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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Sir Liam Donaldson
- John MS PEARCE (20 October 2006)
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Hot air
- ANDREW MONTGOMERY (20 October 2006)
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Operational Definition of Health
- Robert J Reynolds (20 October 2006)
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Anti climax
- Radhika Vohra (21 October 2006)
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The Liam Donaldson Interview
- Stuart Sanders (21 October 2006)
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Editing
- benjamin dean (21 October 2006)
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CMO spot on
- Roger M Goss (21 October 2006)
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Re: CMO spot on
- ANDREW MONTGOMERY (22 October 2006)
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Balance of probablities : Bad news for Doctors!
- Charles O Olojugba (22 October 2006)
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Re: Re: CMO spot on
- Paul Brook (23 October 2006)
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Re: CMO spot on
- Robert J Reynolds (23 October 2006)
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Patients at Risk
- John A Gilmore (24 October 2006)
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Justice matters
- John Hopkins (24 October 2006)
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Re: Re: Re: CMO spot on
- ANDREW MONTGOMERY (24 October 2006)
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The health services and the dream.
- William G Pickering (25 October 2006)
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Avoiding the painful truth and scapegoats
- Daniel McQueen (25 October 2006)
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Response to Dr Dean
- Fiona Godlee (26 October 2006)
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thankyou
- benjamin dean (27 October 2006)
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Softly Softly
- Saj Ishaque (28 October 2006)
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CMO certainly NOT spot on!
- Hazel Thornton (29 October 2006)
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Re: Response to Dr Dean
- Robert J Reynolds (31 October 2006)
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Re: CMO certainly NOT spot on!
- Robert J Reynolds (31 October 2006)
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Sir Liam Donaldson interview
- John MS PEARCE (31 October 2006)
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John MS PEARCE, Emeritus Consultant Neurologist Hull, E. Yorks HU10 7BG
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The problem with The BMJ Interview was that Sir Liam gave typically politically tuned answers. He serves the politicians and despite his medical background has failed to achieve actions which would prevent non-medically trained personnel from taking on clinical reponsibilities that should fall exclusively to doctors. A few examples: 1. Inadequately supervised nurse-practitioners running diabetes,
asthma and
epilepsy clinics,
Further, the diminution of medical responsibilities, such as:
The CMO has shamefully let down both patients and doctors. How can a CMO with a medical conscience allow such deteriorations of service to take place? Has he no clout with the politicians of any colour? Competing interests: None declared |
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ANDREW MONTGOMERY, locum Auckland
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It all goes on and on. The ingredients required for the efficient and safe delivery of health care are simple. Intelligent and insightful doctors. This requires successful auditing of unsuitable prospects at the entry level to medical schools. It is not rocket science. It is essential that prospective doctors are possessed of EQ equivalent to IQ. There are many doctors in practice with genius level IQ - but who lack the capacity to recognise that they might be wrong. They are more dangerous than those with relatively low IQ but high EQ. It is called arrogance, psychopathy or whatever. they should never be allow into the profession in the first instance. To err is to be human. Doctors will always make mistakes some of which will lead to significant morbidity or mortality. So what. So do all human beings. It is life. It is necessary to have in place as many feedback mechanisms as possible in order to minimise patient harm. After that we can do nothing except be as vigilant as possible. It all comes down to individual moivation combined with system feedback mechanisms. I found Sir Liam's discourse patronising and entirely lacking in the communication of fundamental insights. Political speak. Competing interests: None declared |
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Robert J Reynolds, Hospital Staff Grade, Ophthalmology North Devon District Hospital, Barnstaple, Devon EX31 4JB
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In our daily lives, education, experience and conscience are our vital guides. We rely on the commonsense of our times for our awareness of success or failure. The latter will generally reflect some combination of ignorance and pressure. We can expect that, as with Sir Liam Donaldson, the aims and efforts of our Chief Medical Officer (CMO) will at least command respect, and often call for gratitude. Sue McGregor's interview has afforded an opportunity for reassurance that the public, the profession of medicine and the party in power, all have the benefit of conscientious advice from our current CMO. At this level of public health determination, however, I believe that we should wish to know the underlying political definition of health that informs the CMO, and the definition that he sees or believes to guide the government. The principal issue here, I believe, is not the listing of an infinity of health objectives, but a declaration of awareness and of personal choice, with regard to the process of health definition, the context within which objectives arise and compete. Much is spoken about inequalities of individual health, of the health of societies, and of the health of the world. Most