Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Chairman's letter re GMC
- Roger Ferguson (31 January 2005)
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Re: Chairman's letter re GMC
- Scott.R. Price (1 February 2005)
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Re: Chairman's letter re GMC
- Stevie M Gamble (1 February 2005)
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Re: Re: Chairman's letter re GMC
- Stevie M Gamble (2 February 2005)
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Re: Re: Re: Chairman's letter re GMC
- Scott R Price (3 February 2005)
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Clinical outcomes eclipsed by politics.
- William G. Pickering (3 February 2005)
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Re: Clinical outcomes eclipsed by politics.
- Jay Ilangaratne (3 February 2005)
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Re: Re: Re: Re: Chairman's letter re GMC
- Stevie M Gamble (4 February 2005)
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Roger Ferguson, Consultant Physician Wirral Hospital CH49 5PE
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I thought this to be an excellent and well balanced letter. I was appointed as a medical member to what is now called the Fitness to Practice panels in 2001. This followed a rigorous selection procedure run by an outside agency. I was subsequently appointed to chair panels following an equally rigorous whole day of tests and interviews, again run by an outside agency. Since sitting on these panels, I have been impressed by several factors. First the quality of my fellow lay and medical members. The lay input on the panels is equal to the medical apart from the fact that there is usually one more medical member. Secondly it is absolutely clear that the protection of the public is paramount. The panels take very seriously the concept of proportionality. As well as protecting patients we have to be fair to doctors. No panel that I have sat on has "taken the side of doctors". Thirdly, whilst panels operate within strict rules laid down by parliament, each panel is independent of the GMC. Fourthly every panel is assisted by a legal assessor, a senior lawyer. Legal assessors are also independent of the GMC. Yours sincerely Roger Ferguson Competing interests: Member & Chairman Fitness to Practise Panels GMC |
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Scott.R. Price, Consultant in Anaesthetics and Intensive Care Burnley General Hospital, BB10 2PQ
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Dear Sir, ‘Never another Shipman’ Dame Janet Smith in a televised clip from The Shipman Inquiry [1] said that; ‘It has been said Dr Shipman was a murderer who happened to be a doctor. I disagree. It was because he was a doctor he was able to murder.’ One of the aims of the inquiry was to give recommendations for future ‘protection of patients’. [2] To this end, we have been given revalidation and a licence to practice by the General Medical Council. These measures may show that the doctor is up to date, and is trained for the job he or she is employed, but will not stop a determined murderer from killing. It should be remembered that not only doctors can kill patients; other healthcare workers are also able to do so. So how can the public be truly protected? To ensure that any murderous acts, intentional or due to poor practice, are not allowed to go unchecked then the assumption would need to be made, that, all patients dying during ‘healthcare’ ( in the community or hospital, even if death was expected) had been murdered; and the appropriate investigations instituted. This would involve looking at all the aspects of the care the patient received, who was involved, and if a pattern was present. It would be a full time job. The balance of proof would be that of ‘reasonable probability’, again in order to ensure that there are no mishaps, with doctors, or others, slipping the net. I believe this would be the only way that patients could truly feel protected, and the authorities be able to say with confidence, ‘This could never happen again’. A nightmare scenario perhaps, but in the current climate we find ourselves, with our error being criminalised, [3] and the public and politicians unwilling to accept any risk, I would not be prepared to say it would never come to pass. Dr. S.R.Price. Consultant in Anaesthetics and Intensive Care, East Lancashire Hospitals NHS Trust. Burnley General Hospital, Casterton Avenue, Burnley, BB10 2PQ. Competing Interests – NONE. REFERNCES. [1] BBC NEWS 27th January 2005. [2] The Shipman Inquiry. Terms of Reference (d) [3] Jon Holbrook The criminalisation of fatal medical mistakes BMJ, Nov 2003; 327: 1118 - 1119. Competing interests: None declared |
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Stevie M Gamble, retired EC2Y 8BL
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Roger Ferguson, Member & Chairman of Fitness to Practise Panels, GMC, asserts in his Rapid Response of 31st January that: ‘The lay input on the panels is equal to the medical apart from the fact that there is usually one more medical member.’ One might just as well assert that two equals three apart from the fact that three usually has one more than two. Stevie Gamble Competing interests: None declared |
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Stevie M Gamble, retired ec2y 8bl
