working in medicine. We were told of a number of occasions when it was felt there was a lack of support both during the day and when problems arise whilst oncall. The Trust has acknowledged that medical staffing at all levels is under resourced in medicine". The letter dated 2nd December 1998 was found in the West Midlands Deanery files and had been accessed by Professor Temple prior to the newspaper interview. The eminent doctors on this site who attempt to encourage young doctors into the profession should pay some heed to the New Doctor and GMC guidance on supporting new doctors. Indeed, it states that PRHOs should never be left unsupported. This is simply an example to illustrate the activties of the Deanery Dr Leaman works in. In contrast to his views, a large number of doctors are in support of Richard Smith and welcome his article. As for Mr James Johnson, he should be aware that the BMA refused me representation in 1998. I am also acutely aware of the condescending remarks at the Birmingham BMA office and indeed I have access to all the information. Indeed, it will be enough to state that the BMA left me as a PRHO without any support and sought to represent my consultant at the time. The above evidence causes some embarassment to them on this occasion. The BMA remains unsupportive of whistleblowers. I hope the above will go someway to illustrate why editorials from Richard Smith are needed. He is a doctor who speaks for us all with the accuracy of experience. He deserves the respect from his peers. Indeed, Richard should be packed up from his present job and deposited at the BMJ editors office forthwith. Doctors like him are acutely needed to represent the interests of the vast majority of medical professionals. Kind Regards Dr Rita Pal Editor www.nhs-exposed.com Competing interests: R Pal v GMC |
|||
|
|
|||
|
William G. Pickering, Doctor 7 Moor Place, Gosforth, Newcastle upon Tyne. NE3 4AL
Send response to journal:
|
Clinical accountability. It did not need Shipman to tell the world that the British health services are all too often in deep clinical trouble. Disasters such as Cleveland in the 1980s told us that, and even long before there was plenty to chew on [1]. Few antennae were alerted, lessons were ignored, and so today one serial medical disaster still follows another. Rudimentary single medical errors, sometimes isolated, sometimes the fuel of serial debacles, coexist alongside decent medical practice. Nobody looks for, counts or remarks upon them to their perpetrators. No sentient medical mortal, therefore, need ask 'how could Shipman happen?'. All sorts of things can and do happen in the health services (public and private). No one is looking. To make her point, the reports produced by Dame Janet Smith's Inquiry occasionally utilise observations of others. In conspicuously bold type (presumably so nobody misses it) one such contributor says: "The conclusion I have come to is that all doctors, and not general practitioners alone, share responsibility for creating the circumstances that enabled Shipman to be so successful a killer". This comment was, we learn, in a lecture given to 'honour' an ex-president of the GMC [2]. It must have been some 'honour' to hear this. The speaker might just as well have said to his heady medical audience, 'all your working lives you have been complicit with the evolution of medical disasters by not batting an eyelid to stop them'. The pitiful list of horrors set out weekly in the public press would rather have borne him out [3]. Current GMC president Catto writes to the BMJ telling of his "delight" that 'revalidation' has been stopped in its tracks [4]. "It is only common sense" he wholesomely tells us. Ex-GMC president Irvine confides to The Guardian he is "delighted" too [5] - both gentlemen speaking as though the GMC had nothing to do with revalidation's inadequacies. With the benignity so often found in medico-politicians, he further informs Guardian readers: "People believe they should have a good doctor - it shouldn't be left to chance". The value of such of wisdom is very nearly incalculable. People also believe everyone should pay their taxes, and that it too shouldn't be left to chance. It isn't. There are Tax Inspectors - not tax revalidators. By examining the client's records when necessary, they make the client accountable, one way or another, for what they have done - promptly. People whistleblow to the Revenue too. Some may think this is a long way from medical regulation. It is. The Revenue respond. Irvine further unburdens himself: "poorly performing doctors make mistakes because they are not up to date" [5]. Not up to date? Which medical disaster did he have in mind? Most are caused by disobeying very old-fashioned medical rules indeed (but which are still the bedrock of clinical medicine). There has been a recent professorial blunder to remind him of this [7]. Being up to date is very desirable. But if the GMC (or anyone else come to that) think that 'not being up to date' is the root cause of medical errors then things are even worse than Dame Janet thinks. Not examining the patient, overlooking an abnormal electrolyte result, taking a slipshod history, disregard of current medication, etc., are the source of most errors. Revalidation (or "regular MOT tests for doctors", as Catto loves to call it [6]) will not address these rudiments, nor will address what actually happens — any more than re-sitting the driving test would obviate the need for traffic police. There is no extant or planned mechanism (yet) that has even a chance of promptly stopping doctors who drive through a clinical red light [7]. Irvine, with that sudden access of carefree openness which so frequently accompanies the superannuated, uncorks the news that there are "11,000 doctors who are just not good enough" [5]. Why did he not tell us this when in harness? We realise he endured the embarrassment of probably more medical debacles than anyone else (the most noteworthy being from his own specialty of general practice) and he may be dazed: but how and from where does he get his figures? Above all, what does the GMC know about medical errors or how many there are? It is always several laps (or years) behind the victims, the press and the law. The GMC spectate upon their own pathology without, it seems, the slightest clue as to what is wrong with them. They pull this possible treatment out of their formulary, and then after another disaster or Inquiry, they try a new one. Some commentators, lay and professional, write that 'the GMC should do this or do that' as though there must be a never-ending resuscitation of that institution. The current BMA Chairman (who thinks doctors and the GMC "deserve credit" for producing revalidation) nonetheless laments: "Doctors in this country already feel more regulated, micro-managed and subject to bureaucracy than colleagues in other countries" [8]. Leaving aside the striking matter of the BMA complaining about bureaucracy [9], one reason doctors feel more regulated is because none of the measures of the last few decades have been even slightly effective. More disasters. More layers of ineffective regulation. And so on. "The BMA is in favour of professionally led regulation" the chairman adds mysteriously. Can he un-bureaucratically clarify? Is this different to the professional self-regulation which leads to disasters? If so, how? If a mentality embracing 'clinical accountability' were to replace the ever-changing, stuttering bandwaggon of 'revalidation' then this might break the habit of seeing all quality issues through the narrowness of GMC spectacles. Of this body Dame Janet pointedly writes: "It is axiomatic that the best indicator of future attitude and performance is past attitude and performance" [10]. A welcome change of view and focus, needing only a little versatility and energy of thought, may lead directly to the method required for identifying at least some single clinical errors. It would logically compel implementation of an impartial, informed mechanism to bear down on them so that daily, and in all regions, they promptly cease [1,11,12]. And no, not all errors