will acknowledge we are here concerned much with personal income distribution, personal choices and the work of those in allocative roles, in government, commerce, charity. At least in the West, most would wish to rest their faith in the democratic context for resource allocation towards health objectives: we need hardly list other options, except perhaps to hope for a 'good leader' in 'time of war'. The opportunity missed by Sir Liam, and by Sue MacGregor, was with respect to our understanding of democracy. If, just for a moment, we can allow what some would see to be an oxymoron, an inegalitarian democracy, could we be surprised at unequal health outcomes, at global harm from selfishness, at, in short, the consequences of a fearful slavery, to Mammon, thus governed? I would like to know how far our CMO has explored the possibility of health benefit from egalitarian democracy. I believe we would have a better world if conscience could be voiced without risk to career and pension - if everyone from George Bush to Harold Shipman were freed from the direct or indirect influences of fear and greed. I do hope no one will see this as an offensive belief upon which to invite comment. I look forward to the debate. Competing interests: None declared |
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Radhika Vohra, GP Registrar Surrey
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This interview was long awaited and despite being done beautifully - it is on it's content, hugely disappointing. To me, it was a simple reinteration of the points in the original report. There was no consideration of the concerns Drs, GPC, GMC and BMA have shown. A very disappointing and transparent political exercise. Competing interests: None declared |
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Stuart Sanders, Independent family doctor 22 Harmont House, 20 Harley Street, London W1G 9PH
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Sir Liam comes over as a considerate and caring doctor who wants patient care and safety to be paramount in our NHS healthcare system. Having previously been sceptical about his proposals, I have been won over by his candour and wait eagerly to read the results of the consultation process. Competing interests: None declared |
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benjamin dean, sho oxford
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I took part in the interview with Liam Donaldson and was glad to have been given the opportunity to put my question to him. However in my opinion the interview was not as testing as it could have been and there are certain question marks in my mind as to the way the interview was edited. My first question specifically mentioned 'targets' as having a detrimental effect on patient safety. However when I listened back and read the transcript, this important detail had vanished. This detail seemed fairly key to me and by editing it out, it let the CMO off the hook to a degree. Interestingly when the CMO responded about the shortening of training, he specifically mentioned a special fast track form of radiology training as if this could be applied to all specialties. This was not included in the final transcript. I then mentioned that clinical experience was key and could not be rushed in all cases. The CMO agreed with this. However this was again left out of the interview. Obviously editing is vital and helps iron out certain creases, however I must question why important details were lost in the editing process? I am a very opinionated individual and will therefore give my opinion. The CMO was largely mollycoddled and given some very easy questions indeed. Given it is rare to hear him interviewed, I feel more time should have been spent pressing him on several key issues. Why was the regulation of other medical professionals not mentioned? I am talking here of physician's assistants and nurses who are being given extended clinical roles with insufficient training. Why has the disastrous governmental reform of the NHS not been mentioned? Surely patient safety is a grave concern here, especially when ISTCs are not regulated any way near as tightly as their NHS counterparts. What about the continued waste of money by health related quango agencies of billions and billions of pounds? This is while the NHS is being squeezed for snmall change, and valuabe staff and services are cut with little regard for patient safety. What about the scandal of MMC and its impact? I could go on. Many doctors are dissappointed with the BMJ's line on a number of issues, and this easy ride for Liam Donaldson is yet another missed opportunity in the eyes of many. Competing interests: None declared |
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Roger M Goss, Co-director Patient Concern
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Sir Liam Donaldson's explanation of his recommendations for improving medical regulation to protect all of us from the small, but potentially lethal, number of doctors out there are lucid and accurate. Patient Concern has yet to encounter a patient advocate that doesn't support these recommendations. The bottom line is that ultimately, lives matter more than livelihoods. Competing interests: None declared |
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ANDREW MONTGOMERY, locum Auckland
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It is clear from listening to Sir Liam’s discourse and the responses to his dialogue that the UK suffers from the same malady as New Zealand. Burgeoning bureaucracy in the health industry with its associated costs combined with declining numbers of competent health providers. Mr Goss makes a common comment with respect to the value of “lives” over “livelihoods”. I am not sure whether the deeper issues articulated by the commentators preceding his comments were fully understood. Doctors and their families are as prone to disease as the general population. We are subject to the same degree of medical error – despite any belief to the contrary. My concerns are twofold. Firstly – that there is a false belief that the creation of additional layers of administration will improve patient safety, and secondly – that there is a belief that there are shortcuts to education and experience. Doctors are largely selected for training because they have superior intelligence and are therefore faster to learn from education and experience. It requires a level of intelligence to know what you do not know. A little knowledge is a dangerous thing. So – despite the errors doctors make – the public might like to entertain a simple thought experiment. Let’s make medical treatment really cheap and give prescribing and treatment rights to the unemployed on “back to work” programs. Yup it’s the reduction ad absurdum position but it has passed Sir Liam and others by. Doctors will never be perfect – but probably better than any alternative. There are no short cuts Competing interests: None declared |