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Scott. R. Price’s Rapid Response of the 1st February is a textbook example of the perils which lie in wait for those who fail to check their sources. He claims that Dame Janet Smith said that ‘It has been said Dr Shipman was a murderer who happened to be a doctor. I disagree. It was because he was a doctor he was able to murder.’ and goes on to build an edifice of fantasy on this statement. There are a number of different reports in the media; I will proffer three examples. Channel 4 gives it as: "It is sometimes said that there is no need to reform these systems, even though they have been found to be defective, because there will never be another Shipman. "In other words, there will never be another doctor who is a mass murderer. In my view, it was the very fact that Shipman was a doctor that enabled him to kill and remain undetected." http://www.channel4.com/news/2005/01/week_4/27_shipman.html The Guardian has: "His profession not only enabled him to kill, but it allowed his killing to go undetected," she said. http://society.guardian.co.uk/nhsperformance/story/0,,1400930,00.html The Scotsman has ‘She said she did not agree with the view of the medical press and the medical profession that Shipman was a one-off and that his profession was not linked to his killing spree. "His profession not only enabled him to kill, but it allowed his killing to remain undetected," Dame Janet said.’ http://news.scotsman.com/topics.cfm?tid=484&id=103532005 Had Scott R Price bothered to read the Reports of the Inquiry he would be well aware that Dame Janet never claimed that it was possible to prevent all cases of murder. He would also be aware that Dame Janet had noted that other healthcare professionals have murdered patients. The general public, unsurprisingly, does not hope for a society in which no-one commits murder. It does, however, expect there to be systems in place to deter murder, and where deterrence fails, to detect it at an early stage. Stevie M Gamble Competing interests: None declared |
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Scott R Price, Consultant, Anaesthetics and Intensive Care Burnley General Hospital
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I thank Dr.Gamble for his response to my posting. Unfortunately I do not have the time to trawl through the various news organisations reporting, and so use only the one source - the dangers of this he exposes most eloquently. However, I believe my point remains valid. If the protection of patients is to be made as watertight as possible, then instead of only investigating these deaths (during healthcare) that seem suspicious, ALL deaths should be investigated to exclude either a poor standard of practice, or even deliberate harm. As an Intensivist, then I would be one of the first people to be called into question, as I use opiates in large quantity,carry out invasive procedures,and actively stop treating patients - who then die. If I am able to demonstrate that my practice is acceptable then I have nothing to fear, and patients can then have faith in me.If not, then I either have to change my practice, or face censure. Such a system would not be pleasant, but I belive it would be the most reliable way of detecting further rouge healthcare providers at an early stage, although it would not stop poor practice or, in the extreme, murder. Competing interests: None declared |
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William G. Pickering, Doctor 7 Moor Place, Gosforth, Newcastle upon Tyne. NE3 4AL
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Clinical outcomes eclipsed by politics. Johnson's letter is another BMA bureaucratic masterpiece [1,2]. He remarks, disapprovingly one senses, upon the BMJ's "editorial independence", and then appears to settle personal scores with ex-editor R. Smith. He does not forget though to makes an ostentatious political curtsey to Dame Janet Smith; and, lest anyone is confused about his allegiances, he affirms his seamless agreement with the GMC. The rest of his letter is less penetrable. He, like others in the BMA, GMC, royal colleges and Department of Health, is not a politician like an MP. He is a medico-politician. He once wore, perhaps still wears, a stethoscope (the military equivalent is called a 'politician in khaki'). One expects slogans and clichés, and Johnson doesn't disappoint. But the word 'clinical', it will be noticed, is absent from his piece. Medico-politicians will not go near clinical examples to clarify their announcements - as though they were inapplicable. This remote, starry-eyed approach (undoubtedly related to a self-regulation mentality) seems politically compulsory. Perhaps it has, in large part, brought the profession to the pretty pass in which Dame Janet Smith now finds it. She says in her Forward: 'I have at all times recognised that there are other important public interest objectives to be borne in mind besides the prevention and detection of misconduct' [3]. Insisting that medico-politicians jettison jargon in favour of comprehensible and relevant language for example. With echoes of a desperate doctor at the end of his therapeutic tether ('well try these pills , they might work, given time'), Johnson, as though on St Peter's balcony, declaims: "Let us allow time for the benefits of changes … to be shown as being fair to doctors and protecting patients". How will these "benefits" and "changes" identify an ignored abnormal laboratory