Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Revalidation process would not pass appraisal
- Roger A Fisken (22 May 2005)
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External quality assessment is old news in histopathology
- Peter N Furness (23 May 2005)
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A lesson from the GMC.
- William G. Pickering (23 May 2005)
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Is Dame Janet Smith Qualified to comment on Revalidation
- Bruce J Ella (24 June 2005)
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Re: Is Dame Janet Smith Qualified to comment on Revalidation
- Stevie M Gamble (25 June 2005)
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Re: Dame Janet's Terms of Reference
- John F Morgan (27 June 2005)
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Re: Re: Dame Janet's Terms of Reference
- Stevie M Gamble (28 June 2005)
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Whose Terms of Reference?
- Michael O'Donnell (29 June 2005)
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Roger A Fisken, Consultant Physician Friarage Hospital, Northallerton, North Yorkshire, UK,, DL6 1JG
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Sir Graeme Catto's paper, though very thoughtful, fails to address many of the problems with revalidation as it has been discussed hitherto. He also fails to understand that Dame Janet Smith's enquiry report is largely irrelevant to revalidation, particularly for those of us who are not general practitioners. The current appraisal process, on which revalidation appears likely to be based, is clunky, time-consuming, bureaucratic and largely irrelevant to an assessment of whether a doctor is fit to practise or not. Firstly, the current process does not contain any mention of 360 degree appraisal, surely one of the most effective ways of shining a light into the darker corners of a doctors' practice. Secondly, although audit is no doubt essential, to perform meaningful audit is extraordinarily difficult if the person being audited is not a surgeon. If I see a patient with pneumonia on a post-take ward round and then hand that patient over to my respiratory physician colleague, is the patient's ultimate outcome my responsibility or that of my colleague, or both? Even something as simple as prescribing audit requires a degree of commitment and resourcing which most NHS trusts would struggle to match at present. Providing evidence that a doctor has attended training courses is all well and good but it does not prove that the doctor has changed his/her practice on the basis of the training received. The GMC really needs to get a lot smarter in its approach to revalidation if it is to overcome the huge cynicism that exists in the profession and, more importantly, if it is actually going to achieve its aim of satifying itself, parliament and the public that doctors on the register are, and remain, fit to practise. Competing interests: None declared |
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Peter N Furness, Consultant Histopathologist Leicester General Hospital LE5 4PW
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Sir I share the belief expressed by many colleagues that improved revalidation exercises would not have stopped Harold Shipman, as he was clearly clever and competent as well as malevolent. Better answers surely lie in improved death certification procedures and audit. It's more relevant to know what doctors actually do, rather than what they are capable of doing. However, if mechanisms for revalidation are being studied, may I point out that external, objective assessment of the performance of histopathologists started about 15 years ago? In 1998 the Royal College of Pathologists published guidance on external quality assessment in histopathology, including criteria to define 'persistent sub-standard performance' and how it should be managed - see http://www.rcpath.org/resources/pdf/HistoCytoEQASchemes.pdf The procedures involved have been universally accepted by histopathologists in the UK and would be readily applicable to many other specialties. Yours faithfully Professor Peter Furness Competing interests: The author was Chair of the working group which wrote the report cited in the text. |
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William G. Pickering, Doctor 7 Moor Place, Gosforth, Newcastle upon Tyne. NE3 4AL.