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Charles O Olojugba, Spr in Psychiatry St Pancras Hospital London NW1 OPE
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I was disturbed by Sir Liam Donaldson's response on the issue of the burden of proof required for doctors to face disciplinary action shifting from 'beyond all reasonable doubt' to 'on the balance of probabilities'. His view that patient's health needs to be protected is of course correct. However his suggestion that a dr required to undergo retraining is not a major issue is not! He hinted that in cases where the likeey outcome of a GMC hearing is for the dr to retrain the GMC will have a low threshold for finding that dr guilty reasoning that its not a big deal because at least the dr is still allowed to work. Surely that is not the issue! Any dr convicted by the GMC of any offence is likeey to find it emotionally difficult as well as professionally damaging. Dont get me wrong, drs at fault should be held to account but lets not be mistaken some innocent drs are going to be unfairly treated by his shift in proof burden. Competing interests: None declared |
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Paul Brook, writer london se8
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"Doctors are largely selected for training because they have superior intelligence" It is because of attitudes such as this amongst doctors that the GMC is in such trouble. How is the intelligence of doctors superior to that of the patients they treat ? It quite simply is not. Competing interests: None declared |
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Robert J Reynolds, Hospital Staff Grade, Ophthalmology North Devon District Hospital, Barnstaple, Devon EX31 4JB
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Sir Liam Donaldson's report is a very worthy personal effort. Its welcome by Roger Goss, writing for Patient Concern, reflects a perspective no doubt widely shared. Unfortunately, the recommendations are as a stack of sticking-plasters to a patient principally in need of food. The essential context of the problems and tragedies we all wish to prevent, has been left entirely unaddressed. What we have to deal with is the basis and breakdown of trust. We have to probe more deeply, beyond 'the problem of student selection', 'the weakness of support for continuing medical education', and 'the failures of early statistical detection of under-performance'. However much 'help', however many 'hoops', our doctors - those we all face as individuals - will win and retain our trust, or not. The question is, on what basis can we - all of us patients - reasonably expect that impressions of knowledge, skill and trustworthiness, will prove to be justified? From my own decades of observation, through changing fads of student selection and medical education philosophy, my impression is that successive generations of doctors remain - both gloriously and stubbornly - human. Still just as human are those moved to specific and general praise and criticism of doctors. As patients and relatives we may experience overwhelming gratitude, disappointment, dismay, even anger, justified or not. Commentators, from within and without the profession and the health service, may still take years (or from lack of experience fail utterly) to grow out of early illusions and blanket prejudices. 'Sound and fury' can engulf us. My recommendation would be to look to the trustworthiness of all - that of politicians and pundits, doctors and divines, financiers and fishmongers. How significant, we should ask ourselves, are the conflicts of interest that shaped the development and continuation / survival of each of us in our respective posts? Do we, for instance, 'owe it to' our families or friends or colleagues, to soldier on, say, in government or in brain surgery, when value and skill are on the wane? Is this person, am I, part of a self-regulating community, able to work from unencumbered vocation, free to tell truths, free to move on or encourage others to go whenever appropriate? What would happen to income, school fees, pension, and political donations, if I moved on, too soon, from theatre to clinic work, from medicine into landscape gardening, or from politics into paperbacks? Are many of us 'trapped' by high spending life-styles, high debts, and fears for our children in an unfair world? As merely a sometime jack-of-many-trades, I marvel at those who, after 18 years in child-labour at school, have given another intensive 18 years, perhaps their 'best', to the wiring of their minds for particular spheres of practice. However, I am almost sure that I have never met and never will meet the perfect doctor as might be conceived by a stern judge; that many 'good doctors' have been brought down by the weight and last-bale conditions of their employment; and that some 'potentially good' doctors have been over-indulged in the debilitating context described above. A very few colleagues have, from their own claims, come close to obligate sociopathy - none in the clinical sphere. My conclusion, therefore, is that for positive reform the issue, overwhelmingly, is just how, from our 'human nature', to bring out the best. Some may believe that 'over-pay' attracts the worst and corrupts the vulnerable. Hope is placed also in 'a better human nature', or in a more easily regulated narrowness of practice, perhaps from non-doctors, working from a different base of knowledge and experience. Experience will tell, but as we work to optimize the deployment of our deck