result which results in preventable clinical disaster; or a man from whom a shoddy history is taken who, undiagnosed and unfollowed-up, a few days later proceeds to get toxic ulcerative colitis; or a doctor who is hounded by groundless allegations and complaints? How will these "changes" have a chance to identify such everyday events and stop them recurring? What is the BMA chairman's understanding of his chosen term: "substandard performance in doctors "? Is it synonymous with the GMC's obscure 'poor performers'? [4]. Does it mean some doctors are substandard across the board, or that some doctors who practice usually reasonable medicine occasionally make substandard decisions [5]. The notion that medicine contains good doctors and bad ones is politically handy and neat — flush out the bad ones and all will be well. It is hopelessly naïve to suppose that poor medicine is the domain of one sort of doctor (whatever their collective name). Doctors, even so-called "eminent" doctors as the BMA call them, are human and fallible and subject to all influences [2,6,7]. Carelessness or glory-seeking or knowing better than to follow ground rules or believing themselves to be possessed of a unique view, can result in awful rudimentary clinical errors [7]. Should they pass without identification and comment because the doctor's credentials have been examined and appear good? Of the myriad of 'initiatives' alleging to promote quality none start at clinical outcome - the sharp end. They start and stop at what the doctor appears to be and appears to do, the blunt end. Why? Because it is politically plausible, and because it spares established doctors clinical accountability. Inspecting outcomes when indicated (eg. via complaints, whistleblowers, and medical records) is the surest way of ensuring less patchy medical practice nationwide and daily. [8,9,10]. An advantageous and economical side-effect is that other 'regulatory dreams' will be made largely irrelevant. Not every consultation or intervention can be assessed. Many clinical outcomes are poor despite reasonable or first-class medical intervention — that is the nature of things. But one rudimentary clinical error identified promptly and brought to the attention of the perpetrator will have a greater effect for good that anything else [8,10]. It would soon haul out miscreants and raise and maintain standards in the rest. There is no logical reason to let all single medical errors pass without remark. We know what that can lead to. An ex-chairman of the BMA correctly notes that revalidation is "now seen to be flawed" [11]. Johnson, the current BMA chairman, disagrees with his kinsman; he wants to rush on and querulously "hopes that the current delay in its introduction is as short as possible". "Delay"? Do we need to hear about "delay" from the BMA or any medico-politician?. If he and others had spotted the lack of clinical accountability over two decades ago (it was as obvious then as now), and had urgently written and acted upon it instead of pusillanimously or indifferently ignoring its lessons, how many disasters and unnecessary iatrogenic heartaches may have been avoided? Two more of Johnson's kinsmen, both from the GMC (one a president, the other an ex-president), are "delighted" revalidation has been stopped in its tracks [12,13]. Johnson disagrees with them, as he does with Macara and R. Smith. Dame Janet Smith pointedly remarks of the GMC: "It is axiomatic that the best indicator of future attitude and performance is past attitude and performance" [14]. Johnson of the BMA, though affianced to the GMC, does not mention this. Does he disagree with her too? It has required more and more serial disasters to awaken the medico-political establishment. The proper mechanism to bear down on them could have been up and running after the Cleveland affair in the 1980s [15]. It should have been. Yet such method, utilising outcomes and accountability, is still not medically or politically conceived, let alone delivered. We must hope further avoidable poor clinical outcomes (to which much of the profession and its politicians are still blind until they read their newspapers) do not erupt in the future to underline this continuing omission. But they might. There is nothing to stop them. Shipman knew all this of course and was hideously emboldened by the nonchalance shown by doctors and their regulators towards clinical outcome. He also knew that suspicious onlookers, medical and lay, would not trouble to blow the whistle, having not an atom of confidence that any official body, if they could find one, would pay the slightest attention. This happens all the time in the health services to this day. The medico-political coterie, if they own up, must surely now know it too, but obdurately refuse to tackle the issue head-on. Instead, doctors continue to be suffocated by successive layers of illogical 'initiatives', augmented with thick blankets of impenetrable political language designed to imply the certainty of their efficacy. William G. Pickering. 01.02.05 email: wgpi@hotmail.com References: 1. Johnson J The GMC: expediency before principle: BMA chairman responds BMJ, Jan 2005; 330: 252. 2. Pickering W.G. Re: Experts & Quality Control http://bmj.com/cgi/eletters/329/7478/1353#88520, 9 Dec 2004 3. The Shipman Inquiry. Chairman: Dame Janet Smith. Fourth Report. July 2004. Forward. Para 2. 