can be picked up, any more than can all bad drivers. But one doctor stopped over a rudimentary clinical error in Swansea, Sheffield or St John's Wood would give all others in the vicinity pause for thought. Another the next week, and the next, would clinch the issue. Ripples of accountability would not take long to raise standards. Because the mechanism to exact clinical accountability of doctors will necessarily involve access to the medical records, this also makes patients accountable. Vexatious complainants and vexatious whistleblowers (medico-politicians discuss this important matter privately frequently, publicly never) will be as identifiable as errant doctors [13]. This, by sparing them from groundless allegations, might make clinical accountability a less bitter pill for decent doctors - and a no less welcome innovation for the majority of patients whose complaints, properly examined, are crucial to raising standards. The lawyers may cough a little, but that is of no moment. The taxpayer will rejoice. Not least because they are occasionally patients. Author: William G. Pickering. Date: 07.01.05 Email: wgpi@hotmail.com References: 1. Pickering W. G. Glasnost and the medical inspectorate. J of RC of Gen Pract. 1988. Nov. 38:316:517-518. 2. The Shipman Inquiry. Chairman: Dame Janet Smith. 2004. Fifth Report. Vol 1. Para 1.10. p69. Quote from Sir Richard Baker, Director of Clinical Governance Research & Development. University of Leicester. 3. Pickering W G. The GMC, royal colleges and DoH ignore warning signs for decades. http://bmj.com/cgi/eletters/329/7466/591-c#74370, 15 Sep 2004 4. Catto G. The GMC: principle not expediency http://bmj.com/cgi/eletters/330/7481/1#91079, 3 Jan 2005 5. The Guardian. 18.12.04. Page 1. "Doctors failing 3m patients". 6. Catto G. BBC Radio 4. "Down With ?" [the GMC]. May 2004. 7. Pickering W. G. Rudimentary medical errors. http://bmj.com/cgi/eletters/328/7454/1455#63653, 21 Jun 2004 8. Johnson J. BMA Chairman responds to GMC Editorial http://bmj.com/cgi/eletters/330/7481/1#91576, 6 Jan 2005 9. Pickering W. G. Re: Experts & Quality Control. http://bmj.com/cgi/eletters/329/7478/1353#88520, 9 Dec 2004. 10. The Shipman Inquiry. Chairman: Dame Janet Smith. 2004. Fifth Report. Volume 2. Page 465. Para 15.80 11. Pickering W.G. An Independent Medical Inspectorate. In: Gladstone D, ed. Regulating doctors. London: Institute for the Study of Civil Society, 2000: 47-63. ISBN 1-903 386-01 12. Pickering W. G. Systematic clinical accountability is required. British Medical Journal 2003;327:1109 (8 November) 13. Pickering W. G. How to control the misuse of health services. British Medical Journal. 1996;313:1408. (30.11.96) Competing interests: None declared |
|||
|
|
|||
|
Stevie M Gamble, retired EC2Y 8BL
Send response to journal:
|
James Johnson, Chairman of the BMA Council, asks 'Would it not be sensible to allow the new system a chance to prove itself before condemning its existence?'. No, it would not. One might just as well argue that all clinical trials should be continued to the projected endpoint, irrespective of the number of adverse events occurring, on the grounds that the drug should be given a chance to prove itself. The new system is irremediably flawed by the removal of precisely those factors which would have made revalidation a genuine test of a licensed doctor's fitness to practise. It is irrational, therefore, to suggest that if it is applied over a period of time it will, in some mysterious way, achieve that goal. Stevie M Gamble Competing interests: None declared |
|||
|
|
|||
|
Deborah M Henshall, parent/carer home
Send response to journal:
|
Thankyou Dr William Pickering for your enlightened,extremely consciencious and brazenly truthful response. How refreshing in these times to read such a forthright response that clearly shows it is indeed possible to be a practicing doctor who understands the patient viewpoint and the importance of prioritising patient safety. I agree strongly with all that you say and sincerely hope that you are heard by those that are fortunate enough to instigate change in the NHS. I wish to thank the BMJ and indeed Richard Smith for thier efforts to improve standards of clinical practice not least by inviting open debate on some fundamental issues that normally bypass patient input. Keep it up it is appreciated by those that care and particularly service users. Competing interests: None declared |
|||
|
|
|||
|
Nigel Dudley, Consultant in Elderly Medicine St James's University Hospital LEEDS LS9 7TF
Send response to journal:
|
The response of Mr James Johnson on behalf of the BMA in support of the GMC is very likely to be perceived by the public and others as a further example of doctors closing ranks rather than welcoming outside scrutiny that may ultimately benefit the public and improve safety and quality of patient care. Mr Johnson's claim of the "new system of appraisals and Revalidation" being able to detect "aberrant behaviour or substandard performance in doctors" would not for example seem to be supported by the evidence provided by the recent Healthcare Commission investigation into the long running corporate and clinical governance failures in the Mid-Yorkshire trust. [1] Furthermore, the appraisal system failed to the extent that Mr Johnson along with others on the national ACCEA committee managed to provide a silver award to the group medical director of that organisation - a person who was subsequently highly criticised in the Healthcare Commission's report - in the latest round of awards. Under the circumstances, such an award undermines the credibility of the current system to reward consultants for "exceptional contribution of NHS consultants, over and above that normally expected in a job, to the values and goals of the NHS and to the patient" and arguably brings the ACCEA (Advisory Committee on Clinical Excellence Awards) system into disrepute. This is a taxpayer funded system. It would be interesting to read what was in the personal statement of the consultant applicant and that of the chief executive supporting the application for the national award and observe the extent of the discrepancy between these statements and the reality discovered by the Healthcare Commission's investigation. Appraisal detects underperformance and substandard performance? Perhaps not, but would regular re-testing and re-examination have picked up on these weaknesses? The GMC should perhaps concentrate on all matters other than discipline and leave that to a new body that could deal with nurse, therapist, doctor and manager failures to protect the safety of patients through substandard practices. There should be a fair system. However,it should be one that is fair to the public and also to the staff in the NHS and private healthcare sectors and one that receives the support, trust and confidence of both the public and professions. At present the GMC does not inspire public confidence in protecting the safety of patients and no matter how fast and far it changes it may never achieve that goal in relation to disciplinary procedures. [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: Interest in manager regulation and events in Mid-Yorkshire. Consultant at Pinderfields Hospital, Wakefield 1993 - 2000 Editorial note
|
|||
|
|
|||
|
Anita M Houghton, Careers counsellor and coach London SE3 0QR
Send response to journal:
|