chairs, let us recall the fate of the Titanic, and the supposed fate of bureaucracy as it approaches 'perfection'. Let us look at history, and at the wide world. Mighty civilizations have passed: there is more to survival than might and greed and living in fear of each other. The truth that at first sight some may find a little uncomfortable, is that only with general equality of incomes can there be a general at least provisional trust, based on real freedom of conscience for all. If resource allocation proceeded from freed communication, in a truly - representative democracy, defined and sustained by its secure equality of income shares, we would I believe approach truly appropriate support for health service facilities, staffing, and training. Individuals' niches would be where most comfortable, wherever they could compete with themselves to raise standards. We should not be content to rely upon burdensome mass filtration, with random sudden-death fears for ordinary very hard-working people. In today's society, we should at least make service stability and planning independent from the annual adjustments of NHS-pay. And we should end the penny-pinching study lottery that for decades has undermined training. Competing interests: None declared |
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John A Gilmore, Project Manager Manchester M17 1HH
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I thought that Sir Liam gave a clear picture of what is required however, my concern is that while the NHS is striving for better patient safety the government have now revealed that they intend to have minor invasive surgery carried out in GP surgeries, will this not just pass the MRSA issue down to Primary Care? and will it not put more patients at risk? Competing interests: None declared |
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John Hopkins, GP DL9 3PS
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Dear Madam, Roger Goss says that lives matter more than livelihoods. This has a fine rhetorical flourish but misses the point that everyone is entitled to a fair hearing, a fact certain to be pointed out to the High Court and the European Courts by any doctor caught up in Liam Donaldson's plans. The last couple of years have seen at least one case involving a nurse who was found to have murdered patients and another nurse who died while awaiting trial for allegedly killing patients. Train drivers and policemen have faced similar claims. If Goss is really saying that all of these groups should loose the right to the presumption of innocence then he is declaring war on society. If he argues that only doctors should be subject to such a change then he must explain why they should be singled out in comparison with other occupational groups who may be in a position to visit harm on the public. Dr J Hopkins Competing interests: I am a doctor |
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ANDREW MONTGOMERY, locum Auckland
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Sorry to have offended. Many occupations require high (superior) intelligence. Those who don't choose medicine are fortunate to be in professions which are not subject to close media scrutiny. My own parents were of "superior" intelligence and had nothing to do with medicine. In fact I would suggest that many of the smartest folk stay right away from the job as much medical work is dull uncreative and repetitive. Doctors die young on average. I would prefer to be a professional musician. I am immensely grateful that there are so many dedicated doctors - particularly those with considerable on call requirements - who literally give their life to the job. My family has had considerable exposure and help from these dedicated people. They deserve a medal. 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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The health services and the dream. The audience for this BMJ Interview should perhaps have moderated their expectations. The main participant was an esteemed spokesman of a huge state bureaucracy — the personal advancement for whose employees depends upon compliance and complaisance towards their masters, whilst range of thought and articulation of unwelcome facts are considered less essential. This partisanship and partiality, be they impediments or assets, can become habitual over a working lifetime and are usually unabated by promotion to a top medico-political job. As it happens, this top job, that of chief medical officer, is also the incumbent’s "dream job". Being hungry for insight and progress we willingly shelved any reservations, and awaited his "dream" with extravagant hope. What fare the interview might have been if the media had had the intrepidity and nous to ask the CMO: ‘How have the health services managed to conjure an inverse relationship between doctors’ salaries and doctors’ morale — is this a trick of a mature democracy or a circumstance unique to the British health services? Also: ‘You mention "primary victims" and "patient safety": were there not lessons even 20 years ago (eg. the Cleveland affair) which, if heeded, might well have built in the "potential avoidability" (your term) of aftercoming disasters, including professorial blunders? Today, why is there still no mechanism to uncover, and therefore deter recurrence, of even some daily, rudimentary, single medical errors nationwide – important enough on their own, scandalous when medically ignored and enabling repetition. You talk of medical "regulation" — which is not accountability (any more than is "education" or "training"). Was it not exactly this present lack of clinical accountability which emboldened known serial medical miscreants – until the press, patients or police brought them to account?’ Media events do not permit dull programming. Just one of these questions might have taken the whole interview to properly address — unthinkable in the sharp, glossy world of presentation. But it would have elevated the programme to a quite different level. William G Pickering 24.10.06 wgpi@hotmail.com Competing interests: None declared |
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Daniel McQueen, Specialist Registrar in Psychotherapy Cassel Hospital,1 Ham Common, Richmond, TW10 7JF.