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A lesson from the GMC. This new piece from the GMC's president Catto provides a pleasant illustration of the value of accountability [1]. Dame Janet Smith commented that 'revalidation is not an MOT test for doctors as Catto proudly claims' [2]. He now desists from using that misleading analogy [1,3]. That he has been forced to change his tune, and how this came about, is instructive for medicine in general. His error, it will be noted, was not brought to light by revalidation, or assessment of performance, or "folders", or governance [1]. And rather like most clinical errors, it was rudimentary and had nothing to do with "not being up to date". Nor was it a 'system failure'. Observations (complaints) from informed, impartial observers were made [4], then noticed by the Inquiry, and by examining the records of what he repeatedly said, he was flatly told he was wrong [2]. Though he appears to grumble about people "spinning in the aftermath of the Inquiry" (as though he and the GMC were spotless in that department), one trusts that identification of error is not conceived by the GMC as "spinning"[1]. On a brighter note, how relatively easy it was to nip this medico-political error in the bud and so stop serial disinformation. But to facilitate such remedy certain pre-requisites were essential. In response to a complaint, there need be informed impartiality co-operating with clout and access to the records. There is an all too clear lesson here for clinical medicine. Royal colleges, BMA, GMC and Department of Health, take note. The president finds it irksome that "some people reach conclusions on the basis of anecdotes" [1]. It would be another frightful mistake for the GMC to denigrate the value of anecdote [5]. Daily and nationwide clinical errors are exceptionally important anecdotes. By no means all of these are perpetrated by, as the handy but misleading GMC slogan puts it, 'poor performers'. Single anecdotal episodes can, as is so clearly demonstrated here, be identified as right or wrong, and if the latter, then stopped. So-called poor performers (if such they be) will, by the overall method, also be hauled out very early on, without burdening the entire profession with ever more expensive regulation of nebulous value. William G. Pickering wgpi@hotmail.com 22.5.05 References: 1. Catto G. Building on the GMC's achievements BMJ 2005;330:1205-1207 (21 May), 2. Shipman Inquiry. Chairman Dame Janet Smith. 2004. Fifth Report. Vol 3. Para 26.187. Page 1086. 3. Pickering W G. GMC pre-emptively wash their hands of responsibility for poor practice and clinical errors. http://bmj.com/cgi/eletters/330/7481/1#100104, 11 Mar 2005 4. Pickering W G. Rudimentary medical errors. http://bmj.com/cgi/eletters/328/7454/1455#63653, 21 Jun 2004 5. Pickering W G. The negligent treatment of the medical anecdote. BMJ 1992;304:1516. (6.6.92). Competing interests: None declared |
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Bruce J Ella, GP Registrar Harpenden, UK
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Dame Janet Smith had a clear remit to investigate the events surrounding Dr Harold Shipman’s activities and murder of his patients. She has taken it upon herself to broaden the scope of this remit and to advise on how revalidation should be carried out. This is to improve public confidence in those entrusted to care for them. This seems in contrast to numerous surveys that have confirmed that the public have far more confidence in the integrity and competence of doctors rather than lawyers such as Dame Janet Smith. I am intrigued as to what basis she makes her recommendations. Was there any evidence that Dr Shipman was incompetent or a poor performer? It seems that her investigation revealed he knew all to well how work the system to hide his activities. It seems that having a certificate to show no evidence for concern would be more useful for picking our malevolent doctors than a knowledge test as Dame Janet Smith recommends. If GP's are able to do their jobs, they need to be able to administer drugs such as potent opiates to relieve pain. It is well established that, particularly in terminal care, this might hasten the death of the person. This is considered morally justifiable if the aim is to relieve pain. In order to do their jobs, there will therefore always be a risk of a malevolent doctor "getting away with it." Clearly therefore most of her recommendations on revalidation will not affect this risk. If anything, doctors have a history of being overly cautious in administering adequate opiates when required. The result of Dame Janet Smith is now an increased risk of dying patients being left in poorly controlled pain. If revalidation is unlikely to prevent a murderer such as Dr Shipman, then we should concentrate on its true value, to provide the opportunity to support and train doctor's in needs. It seems then that organisations such as the GMC and RCGP are better qualified to determine how this could be achieved, and they should look at the merits of their own systems rather than bowing to political pressure as applied by Dame Janet Smith. Competing interests: As a practicing doctor I believe any doctor has a competing interest when discussing revalidation |
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Stevie M Gamble, retired HMIT EC2Y 8BL