4. Irvine D. The performance of doctors. II: Maintaining good practice, protecting patients from poor performance BMJ 1997;314:1613. 5. Pickering W.G. Single medical errors. Lancet. 2.12.00:356:1933-34. 6. Wise M E Jan. Experts & Quality Control. http://bmj.com/cgi/eletters/329/7478/1353#88159, 6 Dec 2004 7. Pickering W.G. Rudimentary medical errors. http://bmj.com/cgi/eletters/328/7454/1455#63653, 21 Jun 2004 8. 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 1-903 386-01-2 9. Pickering W. G. Systematic clinical accountability is required. British Medical Journal 2003;327:1109 (8 November) 10. Pickering W.G. Clinical accountability. http://bmj.com/cgi/eletters/330/7481/1#91742, 7 Jan 2005 11. Macara A W. The GMC: expediency before principle: A former BMA chairman responds BMJ, Jan 2005; 330: 252 - 253. 12. Catto G. The GMC: principle not expediency http://bmj.com/cgi/eletters/330/7481/1#91079, 3 Jan 2005 13. The Guardian. 18.12.04. Page 1. "Doctors failing 3m patients". 14. The Shipman Inquiry. Chairman: Dame Janet Smith. 2004. Fifth Report. Volume 2. Page 4 15. Pickering W.G. Glasnost and the medical inspectorate. J of the R C of GPs. Nov 1988; 38: pp 517-518 Competing interests: None declared |
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Jay Ilangaratne, Medical-Journals.com Founder
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Well said, Dr Pickering. When the BMA Chairman is most publicly giving the impression that he is trying to settle personal scores with former BMJ editor(Richard Smith),it can also be rather worrying for the BMA membership.Such expressed emotions of the BMA Chairman can also give the impression,that members like myself who have been openly critical of some of BMA's policies and conduct (and indeed have taken the BMA to court), could be severely vulnerable to less than professional and unjust treatment from the BMA. Indeed, the BMA Chairman's letter is very revealing. JS@medical-journals.com Competing interests: See Text |
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Stevie M Gamble, Retired HMIT EC2Y 8BL
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Scott R Price in his Rapid Response of the 3rd February makes the entirely reasonable point that busy practioners, up to their eyeballs in work, do not have the time to carry out extensive research on matters not directly connected to their work. I hope therefore that the Readers Editor will not object to a somewhat lengthy quotation on the issue he raises. In Chapter 19.3 of the Third Shipman Report, ‘The Aim and Purposes of the New Coroner Service’ Dame Janet comments that: ‘The aim of the Coroner Service should be to provide an independent, cohesive system of death investigation and certification, readily accessible to and understood by the public. For every death, it should seek to identify the deceased, to discover where, how and why the deceased died and should provide an explanation for the death to those associated with the deceased or having a proper interest in understanding the cause and circumstances of the death. It should seek to ensure that all the necessary formal details relating to the death are correctly and accurately recorded. Its procedures should be designed to detect cases of homicide, medical error and neglect. It should seek to meet the needs and reasonable expectations of the bereaved, including those from minority groups who wish to dispose of their dead within a short time after the death. The Service should also provide a thorough and open investigation of all deaths giving rise to public concern. It should ensure that the knowledge gained and lessons learned from death investigation are applied for the prevention of avoidable death and injury. It should provide accurate information about causes of death for the purpose of maintaining mortality statistics and to assist in the planning of healthcare provision and public health strategies. It will be observed that I have not sought to draw any distinction between 'natural' and 'unnatural' deaths. This is a distinction that sometimes causes practical difficulty and results in decisions that are difficult to justify logically. The aim of the Coroner Service should be to investigate all deaths to an appropriate degree. With many, it will be sufficient to confirm and record uncontroversial basic information about the deceased and the medical cause of death. With others, there will be a need for investigation of the circumstances of the death and its medical cause. There should not be fixed categories of deaths that require and do not require in-depth investigation. Coroners should receive guidance about what types of death are likely to merit detailed investigation but the extent of the investigation in an individual case should depend upon the circumstances and any concerns expressed.’ http://www.the-shipman-inquiry.org.uk/tr_page.asp?ID=248 It is not clear to me, therefore, how his proposal would go beyond those already suggested by Dame Janet. Incidentally, Scott R Price assumed that I am a retired Doctor; the identity box on the Rapid Response web-page is not conducive to detailed information. I am, in fact, retired from Her Majesty’s Inspectors of Taxes, which probably explains my rather boring insistence on finding and considering the evidence, and my scepticism about unsupported assertions. Credulity is not a career asset in that particular profession. Stevie M Gamble Competing interests: None declared |
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