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Dear Editor, I do not support the proposal of the Chief Medical Officer that “In adjudicating upon concerns about a doctor’s performance, health or conduct, the standard of proof should be the civil standard rather than the criminal standard.“ He is correct when he write that "...the quality of an individual doctor's practice is influenced by the nature, culture, working practices and performance of the health organization in which the doctor works", and that "The quality and safety of the care received by patients is not yet central to the goals, culture and day-to-day activities of every organization and every clinical team delivering care to NHS patients. Financial and activity targets often have a higher priority…" The individual doctor is however the natural target when things go wrong and someone is needed to carry the blame, but this is called scapegoating. When this occurs other more abstract, institutional factors are missed. It is clear that when facing illness, disability, pain, blighted lives and death many patients, families and professionals invest medicine and doctors with a supernatural power, to overcome illness. But these fantasies cannot be sustained when reality reveals the truth that doctors are limited and that some are more limited than others; the disappointment that follows can create a wish for revenge. The revalidation agenda is politically expedient. The reality of rationing cannot be denied. However the political debate we have avoids acknowledging the reality of the fragility of human health, limited public resources and the limited power of medicine to 'make things right'. Instead the Government and CMO have encouraged fantasy thinking by promising ever better care, and ever higher standards, more nurses, more doctors, more operations, etc. The consequence of this manic response is that someone or something has to carry the badness, and this appears to be the 'underperforming doctor'. The revalidation debate risks colluding with this manic response and makes the scapegoating of individual doctors more likely. As doctors we should lead the way in pointing out the painful truths of human existence, sickness and death, the limitations of medicine, and acknowledge explicitly the limitations of funding that occur in any health system. The criminal threshold should be retained for actions that threaten the livelihood of the doctor under investigation. If this threshold were to be lowered to the civil level then 'on the balance of probabilities' many doctors may find their lives wrecked as they become scapegoats of a system in denial. Yours sincerely Daniel McQueen. Specialist Registrar in Psychotherapy. West London Mental Health Trust Good doctors, safer patients: Proposals to strengthen the system to assure and improve the performance of doctors and to protect the safety of patients Chief Medical Officer, Sir Liam Donaldson, Department of Health, 14 July 2006 Competing interests: None declared |
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Fiona Godlee, Editor BMJ
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The full recording lasted nearly an hour and had to be shortened to a manageable length and to make a coherent whole. There was no intent to remove or minimise discussion of politically sensitive issues. Fiona Godlee Competing interests: I am the editor of the BMJ, listened to the recording session and signed off the final edited version. |
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benjamin dean, sho oxford
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Dear Editor, Many thanks for taking the time to reply. Perhaps I was just a little frustrated that there wasn't time for a few more questions that could include some issues like targets and their effect on patient safety. I still feel Liam Donaldson didn't have to sweat quite as much as he should have. Anyway thankyou for the interview, regards, Competing interests: None declared |
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Saj Ishaque, GP GU6 8AE
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I am still not sure how 'independent' Sir Liam is or for that matter every practicing doctor . My take on the interview is that the questions were not difficult enough and I would have loved to hear some one like Jeremey Paxman ask the questions to LD, not the nice, good lady who did. I am bemused by this softly softly approach. I have always admired Fiona Goodle but this time I am disappointed by her as I feel that crucial points were deleted from the Dr B Deans section of the interview. Money spent so far on the NHS has meant fatter paychecks for the NHS staff and not better patient care. Billions of new money has rained on the NHS and still we need to close more hospitals and sack more nurses. Well Done Mr Blair. By the way, Doctors are NOT of "superior" intelligence. Competing interests: None declared |
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Hazel Thornton, Honorary Visiting Fellow, Department of Health Sciences, University of Leicester. "Saionara", 31 Regent Street, Rowhedge, Colchester, CO5 7EA UK