I was very grateful to Richard Smith and Clare Dyer for their concise and lucid exposition on the latest report on the GMC. While it is crucial that the public are happy with the way in which the profession regulates itself, there is something which troubles me about the conclusions of the report, and that is the assumption that protecting the interests of doctors and protecting the interests of patients are mutually exclusive. It has been said by many a management guru that if you want to provide excellent customer care, you should treat your staff in the same way as you would like them to treat your most valued customer. Taken to its logical conclusion, patients can presumably look forward to being treated as incompetent until proven otherwise, at best, and as potential psychopaths at worst. As someone who regularly supports and counsels doctors, I weep for the vast majority who work with competence and enormous commitment, often to the detriment of their health and personal lives, and yet are subject to blanket condemnations and more monitoring every time a rogue doctor comes to light. But if it is true that people treat customers in the same way that they are treated themselves, it is the patients, paradoxically, who will ultimately pay the price for this relentless and hopeless quest to eliminate risk. The question arises, therefore, is it in the interests of patients for the profession to acquiesce every time there is a report like this, or should we be doing something else? Competing interests: None declared |
|||
|
|
|||
|
C Kevin Connolly, Retired Consultant Physician Aldbrough St John, North Yorkshire, DL11 7TP
Send response to journal:
|
It is arrogant beyond believe of Dr Richard Smith to dismiss views contrary to his as those of ‘the old guard’ supported by one intellect. In doing so he misses Lady O’Neill’s point that trust is essential, and can never be replaced by tests of accountability. Transparency itself is impossible without trust as ultimately fully independent validation is never possible without global knowledge, something to which no-one aspires. Accountability can and only can flourish in an atmosphere of trust and not vice versa. Trust does not prevent proactive measures provided they not become the oppressive norm. Realistically, as medicine has become more complex, it has become impracticable to perform a timely and adequate review of every practitioner, particularly the more experienced. Perhaps Dr Smith, Dame Janet and I might agree in this respect, inadequate review is a potent source of mistrust and therefore worse than nothing at all. Perhaps the GMC should learn from the Inland Revenue which now depends on trust for income tax returns, backed by random review. Unlike the Revenue the GMC should be open about its motive and meet the full costs of the inevitable disruption necessarily caused by an adequate and therefore prolonged review. The penalty of starting from a presumption of mistrust is that it is a self-fulfilling prophecy, the devious remaining devious, the previously naive and innocent try to protect themselves from the mistrusting regulator, and the honest but timid are driven out. Those who have been involved in specific investigation are rarely capable of making dispassionate broad recommendations over the whole field, as they will inevitably be unable to detach themselves sufficiently and so concentrate on measures to correct those faults irrespective of the collateral damage caused. The narrow expediency of Dame Janet (Shipman) and Dr Smith (research fraud) cannot match the broad wisdom of Lady O’Neill. Competing interests: Generally unsympathetic to legislative change aimed at achieving 'political correctness' |
|||
|
|
|||
|
Kiaran Asthana, GP Lakeside Medical Centre,Church Rd, Perton, wolverhampton WV6 7PD
Send response to journal:
|
The GMC is the price we pay for self-regulation. Are we defending a redundant principle? To the lay observer, the idea that professional self-regulation is better and more reassuring than a process owned by and accountable to Parliament must be a little hard to swallow. Similarly, a doctor might need some convincing that a post-Janet Smith GMC would be self-regulating at all, let alone that the profession should support it. Yet such support, from public and profession alike, is vital if the proposed reforms are to succeed. From what has been said, this cannot be taken for granted. The profession needs to decide whether or not it wants the privilege of running itself, and what sacrifices it would make to this end. An informed debate in the BMJ would be timely and welcome. The GMC needs to know if it has the support of its' members, and the BMA should consider a vote of confidence. A "yes" vote would give the GMC a mandate for reform. A "no" would spare us the pain and futility of fighting a lost cause, and allow us to move forward. Competing interests: None declared |
|||
|
|
|||
|
Rita Pal, Editor www.nhs-exposed.com
Send response to journal:
|
There are ofcourse many doctors who support patients and work extremely hard to overcome a number of hurdles placed by a underfunded NHS. Having dealt with the patient population for about four years, I have often found them to be unsupportive of doctors who find themselves to be in trouble with the authorities. It is as if the plight of doctors is completely separate from that of patients and many can say " we're not listening, we're not listening". The behaviour is very similar to their views on doctors. Often, there are a number of patients who are of the opinion that every doctor should place their own livelihoods at risk to support a patient. There are relatively few patients who support a number of doctors facing turmoil in their professional capacity. A relative once emailed me and stated " In my view, all doctors should place their profession on the line for us and obey the Hippocratic Oath otherwise they should not have become a doctor". One wonders if the public or patient population would sacrifice their profession for a doctor. The answer is ofcourse "no". In general, I have found the patient population to be ingrainly self centred - more concerned and even obsessed on occasion with their own cases. There are ofcourse a number of exceptions to this. The Shipman Inquiry tends to encourage a anti - doctor approach where each patient considers their doctor to be a Shipman or a Neale by default. This ofcourse remains the danger of the Inquiry findings. Many patients and their relatives misunderstand science and a number of complaints originate out of vendetta. I have known a number of doctors to be harassed for no reason - who have struggled through the FPD procedures simply because their patients have misunderstood science. Vexatious complaints is something the GMC does not understand and continues the " process". A doctor can be stuck at FPD and have to declare to their employer for about a year following a simple complaint. The GMC has stated in an email to me that " All complaints must be declared to your employer". Ofcourse we live in times of patient autonomy where the patient comes first and the doctor comes last. While Dr Pickering would back patient rights, one wonders whether Deborah would back doctor's rights? That is a very important question. In effect, doctors whose livehoods are ruined by GMC procedures are left by the wayside to fend for themselves. Deborah may well be aware of one case relating to this. In my own view, I see no reason why doctors should place their heads on a chopping board for patients who in the end will never support or thank them. The Shipman Report provides the license for many patient groups to harass doctors - out of vendetta or misunderstandings of science. This is a trend similar to journalists who fail to understand science in many instances and reduce thenselves into a tub thumping scenario. In my view ( from a great deal of experience), no doctor should raise their head above the parapet and whistleblow because when push comes to shove, you will notice that the repercussions are left for you as a doctor to face alone. Most will watch while you struggle to survive and offer you sympathy as opposed to constructive assistance. In addition, we know from the Shipman Inquiry itself that the NHS and the GMC are not supportive of whistleblowers. Indeed, while the patient population often complain that the doctors do not support them - one needs to examine the reasons for this. The patient population is not blameless, innocent or as vulnerable as they would have us believe. Chaudhari v King Georges Hospital and Great Ormond Street is a case where doctors were harassed ( an injunction obtained by the Trust) for four years through the GMC procedures and repeated complaints. Sedley LJ found no scientific basis for the relative's concerns. This is simply one example of the manner in which the GMC is used by patients to harass doctors. The NHS remains powerless to prevent the harassment of doctors. Indeed, the procedural necessity of the GMC can often propagate this harassment. The GMC complaints procedure is a interesting instrument of harassment - used by Trusts, patients and anyone who develops a disliking for the doctor. In effect, the GMC Registration will now be a sword of Damocles for every doctor. With revalidation looming, anyone can use the registration as a tactic to harass and threaten and there are no measures in place to prevent it. Kind Regards Dr Rita Pal
