Observations Medicine and the Media

Secret filming shows fundamental problems in general practice

BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d6392 (Published 04 October 2011) Cite this as: BMJ 2011;343:d6392
  1. Aneez Esmail, professor of primary care, University of Manchester

Random inspections would improve patient safety, says Aneez Esmail, who advised a television programme that covertly found that “failing doctors routinely slip through the system”

It was a comment that I made in an interview for BBC Radio 4’s File on 4 programme that caught the attention of producers at Channel 4’s Dispatches. I had been speaking about the problems of understanding patient safety in general practice and how little we knew about issues related to wrong diagnosis and misdiagnosis. I also raised the question of who would monitor general practitioners in the brave new world of commissioning. Would I, they asked, be willing to take part in a documentary that would open the lid on some of these issues?

Improving patient safety in primary care is one of my research interests. I have investigated the main problem areas and how we can monitor and improve things. As the medical adviser to Dame Janet Smith on the Shipman inquiry I was part of the team that attempted to put in place systems to prevent general practitioners harming their patients. I have a keen interest in identifying poor and unsafe practice—not to shame and blame but to show these problems exist, and that we can and should have mechanisms for improvement.

When I was asked whether I would be willing to be involved in consulting on the secret filming of general practitioners my first reaction was to run a mile. How could I justify being involved in this kind of subterfuge? What were the ethics of it all? Critical to my agreement to take part was a realisation based on my research that there was poor and dangerous practice that the public were completely unaware of, and that the quality of general practice was variable—and frankly very poor in some areas. I also knew that the monitoring of general practitioners who had been brought before the General Medical Council and criticised for poor performance was grossly inadequate. In my view, the over-riding public interest justified the secret filming.

In 1993, as part of our research, my colleague Sam Everington and I used false résumés to prove that many Asian doctors were being discriminated against. Although we were heavily criticised by the medical establishment and accused of professional misconduct by the GMC, we exposed a gross injustice. Because of the furore that followed, the previously unacknowledged problem of discrimination was brought into the open. The research ultimately led to changes in the recruitment of doctors, in the way that the GMC investigated and dealt with complaints, in the selection of students to medical school, and in the way in which aspects of doctors’ remuneration were determined through the allocation of clinical excellence awards.

I helped the Dispatches team develop case scenarios based on examples of patients who had taken cases to the GMC or to the medical defence unions. These patients had sought action and sometimes compensation when doctors had failed to make the correct diagnosis. The cases we used were not difficult to diagnose and most doctors would have easily recognised the symptoms.

Overall I think Dispatches painted a picture of general practice where there are still fundamental problems with the monitoring and regulation of doctors, especially those who give cause for concern. The Shipman inquiry cost £25m (€29m; $39m) and lasted nearly six years. It was the most comprehensive investigation of the state of primary care since the creation of the NHS. Sadly many of the recommendations that related to safeguarding patients are still to be implemented. This is despite consensus from all the medical professional organisations and political parties—until the 2010 general election at least.

So what have we learnt? The secondary school for which I am chairman of governors was recently inspected by Ofsted, the government’s monitor of teaching. We were given three days’ notice of the inspection and more than 60 lessons were observed by the inspectors. Where is that same scrutiny of general practitioners? During the Shipman inquiry we were given examples from Canada, where part of the monitoring mechanism involves random visits to practices to assess the quality and safety of care. Do we really know how safe general practice is? And where we identify problems, what mechanisms do we have to ensure that the poor practice identified in the programme is tackled? The secret filming showed that there are mechanisms to identify poor practice. If we can do that, then can we begin the task of improving standards and safety.


Cite this as: BMJ 2011;343:d6392


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