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Might I suggest that Roger Goss takes a look at www.gopetition.com/online/9679.html where he will find more than 900 signatures opposing the proposals set out in Sir Liam Donaldson`s report “Good Doctors; Safer Patients”, [1] some of whom are patients? The comments against many of these signatures reveal the reasons for their opposition, and the strength of feeling there is amongst health professionals of all kinds, and of patients, about this threat to medical professionalism. Following publication of an open letter in The Times [2] the Chief Medical Officer acknowledged receipt of this petition (at that time containing over 700 signatures) [3] which, we are told, will be fully considered with others as part of the Department of Health`s response to the consultation process. Hazel Thornton. Independent Advocate for Quality in Research and Healthcare. [1] Chief Medical Officer. Good doctors, safer patients. London. Department of Health, 2006. [2] G.Querci della Rovere, Hazel Thornton, Dr. Margaret McCartney et al, and 720 other doctors and patients. New check-ups for doctors. The Times October 17 2006, page 18. [3] Zosia Knietowicz. Is Liam Donaldson the new José Mourinho? BMJ 2006; 333:878 Competing interests: None declared |
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Robert J Reynolds, Hospital Staff Grade, Ophthalmology North Devon District Hospital, Barnstaple, Devon EX31 4JB
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It takes editorial courage to bring deeper issues and uncomfortable truths before the public. Editorial survival after radical analysis of options and confrontation of issues, requires not only editorial skill but also some measure of public support. I write to encourage others to commend to the BMJ the inclusion of analysis from a radically democratic perspective. Surely we have now seen enough to heed the advice of Disraeli: we must educate our masters. As an example we could look at the latest GMC update on Good Medical Practice. Credit for this work is shared with 'the profession and the public'. Why, it was not asked, would anyone entering medicine, dealing with patients, and advising on healthcare, wish to do other than focus on 'the care of our patients', providing 'a good standard of care', with respect for individual dignity, partnership, openness, honesty and integrity? Why, it might further be asked, would the GMC commend the protection and promotion of individual and public health, without troubling to define health? The missed central 'regulatory' truth is that doctors, like patients, reflect the values and pressures 'agreed' or tolerated or imposed within families, tribes, sects, and states. What doctors and patients 'need', from the GMC, is a better example, more than the age-old mix of due respect and defensive humouring to put at ease. Of what real use can reams of 'mission statement' be, unless judgement can be supported by a 'jury' of peers? And if such a jury agrees as to rudeness, ignorance, wilful negligence, or abuse, what might be usefully added to reprimand, or rehabilitation, or punishment, by reference to the GMC's complaint permutation guide? The GMC has for some time been colluding in the pursuit of scapegoats. For sheer futility, this work has now been trumped by a new wave of false prophets, populists, and naive enthusiasts. As the GMC passes towards formal redundancy, having failed to champion adequate funding for continuing medical education, the buck passes to the probably terrified PMETB. Rather than see support for all, each year a scattering of doctors will stand to be compulsorily re-educated, after the ruinous tumbling of the whole profession. The details of 'minimum requirement' for the long and highly specialized, have, needless to say, 'yet to be worked out'. A year ago, perhaps not so very hard-pressed as many for time, I was one of only 166 respondents to the CMO's Call For Ideas. I wished to reassure that financial pragmatism was here in order. True remedy lay elsewhere. I cannot say that I much admire the strategy of giving the stage crowd its 'spot on' wish. It may reflect a belief that the NHS will collapse even before the regulatory scheme starts to impact. The colossal benefits and potentials of national arrangement are now being sacrificed in headlong retreat from commitment to a democratic future. As electoral support and member support dwindle, the party in power still pretends to 'government', and instead of waking up, looks for salvation, support and good cheer, to queueing business opportunists - blamelessly doing what comes naturally. Responsibility for the above can only rest with 'all', but as doctors we must surely take a large share. This is not because we are more good, or more evil, or more courageous, but simply because we have a public trust to live up to. Much as we may feel damaged by particular stresses, and though our immediate fear may be further increase of incidents in which doctors fail or crack or are unlucky, we cannot be content merely to bemoan the folly of regulatory addition to stress. Notwithstanding our natural sympathy for at first timid and now frightened leaders, for the desperately bereaved and the damaged, and even for those whose cries most distract from truth-seeing, we have to 'get serious'. We have