Competing interests: R Pal v GMC |
|||
|
|
|||
|
Dr John Rumbold, n/a West Midlands
Send response to journal:
|
It is an unsettling scenario Dr Pal paints but one I have come to believe is true. There are certainly more and more campaigns that believe the medical profession (usally in league with the pharmaceutical industry, government or both) have a secret agenda to immunise, sedate, dope or otherwise harm the population (why we are not told). Doctors are expected to be exemplary nay perfect not just in their medical practice but also in more peripheral areas like financial probity, sexual liaisons etc. Perhaps the medical profession in a post-religious age is a surrogate for the priesthood? Competing interests: None declared |
|||
|
|
|||
|
susanne mccabe, retired cf24 3pf
Send response to journal:
|
It is understandable that a group which accrues special priviledges, through working in a sensitive relationship with others, should be expected to hold special responsiblities. Very few citizens though expect healthworkers to be perfect saints. Most do a routine day to day good enough job and studies show that the majority of the population still respect and trust the medical profession. They are not silly enough to extrapolate from a few outrageous scandals that the profession as a whole is rotten, their own and others' shared experience tells otherwise. But it would be ridiculous not to expect calls for tightening up failing systems. As for what are termed 'vexatious' complaints, rarely are they trivial to the person concerned. Most often they have been handled badly. A high number of so called are made by colleages within the NHS against their fellow healthworkers. Some are found to be unfounded some are accused of being vexatious as the humiliating term can be part of an effective silencing or bullying strategy.Again there is no one explanation. Neither healthworkers nor those who use services or those who form campaign groups, whether practitioners themselves who feel agrieved or discontent with something or non medical service user groups,are the 'baddies'.They are dealing with serious difficulties and disagreements and the aftermath of negative experiences.Most want a solution to these but it is a process which takes time. Perhaps reading medical journals can give a picture which is unrepresenative of the majority view....after all only a small section of the medical community and the population as a whole participates in debates. Whether their concerns are reflected appropriately is unknown. Quote from Romeo and Juliet Competing interests: None declared |
|||
|
|
|||
|
lucy k cogswell, SpR plastic surgery Stoke mandeville hospital, Aylesbury. HP21 9DU
Send response to journal:
|
Why is the medical profession so insistent on self-regulation? We would laugh if the food industry decided to set up a closed body of self- regulation, choosing which of its practices to audit, and how and when to prosectue. Why should anyone trust us to put the general good of the public before own own interests as a profession; and more importantly, how can we prove that we are doing just that. I do not believe we can. I do not believe we should try. I strongly feel that as doctors, interested in promoting the health of mankind, we should request, and demand external regulation. Our outcomes should be audited by statisticians who know their work. Our junior doctors should spend their time developing their clinical skills and furthering research interests. With our genuiunely National health sevice, we have an unparalleled opportunity in Britain to compare results with our colleagues across the country. What are the baseline outcomes your specialty should audit? Why is the hospital down the road doing better than you? Can you learn from them? What are we scared of? Does the medical profession think that there will be a mass cull of underperforming doctors? Hardly - the government couldn't afford it! Imagine a system where retraining; sharing practices; spending a day in another unit to see how they do things were normal practices, not associated with shame or the risk of losing your job. And imagine all the data being collected by someone else - someone who produced reliable statisitcs, with the power to prove that your poor outcome was the result of underfunding, or lack of staff; not just your incompetence. More importantly for the public, it would be that person's job to identify the next Shipman. I'm not suggesting that we shouldn't be involved in regulating our profession; just that the day to day business of it should be done properly, seriously by people who know what they are doing. Doctors should keep to the business of healing. Competing interests: None declared |
|||
|
|
|||
|
Rita Pal, Editor www.nhs-exposed.com NHS Exposed
Send response to journal:
|
Over the last few months the newspapers have been strewn with doctors who have gone down the FPD route down the dark tunnel of the medical church otherwise known as the GMC. These doctors have not killed patients nor have they lied. They have had sexual liasons with the -- other side. The other side meaning the patient population. These doctors have been struck off the register faster than Dr Shipman. The evidence suggests the GMC is more concerned about sexual liasons than it is about dead patients. These doctors are paraded in front of the media much like the Witch hunts in the past. The noose is ready for weeks ahead and the final judgment is read out much like a death sentence. The GMC preens their feathers because the public pat their head and say "what a good regulator they are". Ofcourse, the GMC fails to understand that people who have affairs with their doctors or indeed find themselves discarded by that doctor are likely to have the " scorned woman" syndrome. Any scorned clever woman knows that the best way to seek revenge is to destroy someone's profession. There is no better way of seeking sympathy than to parade themselves as the hard done by, weak frail female who suffers from anxiety and depression. The average person in the street reads the Sun, browses through Jackie Collins and is influenced by the gossip magazines where the above scenario occurs every day. The "other side" is not always innocent and it does take two to tango. I have seen a number of patients make a play for rather dashing doctors. I often wonder how many cases have an underlying motive that is revenge. The GMC ofcourse expects doctors to be perfect human beings devoid of emotion. It is amazing how many doctors who end their relationship with patients end up at the GMC. Arpad Toth once stated that " the GMC is stuck in the 18th Century". Their repressive attitude to sex is self evident by the proportion of doctors who are struck off. The GMC gleefully parades the concept of abnormality according to their standards. Every doctor is supposed to read the Times every morning, never talk about sex never mind do it :)and formulate and think much like the GMC does - prose with no wit, glamour or personality. Dr Rumbold is right in that every part of our lives is governed by the GMC registration. I should really detail an amusing example of the manner in which the GMC behaves. The audience should remember that the GMC dislikes me. There is no love lost between us and they have craved to see me go down their FPD processes for a number of years. One has to give them 10/10 for effort. One of my hobbies is reading - I read Stephen King and have done since I was about 10 years old. Between the years 2001-2002 ( according to the documentation I have), the GMC decided to print out a posting I had