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Bruce J Ella, GP Registrar, in his Rapid Response of 24th June states that Dame Janet Smith in conducting the Shipman Inquiry : ‘has taken it upon herself to broaden the scope of this remit and to advise on how revalidation should be carried out’ This accusation is untrue, and if Dr Ella had bothered to read the terms of reference of the Inquiry, and the Reports, he would know that it is untrue. (1) He goes on to state: ‘This is to improve public confidence in those entrusted to care for them.’ Again, this statement is untrue. It is the President of the GMC, Graeme Catto, who thinks that revalidation is a public relations exercise, not Dame Janet Smith. (2) Dr Ella further states: ‘I am intrigued as to what basis she makes her recommendations.’ Well, he could cease being intrigued and start being informed if he bothered to read the Reports; it is all set out in considerable detail there. Large numbers of people, both as individuals and as representatives of organisations, gave evidence to the Inquiry. Indeed, Dr Ella himself could have given evidence had he bothered to do so; there was an open invitation. If he was too busy to give evidence he could at least have read the Reports. Instead he makes misleading statements and unfounded accusations about their content and the Judge who wrote them. He is not alone in this; a number of doctors have written in similar terms to the BMJ. This is not the way to inspire confidence in the general public. Stevie Gamble (1) http://www.the-shipman-inquiry.org.uk/home.asp (2) http://bmj.bmjjournals.com/cgi/eletters/330/7481/1#91113 Competing interests: None declared |
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John F Morgan, Senior Lecturer St George's Hospital Medical School
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For those who may not have read the full report, those 'Terms of Reference' were: 1) After receiving the existing evidence and hearing such further evidence as necessary, to consider the extent of Harold Shipman's unlawful activities. 2)To enquire into the actions of the statutory bodies, authorities, other organisations and responsible individuals concerned in the procedures and investigations which followed the deaths of those of Harold Shipman's patients who died in unlawful or suspicious circumstances. 3)By reference to the case of Harold Shipman to enquire into the performance of the functions of those statutory bodies, authorities, other organisations and individuals with responsibility for monitoring primary care provision and the use of controlled drugs; and 4) following those enquiries, to recommend what steps, if any, should be taken to protect patients in the future, and to report its findings to the Secretary of State for the Home Department and to the Secretary of State for Health. That is the blueprint against which to determine if Dame Janet's report was a piece of politically-motivated hogwash with pre-ordained conclusions, established at a time of conflict between government and profession, or the wise words of an independent authority, arguing with dispassionate insight into a complex arena. Competing interests: None declared |
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Stevie M Gamble, retired HMIT EC2Y 8BL
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John F Morgan, Senior Lecturer St George's Hospital Medical School, asserts that Dame Janet Smith’s ‘Terms of Reference’ provide ‘the blueprint against which to determine if Dame Janet's report was a piece of politically-motivated hogwash with pre-ordained conclusions, established at a time of conflict between government and profession, or the wise words of an independent authority, arguing with dispassionate insight into a complex arena.’ Actually, there is one further piece of information needed to make this judgement which John F Morgan has unfortunately neglected to mention; the fact that neither the government nor the Department of Health wanted this Inquiry at all. They wanted an inquiry held in secret with no obligation to make any or all of its deliberations public, and they appointed Lord Laming to head it. Relatives of some of the people Shipman murdered refused to accept it and applied for Judicial Review against Alan Milburn’s decision. They won. (1) Stevie Gamble (1) BMJ 2000;321:784 ( 30 September ) http://bmj.bmjjournals.com/cgi/content/full/321/7264/784/a Competing interests: None declared |
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Michael O'Donnell, FRCGP. Former GP turned journeyman writer Loxhill GU8 4BD
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I don’t see how the additional information supplied by Stevie Gamble affects John Morgan’s argument. After the families and British journalists won a Judicial Review, the High Court recommended that the Secretary of State for Health reconsider his decision that the Inquiry should be held in private. In September 2000, the Secretary of State for Health announced that the Inquiry would be held in public and Parliament ratified this decision in January 2001. The fact that the government may not have wanted a public inquiry did not, however, prevent it, when it was forced into having one, into setting the inquiry’s wide-ranging terms of reference. The excuse for these wide-ranging terms was that the “public” – NewLabourSpeak for the chattering classes – had lost its trust in doctors. Yet every opinion poll I’ve seen since Shipman was unmasked shows that real people have considerably greater trust in doctors than in – to name but a few – lawyers and politicians. I fear, however, that even my great grandchildren are unlikely to see wide-ranging inquiries into the need for regulation and revalidation of those professions, nor the use of a “test of ethics” which Dame Janet recommends for “weeding out” “unsuitable” aspirants. (As I’ve pointed out on this site before you don’t need to search too widely for evidence that an unethical politician can be several hundred thousand times more lethal than a Dr Shipman.) We could judge the likely response to a call for an enquiry by making a simple, practical and eminently reasonable suggestion. How about the BMA Council recommending that every MP should be cleared by a breathalyser before being allowed to vote and that judges be required to pass the same test before every court session. All the BMA would be asking is that people who make decisions that can gravely affect peoples lives, and sometimes cause unnecessay deaths, should at least be sober when they make them. We could leave the need for psychiatric assessment to a later stage. Competing interests: None declared |
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