to address the major explanatory context of that great weight of harm that is systematic and repetitive, that is seen but too slowly comprehended, that if raised is so easily 'defended' as to remain untouched. I refer not just to harm in clinics and theatres, but to harm in schools, workplaces, and would-be representative bodies. My major context is failure to secure freedom of conscience, failure to seek and endorse the social conditions within which ordinary mortals could be expected to exercise such freedom. The GMC's future is in the air. But as a body of relatively aged and financially independent members, one great freedom of action remains. The GMC might be remembered as the first regulatory body to insist upon democratic ambition, upon the definition of health as that combination of 'goods' chosen for pursuit within a democracy that is formed by individuals who understand and support the social conditions for democracy's sustainability. Against the straightforward policy of progressively narrowing income spreads (within and of course between nations), and allowing the various 'markets' to work their magic (with of course our real help as at last free agents), a proper contrast would be struck with the Inequalities Agenda of the government, under the massed flags of which, darkness and disintegration have descended upon the NHS. Turning away from the GMC, and back to the bmjinterview, perhaps the CMO could be invited a second time. I hope one of the selected questions would be on the apparent failure of Public Health, to seek and endorse a democratic definition of objective. How can 'we' know what it is 'we' seek efficiently to pursue through the allocation of funds? Does the CMO think his answer adequate to Josef Milerad's open-ended question? He outlined his value to government as 'an outlook on the population's health' from 'somebody with a medical qualification'. Though for his interviewer, a 'pretty good case' was made, I believe a second chance might be deserved. Editing for balance may explain, but Sue MacGregor's next question, portmanteau-style, seems to have allowed the CMO to evade 'chaos', to pass over the IT fiasco, and - on doctors' organizational concerns - to offer reassurance to all that clinical commitment. would continue regardless It appears that the CMO may miss the point on his visits. Persistence of medical vocation does not signal appraisal of government policy either as good or even merely as to be borne with patience. Honest chaos might be forgiven, but institutionalized occupational insecurity, with no relation to performance failure, cannot be tolerable treatment of those who have 'answered the call' and 'given their lives to medicine'. Regulation of medical school (and nursing and others') numbers may involve many issues, but two-way commitment should be part of the deal. With respect to likely number mismatches, errors should be on the positive side: there is no shortage of clinical work to be bettered by sharing, no likely limit on benefit from education, and no end to scope for research. The health effects of unemployment have been researched: long ago as a profession we should have demanded that Human Relations, throughout the land, should 'make the care of fairness a standard concern'. Finally, on patient safety, while Dr Certainly Bad will properly be investigated until a 'reasonable' amount of 'evidence' justifies conviction, Dr Possibly Good need have no great investigational concern, his charge arising only from an already apparent remediable educational deficit. Might this be regulation Salem-style? Apologies to Arthur Miller. Competing interests: None declared |
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Robert J Reynolds, Hospital Staff Grade, Ophthalmology North Devon District Hospital, Barnstaple, Devon EX31 4JB
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I have much sympathy with Margaret MacCartney’s petition, opposing the off- target and ruinous proposals of the CMO’s Better Doctors, Safer Patients. I would like however to point out need for a clearer view of the basis of doctor-patient trust, ‘the bedrock of medical practice’, to underpin the call for reconstitution of the GMC. It is I fear not enough simply to invoke ‘independence, transparency, and accountability to parliament’ for public reassurance. As with governmental and GMC and royal college pronouncements, willing the ends without the means will only bring further grief. There is great folly in too much distraction of clinicians from the practice and self-directed CME upon which their expertise depends. College elders strive for academic rigour, acting admirably as gatekeepers to ‘independent’ practice. GPs and DGH consultants must deal with clinical variety and detail and whole-person care. The academic and the experienced must be in communication: ‘education’ will be afforded, both ways. But tests of conformity, or of instant recall, for senior doctors on matters of controversy or contextual irrelevance, will be the very reverse of helpful. At the heart of scandal and its prevention, is the likelihood that “Somebody – perhaps many people – knew”, or at least had a fair idea that all was not well. Harold Shipman may never be understood, but can we