written on Stephen King's fansite. The posting simply stated that I was a avid fan of Stephen King and that I liked his books. A GMC worker decided to print the posting out and collect that in my files as evidence of how " abnormal" I was. Indeed, the worker admitted to scowering the internet for material written by me, sailing the sea of the internet and carefully collecting material. ( GMC subscribers should note that they paid the salary for this work). Materials and letters written by me were termed "intemperate". Intemperate is ofcourse a word used to describe - abnormality - not the done thing in the world of etiquette. I see Richard has been labelled with the word intemperate. Different ofcourse does not equal abnormal or insane although the GMC have a habit of construing it in this manner. Not so long ago, they implied that a suggestive number plate belonging to a doctor was unprofessional. Ofcourse, in the " real world" doctors come in all shapes, sizes and personalities". Simply because our regulator is ruled by 18th Century values does not mean this should be used as a yard stick for doctors who are actually in touch with the modern world. I know many eccentric doctors who are respected by their patients. In reality, people appreciate the down to earth approach. In the year 2000, the BBC featured an article where the public accused the GMC of being out of touch :) with the public. Clearly their standards are not having an impact on the public hence they cannot be appropriate to expect doctors to behave much like the GMC. That said, if we all behaved like the GMC ( ref Shipman Inquiry), technically we would be struck off. For the above reasons, I agree with Dr Rumbold. The GMC has not moved with the times - it remains stuck in a time warp unable to set its own Tardis forward to present century medicine. Dr Who was lucky enough not have a GMC registration number but if he did have one - a file would have been collected on him for wearing long scarves, killing darleks contrary to GMC's Good Medical Practice and wearing a checked coat contrary to the GMC regulation tweed jacket. I often wonder what many doctor's files do contain. Indeed, if they conducted and admitted to a " discreet inquiry" on me then who else have they done the same to? Clearly, discreet inquiries are accepted and common practise otherwise the GMC would not defend its position in R Pal v GMC. The GMC often goes fishing but whose pond have they been delving in recently? Many doctors like me probably say - Oh but it won't happen to me - but it could be you.............. and as a doctor you would never know :) because the GMC is much like a magpie collecting their pieces of silver. According to Finlay Scott "transparency was like a greenhouse - you could look in but not enter the room.( External Review statement MLS/G3352/00018 evidence by Dr Richard Coleman). Dr Rita Pal Editor www.nhs-exposed.com Competing interests: R Pal v GMC |
|||
|
|
|||
|
John D Holden, General practitioner Garswood Surgery, Lancs WN4 0SD
Send response to journal:
|
No other health service employees make so many decisions of consequence as doctors. Perhaps as a result general practitioners in the UK can face investigation from fourteen regulatory systems: 1. Civil courts 2. Criminal courts 3. Coroner 4. Health Service Ombudsman 5. Health and Safety Inspectorate 6. General Medical Council 7. Council for Healthcare Regulatory Excellence 8. Mental Health Tribunals 9. National Clinical Assessment Authority 10. Health Care Commission 11. In-practice complaints systems 12. Primary Care Organisation complaints system 13. Family Health Services Appeal Authority 14. Information Commissioner How then can doctors be considered to be 'trusted rather than held accountable'? If doctor's performance was similar to that of senior Government ministers, seven of who have been obliged to resign since 1997, thousands would be forced out each year. The actual figures are tiny in comparison, so why must the policing of doctors be radically reformed again? Competing interests: None declared |
|||
|
|
|||
|
Robert D France, Retired Sandford Streamcross Claverham BS49 4LL
Send response to journal:
|
Dear Sir, As a member of the secretariat of one of the medical defence societies from 1969 until 1983 I was closely involved in advising and assisting in the legal representation of doctors facing disciplinary action by the GMC. I therefore feel qualified to contribute to the current debate upon the functions, failings and structure of that body. Richard Smith (BMJ 1st January 2005, p. 2) refers to certain conclusions reached by Dame Janet Smith in her inquiry arising out of the Shipman case. Whilst I have read only extracts from her report I firmly support her opinion on the attitude and influence of elected members (of the GMC) and her wish to have more appointed medical members. In the days when members of the GMC were appointees of the Royal Colleges, the Universities, the Department of Health and other appropriate public bodies, and under the Presidency of the late Lord Cohen, the GMC set and sought vigorously to maintain the highest standards of professional conduct. Complaints from members of the public or lodged by competent authorities, together with notifications of criminal convictions received prompt and careful scrutiny by the Registrar’s staff and often by the President himself. If a question of professional misconduct arose, detailed fact-finding enquiries were made, the result of which would be considered by the Preliminary Proceedings Committee of the GMC. Having reviewed the facts of the case with scrupulous impartiality, the PPC would decide whether or not there was a prima facie case of professional misconduct to answer. If there was such a case the matter would be referred to the Disciplinary Committee, a separate body of the GMC, which would conduct a formal hearing with all the rigour and formality of a Court of Law and open to press and public. The verdicts of guilty or not guilty, and the sentences of erasure, suspension and reprimand, were firm but reasonable and consistent. Appeals by doctors (to the Judicial Committee of the Privy Council) were rarely lodged and seldom, if ever, successful. The system was effective and commanded respect. With the introduction of elected membership, in response to BMA threats regarding the introduction of the annual retention fee, the appointed members were largely supplanted by medical politicians, some imbued with a spirit of trade-unionism. Standards were relaxed, verdicts on professional conduct became capricious, and in many cases penalties over-lenient. The titles of GMC committees were changed to seem more “user -friendly”, proceedings were made less formal and there arose a tendency to treat errant doctors as sick patients and thus exempt from disciplinary action, although a sick doctor can be just as dangerous as an evil doctor. Self-regulation was failing the public and the profession, but instead of raising and enforcing higher standards of professional conduct of its own volition the GMC retreated before the forces of politicians, pressure groups and the mass media, wishing no doubt to seem politically correct, but losing the respect of the profession. Only last week there were reports in The Times of a 46-year old woman doctor found guilty of serious professional misconduct and suspended from the register for six months as a consequence of having a sexual relationship with a friendly builder who happened previously to have been her patient, and in the BMJ of the GMC changing its mind and pursuing the case against a consultant anaesthetist who had earlier been informed that no charges of misconduct would be made. These are further indications that the GMC is now running around in circles like a headless chicken. In conclusion I suggest that the remit of the GMC be narrowed, its members appointed rather than elected, and its procedures strengthened. Transparency and increased lay representation would not improve matters. Yours faithfully, Dr. R D France Competing interests: None declared |
|||
|
|
|||
|
Charles A. West, General Practitioner Shropshire.
Send response to journal:
|
"Dame Janet Smith concluded that the GMC was not at fault in the Shipman saga." If she was right, it seems to me that it was innappropriate to use the Shipman enquiry as a platform from which to launch a diatribe against the GMC. So now we have two separate issues bing conflated and confused. In terms of reducing the risk of another 'Shipman', one could make a case for suggesting that a doctor found to have been guilty of serious professional misconduct through an addiction to opiate drugs should have their opiate prescribing monitored for the rest of their practicing career. Maybe that should be done by the GMC, or maybe by another body. The subject of the GMC, its constitution, its funding, its role, and its behaviour over many years is a completely diferent subject. As your correspondence columns show there is no shortage of people offering comments. I would offer two. First, self-regulation is, to a degree, inevitable in determining the ethics of professionalism. If we wish to know whether it is reasonable for a GP in 2005 to do 'xyz' we need to ask a number of practicing GPs what they do. Perhaps now that we have the Council for Healthcare Regulatory Excellence we should reclaim the GMC for the medical profession. Secondly, I am amazed to see so often repeated the need for a balance between protecting patients and being fair to doctors. In the context of its quasi judicial role the GMC should be being fair to all parties. It should therefore go without saying that it should be fair to doctors. It should also, of course be fair to patients. In this aspect of its work the GMC should not be about protecting patients any more than it should be about protecting doctors. In seeking to find ways forward on both these subjects we need to remind ourselves and others that we can never eliminate risk, we can only reduce it. Yours, Charles West Competing interests: None declared |
|||
|
|
|||
|
Rita Pal, Freelance Writer and Doctor UK
Send response to journal:
|
You are of course correct in saying that the GMC should be fair to all parties. However, their well documented inability to follow their own procedures strongly suggests that in reality the GMC is fair to no one. For patients or doctors who make a complaint, the GMC's cavalier attitude towards their governing legislation means that important issues may never be thoroughly investigated. For doctors who become the subject of a complaint, that same gung ho attitude disguised as the GMC's duty to protect patients means that the doctor maybe subject to endless scrutiny for no reason other than the GMC feels like it. Even in cases ( like mine) where no complaint has been made, the GMC takes it upon itself to conduct discreet inquiries into a doctor's background with the flimsiest of justification. This cannot be fair to the doctor and diverts GMC resources away from legitimate complaints. The public who by law are supposed to be protected by the GMC have a right to expect that the GMC will carry out that duty. Likewise, the medical profession that the GMC regulates is entitled to believe that this regulation will be carried out proportionately, fairly and in accordance with the law. Sadly, the GMC seems to feel that the unsubstantiated opinions of its clerical staff are sufficient to warrant any amount of intrusion into a doctor's affairs. Under no circumstances can this this be considered fair. Dr Rita Pal Competing interests: R Pal v GMC, Peter Lynn, Sarah Bedwell and Catherine Green |
|||
|
|
|||
|
Terence GOULD, GP Locum Norfolk/Suffolk
Send response to journal:
|
Dear Sir, The Shipman Inquiry has cast a shroud over how doctors see themselves, and produced an unease felt deeply on both sides of the doctor patient relationship. How should the public react, and how the profession? This long and conscientiously in depth public inquiry by a highly regarded judge and her leading counsel, both well experienced in advocacy in clinical negligence proceedings and in the opposing defences of arraigned medical men, has produced a damning report. This is an incredible tale of an evil contravention of everything we have ever learnt and practiced, in what we once understood as a lifetime fraternal fellowship of men and women, dedicated to the health and welfare of those who honoured us with their trust and needs. Many of us have seen warts and disagreement in our professional colleagues, but never such an abhorrent, unforgivable, series of callous executions which would have been regarded as unrealistic even if presented as fictional drama. When the Minister of Health, John Hutton spoke in the House on 23rd January 2001, he stated clearly “We must not allow Shipman's crimes to threaten the essential relationship between doctors and their patients.” Since then the shock and horror have snowballed, and this threat has become a serious reality. Any Government will have its work cut out to keep sight of this major tenet of health care, against an avalanche of righteous public indignation. We are indignant too. Maybe more so because so much that we have lived by in our working lives has been filthied by one aberrant, but cunning man who was trained and nurtured as a doctor, but never was such in any true sense. His aberration was without doubt drug induced, and it seems he escaped the procedural net existing before 1976 because there was a hiatus in the Home Office rules, and the GMC was not prevailed upon to take significant disciplinary action against a monster who was guessed by experts to be enough of a reformed fox to place in the hen coop. Rightly the Inquiry cannot place the blame on the GMC, who were acting in accordance with the Home Office rules and procedures, and apparently had insufficient power to take significant action at that watershed of inadequacy, and stem the resulting flood of horrific consequences for so many innocent patients and their families. To check the efficiency of any of us, doctors, politicians, lawyers, or management, however senior or junior, is a task of incredible proportions, and no doubt in an effort to do the right thing, we will do many wrong things. We are doing exactly that now, with an Appraisal Scheme which is too frequent and too vague and devoid of real medical standards to make good sense, however much a cowed, once proud profession pays it lavish lip service. I would hope that Dame Janet Smith can find within what must be a tremendous fund of experience of the interaction of the reality of what a body of professionals can at best provide, with the highest hopes and expectations of a justly resentful public, a new approach which combines high quality review and practicality of everyday medical care. No Home Office turn to over liberal attitudes regards personal drug use, or just their plain bungling, should allow any health professional who has a record of personal drug abuse, to ever be licensed to handle, let alone prescribe them ever again. The medical expertise of this murderer has not been the absolute question, only his ability to use his professional privileges to satisfy his own diseased needs. Appraisal has no place in that. It has missed the point. I pray our legislators will not. Yours sincerely, Terence Gould General Practitioner
Competing interests: None declared |
|||
|
|
|||
|
Stevie M Gamble, retired HMIT EC2Y 8BL
Send response to journal:
|
Terence Gould,GP Locum, asserts in his Rapid Response entitled ‘Shipman-aberrant man-aberrant reaction’ that: ‘His aberration was without doubt drug induced’’. There is no evidence to support this statement. In the First Report of the Shipman Inquiry, Chapter 13 http://www.the-shipman-inquiry.org.uk/fr_page.asp?id=173 Dame Janet notes that she sought the advice of a team of experienced forensic psychiatrists on the question of why he behaved as he did. ‘They did their best to consider possible explanations for Shipman's conduct but, with the materials available, were unable to reach any conclusions.’ Dr Gould also appears to have entirely overlooked the existence of the Fourth Report of the Shipman Inquiry, The Regulation of Controlled Drugs in the Community, published on 15/7/2004: http://www.the-shipman-inquiry.org.uk/4r_page.asp?id=3068 which considered the whole question of how to safeguard individuals from misuse of controlled drugs, whilst ensuring that the care of patients in need of such drugs is not prejudiced. The discussion paper and seminars provided an important opportunity to make expertise available to the Inquiry; it is a pity that Dr Gould and other correspondents to the BMJ did not take that opportunity. Stevie M Gamble Competing interests: None declared |
|||
|
|
|||
|
William G. Pickering, Doctor 7 Moor Place, Gosforth, Newcastle upon Tyne. NE3 4AL.