doubt his knowledge that he was leading ‘the wrong life’? We need to grasp ‘what goes wrong’, and to determine the conditions needed for (in order of public health importance) prevention (of under-performance and worse), detection (with sensitivity and specificity), correction (if truly appropriate), and fair adjudication. If and when we reach the position in which the performance of doctors, and / or the perception of the public, is such that doctors in general are mistrusted, then judgement as to fault might indeed, in the interest of public safety and reassurance, best be made on ‘the balance of probabilities’. .If, on the other hand, it is widely the case that doctors in general are trusted, then ‘the doctor in the dock’, especially if supported by the evidence and testimonials of patients and colleagues, might then best be viewed as a probable asset to the public good, not to be disgraced and discarded without cause ‘beyond reasonable doubt’. Intermediate positions are of course imaginable – with calibrated responses such as safety-first rehabilitation, probation, or compassionate suspension from duty. If we assume that high risk of medical recklessness, and / or of patient gold- digging, soon would lead to appropriate changes in education and in the deterrence of mischief, then in normal times the bedrock of daily practice will not be a ‘balance of terror’, but rather, as the petitioners have it, ‘a trust in trust’. Given that, unfortunately, trust on both ‘sides’ can be misplaced, the protection of patients, of doctors, and of the invaluable relationship of trust, demands not just apparent ‘investment in prevention’, but credible investment to secure the conditions for success in prevention. Otherwise, we can expect the continued emergence of scandals, and periodic lurches into vain over-regulation. I believe that patients would like their doctors to be primarily accountable not to governments or kangaroo courts or citizen-committees or even the most knowledgeable of ‘expert patients’, but rather to conscience. And if there can be confidence in the doctor’s freedom of conscience (which will drive his / her continuing medical education, and much else), it becomes reasonably less worrying to wonder, “Does the doctor know enough to truly know that his / her advice, and any offered practical skill, are at least reasonable to be offered, to me as to a colleague or to one of his own family?” In emergency, or in Antarctica, we may expect efforts to engender confidence as a vital part of effective management, even when the doctor ‘would rather you were in St Somewhere’s ICU’. In general though, patients should be able to expect, from ‘the system,’ and from their doctor, that if there is any significant shortfall of confidence, the doctor will be free and ready to give time for further assessment and / or seek further help. And so, as we might expect, the public health buck comes back to ‘the system’ – for which we all share responsibility. Put simply, “Is there provision (do doctors collectively or individually insist on provision) for adequate on- going education; and is staffing sufficient to allow due time and expertise to meet each patient’s needs? Thus put, it might appear all we need is sensible investment, in education and staffing levels. For ‘junior’ doctors, in ‘structured environments’, such obvious remedies can go a long way: but what of consultants, and more isolated GPs? Without attention to the general conditions of freedom of conscience, will these doctors hear, or heed, or even consider, “junior” news from St Elsewhere’s? If burdens are humanly ‘impossible’, will they still be carried as age tells, and as extremes of narrow self-sacrifice become moderated by responsibilities to family and wider society? Who will say, in good time, “Let’s go and see how they do it in Newsville” – or “We need to talk about retirement” – when the show is running at full tilt, management bonuses are at stake, the house and college fees are not yet paid for, and in your neighbourhood you and your spouse are at risk of pensioner poverty? To our politicians, of all colours, and to our patients, is it not time to declare the futility, even the hypocrisy, of ‘targeting inequality of health outcomes’ in a social system that (with the reverse of necessity) tolerates inequality (and incurs global degradation) of health inputs? Even if we see wisdom in gentle transition (to avoid excess turbulence and counter productive lurches during market adjustments), surely all should know where it is we need to reach? The issue of freedom of conscience is not just for doctors: it can only exist if possessed by all. Did I mention equal income security? As John Lennon invited, “Imagine!” Competing interests: None declared |
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John MS PEARCE, Emeritus Consultant Neurologist Hull, E. Yorks HU10 7BG
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How interesting that Sir Liam has chosen not to respond to the several pertinent comments and criticisms based on his revealing interview with Sue McGregor. No doubt his decision to confront these issues is politically correct. Competing interests: None declared |
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