Send response to journal:
|
GMC pre-emptively wash their hands of responsibility for poor practice and clinical errors. The Royal Mail letter to all doctors (dated 4.3.05) written and signed by GMC president Catto, and titled "Postponement of licensing and revalidation", will have engrossed and fascinated its 230,000 medical readers. Writes Catto in this letter: "Some have argued that the prime purpose of revalidation is to identify poorly performing doctors. I challenge that". No. It was Dame Janet Smith who challenged that [1]. And Catto's GMC has been embarrassed into belatedly following suit. As with clinical errors and disasters, the GMC is always behind the game. One can see why "some did argue" that they thought revalidation would indeed identify "poorly performing doctors". Catto's own analogy of the GMC's revalidation being like a doctor's "MOT Test" [2] defined that it was Catto himself who argued this. Dame Janet Smith brought him very sharply to heel — revalidation is 'not an MOT' test and does 'not' demonstrate a doctor is 'up to date and fit to practise' as Catto had 'proudly' (her word) claimed [3]. Even before this, others had identified the idiotic MOT claim of Catto, both to the BMJ and also to the Inquiry [4]. Half the world thought that the GMC's revalidation was supposed to pick up bad doctors — who apparently comprise between 5% and 15% of all doctors and whom D.Irvine, Catto's predecessor, tells us (as though he was a clairvoyant) are 'probably unfit to practise' [5]. But revalidation, Catto divulges, far from identifying them and stopping them, is really "to make registration more meaningful". What do patients, who are taxpayers, think of that? Does it make them feel 'protected'? Writes Catto: "It is difficult to see how the GMC sitting in London could, through revalidation, carry the prime responsibility for detecting poor or dangerous practice". "This is clearly the responsibility of those who deliver healthcare to patients". So, if a re-coloured, patched-up revalidation ever takes the stage, when there are subsequent further medical debacles the GMC, even before revalidation's debut, disclaims any "responsibility" for its shortcomings. We have known for decades that as far as insight into identifying doctor's elementary clinical errors is concerned, the GMC is of a supreme irrelevance [6]. Catto now confirms this. Lay persons (most medical ones unfortunately seem indifferent or inured) must find it hard to understand why a GMC with no track record of identifying even huge medical disasters such as the Cleveland affair in the 1980s, are still instrumental in medical regulation [7]. Their record should forfeit and disbar them. Dame Janet Smith hints at this by remarking of the GMC: 'The best indicator of future attitude and performance is the past' [8]. How much is revalidation costing the taxpayer? Who will be accountable when it fails? Exactly paralleling most clinical errors, nobody is to be accountable. Catto's letter is making it clear at an early stage that it certainly will not be the GMC's fault. With such a self-interested, defensive mentality sprawled for so long over the regulation of the medical profession, little wonder it is, as ever, in trouble. Preventable adverse clinical outcomes, clinical accountability of doctors, and the prompt identification nationwide and daily of at least a portion of daily rudimentary clinical errors to their perpetrators, are the key matters to attend to. [eg. 4,6,9,10,11]. Other more expensive, more politically digestible 'initiatives' will by contrast rapidly be shown to be irrelevant and disposable. William G. Pickering. wgpi@hotmail.com 11.3.05 References: 1. Shipman Inquiry. Chairman Dame Janet Smith. 2004. Fifth Report. Vol 3. Para 26.202. Page 1090. 2. Catto G. BBC Radio 4. "Down With ?" [the GMC]. May 2004. 3. Shipman Inquiry. Chairman Dame Janet Smith. 2004. Fifth Report. Vol 3. Para 26.187. Page 1086. 4. Pickering W G. Rudimentary medical errors. http://bmj.com/cgi/eletters/328/7454/1455#63653, 21 Jun 2004 5. The Guardian. 18.12.04 "Doctors failing 3 million patients". 6. Pickering W.G. An independent medical inspectorate. In: Gladstone D, ed. Regulating doctors. London: Institute for the Study of Civil Society, 2000: 47-63. ISBN 1-903 386-01 7. Butler-Schloss (Lord) (1988) Report of the Committee of Inquiry into Child Sexual Abuse in Cleveland 1987. Presented to the Secretary of State for Social Services by the Right Honourable Lord Butler-Schloss DBE, Cm 412, London: HMSO. 8. Shipman Inquiry. Chairman Dame Janet Smith. 2004. Fifth Report. Vol 2. Para 15.80. Page 465. 9. Pickering W.G. Clinical accountability. http://bmj.com/cgi/eletters/330/7481/1#91742, 7 Jan 2005 10. Pickering W G. Clinical outcomes eclipsed by politics. http://bmj.com/cgi/eletters/330/7485/252#95253, 2 Feb 2005 11. Pickering W. G. Systematic clinical accountability is required. BMJ 2003;327:1109 (8 November) Competing interests: None declared |
|||
|
|
|||
|
Huw Llewelyn, Consultant Physician Glantywi, Llanegwad, Dyfed. SA 32 7NL, Azar Chaudhry, Honorary Medical SHO, Vanda McGibbon, Senior Ward Sister, Luton & Dunstable Hospital, Lewsey Road, Luton LU1 4OZ
Send response to journal:
|
EDITOR – The Shipman Inquiry and GMC appear to agree that the main purpose of revalidation should not be to detect poor performance [1, 2]. However, poor performance might be minimised if the GMC, in its role of setting standards and regulating medical education and training, advised that there should be more written transparency in the doctor-patient relationship, in accordance with the Data Protection and Freedom of Information Acts. This process might be helped if letters and summaries incorporated a pre-prepared structured past medical history (PMH) that included details of the very latest management. It could be drafted by using example evidence-based standard text[3]. Each diagnosis in this PMH is followed by an outline of the particular evidence obtained from the patient and a plan [3, 4]. The authors would know that patients would show this PMH when giving their next history to other doctors who would thus ‘peer-review’ it and correct any poor performance as part of their own contribution. We carried out a pilot project when one doctor drafted a PMH shortly after patients were admitted to hospital. This was done using Microsoft Office Excel and Word (which can save each version when a file is closed, thus providing an audit trail). The PMH was read by doctors, nurses, pharmacists and others in the team and corrected or updated after ward rounds. During a subsequent audit for the annual appraisal of the consultant leading the team, it was found from the hospital computer that in the 6 months before the system was used, 376 patients were admitted via the Acute Assessment Unit by the consultant and 161 (42.8%) went home after 2 nights (this was similar for other consultants). However, during the 5 week period of the pilot project, 76 patients were admitted and 45 (59.2%) went home after 2 nights. Thus 16.4% more patients went home after only 2 nights in hospital (95% CI being 4.3% to 28.5%, P = 0.008). This represented a 38% increase. A pre-prepared PMH thus appears to have improved team work and continuity of care (e.g. in handovers) leading to earlier discharge. The creation of a pre-prepared PMH involves a careful process that can detect errors early on. An electronic version might become a part of the NHS’s National Programme for Information Technology (NPfIT). A pre-prepared PMH would be a useful source of data to enter into various data bases for audit, hospital activity analysis and professional revalidation. However, its main purpose is to improve patient care with transparency. The approach seems promising. References: 1. Pickering WG. GMC pre-emptively wash their hands of responsibility for poor practice and clinical errors. http://bmj.bmjjournals.com/cgi/eletters/330/7481/1#100104, 11th March 2005. 2. Shipman Inquiry. Chairman Dame Janet Smith. 2004. Fifth Report. Vol 3. Para 26.22. 3. Llewelyn D E H, Ewins D L, Horn Jackie, Evans T G R, and McGregor. A M. Computerised updating of clinical summaries: new opportunities for clinical practice and research? BMJ, 1988, 297, 1504-1506. 4. Llewelyn DEH, Ang HA, Lewis K, Al-Abdullah A. The Oxford Handbook of Clinical Diagnosis. Oxford University Press, 1995 in press. Competing interests: None declared |
|||
|
|
|||
|
susanne mccabe soostevens@hotmail.com, retired cf24 3pf
Send response to journal:
|
Would you be able to post an example of a PMH? It sounds extremely interesting. thank you. Competing interests: None declared |
|||
|
|
|||
|
Huw Llewelyn, Consultant Physician Glantywi, Llanegwad, Dyfed, SA32 7NL
Send response to journal:
|
EDITOR: Table 1 is an example of a ‘pre-prepared PMH’ and table 2 is an example of standard text used to write it. These examples are updated from those published previously [1]. The format can vary but the principle is that diagnoses (or differential diagnoses) are linked explicitly to the relevant findings and actions, thus making the rationale transparent to the reader. The findings form the ‘outline evidence’ for that particular patient. Ideally this should include the presenting finding(s), sufficient or ‘central’ evidence and the latest marker of progress with relevant dates [2]. A test result might be omitted if the date allows it to be looked up (e.g. via a hypertext link). In one sense, the diagnoses in this type of PMH are ‘evidence based’. However, it is important to distinguish between the particular ‘outline evidence’ for a diagnosis or decision in a ‘particular’ patient and ‘general’ scientific evidence based on observations on groups of patients, of the kind recognised by convention for ‘evidence based medicine’ (e.g. a published randomised trial) [2, 3]. Table 1: Draft ‘pre-prepared’ Past Medical History: ___________________________________________________________________________________ NON-ST ELEVATION MYOCARDIAL INFARCTION (NSTEMI) IN APRIL 2005 OUTLINE EVIDENCE: Chest pain (04/04/05). No ST elevation, inverted T waves S2, V4 – V6 (04/04/05). Raised Troponin after 12 hours (1.7 on 04/04/05). MANAGEMENT & PLAN: Admission to cardiac monitored bed at Oldtown Hospital c/o Dr D E H Llewelyn (04/04/05). Enoxaparin 80mg sc bd from 04/04/05. Aspirin 75 mg from 04/04/05. Atorvostatin 10 mg od from 04/04/05. Atenolol 25 mg od from 04/04/05. Ramipril 2.5 mg od from 04/04/05. Referred for cardiac rehabilitation on 04/04/05. Sub-maximal exercise test requested on 04/04/05. --------------------------------------------------------------------- ------------------------- LEFT VENTRICULAR FAILURE IN APRIL 2005 OUTLINE EVIDENCE: Orthopnoea (04/04/05). CXR appearance (04/04/05). Echocardiogram result (04/04/05). MANAGEMENT & PLAN: Frusemide 40 mg od, Ramipril 2.5 mg od from 04/04/05. --------------------------------------------------------------------- ------------------------- NO OTHER DETECTABLE ABNORMALITY APRIL 2005 OUTLINE EVIDENCE: History and examination (04/04/05). Urine glucose - ve, protein –ve, nitrate -ve, blood –ve. Hb = 13.4gr/dl, WBC = 6.6, Platelets = 137, Na = 134; K = 4.2; Urea= 6.6; Creatinine = 121, Bilirubin = 16, Albumin = 44; ALT = 27, ALP = 38, Cholesterol 3.9 mmol/l on 04/04/05. MANAGEMENT & PLAN: no action. ___________________________________________________________________________________ Table 2: Example standard text: NON-ST ELEVATION MYOCARDIAL INFARCTION (NSTEMI) OUTLINE EVIDENCE: Chest pain? No ST elevation on initial serial ECGs? Inverted T waves, ST depression, Q waves? Raised Troponin after 12 hours? MANAGEMENT & PLAN: Admissions to cardiac monitored bed? Diamorphine IV PRN and Metoclopramide IV PRN? Enoxaparin 1mg/kg body weight sc bd? Aspirin 75mg od? GTN spray PRN? Isosorbide dinitrate infusion? Atenolol 25 mg od? Ramipril 2.5mg od? Referred for cardiac rehabilitation? Sub-maximal exercise test requested? ___________________________________________________________________________________ References: 1. Llewelyn D E H, Ewins D L, Horn Jackie, Evans T G R, and McGregor. A M. Computerised updating of clinical summaries: new opportunities for clinical practice and research? BMJ, 1988, 297, 1504-1506. 2. Llewelyn D E H. Decision analysis in the context of day to day clinical practice, teaching and research. In Llewelyn, D E H and Hopkins, A (eds) Analysing how we reach clinical decisions. Royal College of Physicians of London, 1993, pp 148-9. 3. Llewelyn DEH, Ang HA, Lewis K, Al-Abdullah A. The Oxford Handbook of Clinical Diagnosis. Oxford University Press, 2005 in press. Competing interests: None declared |
|||