Crisis in cremationBMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7157.485 (Published 22 August 1998) Cite this as: BMJ 1998;317:485
Positive action by the Home Office is urgently needed
- Stuart Horner (), Professor in medical ethics.
Disposal of bodies by cremation in the United Kingdom gathered pace in the last 25 years of the last century, following the establishment of the Cremation Society in 1874. It is now the commonest form of disposal, accounting for 73% of disposals in 1996. The legislative framework for cremation was established in 1902: its centenary seems likely to be marked by a system in crisis, on the verge of collapse.
The legislation requires the signature of a medical referee before a cremation can take place. A recent survey of medical referees conducted by the BMA showed that less than 20% are aged under 50. Over half are over 60 and more than a third over 65. No arrangements seem to have been made for replacing this elderly group of doctors. Individual medical referees reported themselves trapped in a system from which there was no escape—required to attend virtually every day, for a fee which does not even pay their travelling costs. They are finding it impossible to recruit deputies or successors.
Several factors may be responsible for this worrying situation. Conspiracy theorists may blame the Home Office, which, having failed to secure the implementation of the recommendation by the Brodrick committee that medical referees should be abolished,1 is now just allowing time to resolve the issue.
A more plausible explanation is the nature of the cohort itself. Almost 60%of referees above retirement age were previously employed in the public health service. Once local authorities (who own the overwhelming majority of crematoriums) could require their own medical staff to undertake the task of medical refereeing. Since 1974, and the transfer of these doctors to the NHS, the use of their successors can take place only by negotiation. Younger practitioners, dazzled by the attraction of quality issues in the secondary care services, dismiss such duties as “not proper public health medicine.” It is, however, difficult to imagine a more effective form of medical audit in an area than every single working day to examine a random sample of the care given to dying patients.
General practitioners may be deterred by the fact that the work, if done properly, requires challenging colleagues about their standards of care from time to time. Most mention the derisory fee. Over half the current medical referees think that the fee is a significant deterrent to recruitment. Another factor is the apparently declining interest of doctors in the establishment of a reliable cause of death, which the medical referee must certify to be “definitely ascertained.” The decline in hospital necropsies has long been documented. 2 A more recent survey found that only 41% of forms presented to a northern crematorium were completed sufficiently for the cremation to proceed without further inquiry.3
The Home Office has been reluctant to give the subject the attention it deserves. Despite frequent rumours that changes to the cremation regulations are imminent, written evidence confirms that no such plans exist at present. Yet change is needed: much of the language of the documentation that doctors have to complete is antiquated. A hundred years ago it may have been possible to deduce from the mode of death that the patient may have been poisoned: it is no longer so. Coroners' certificates now account for about a third of the disposals, yet the coroner is under no obligation to record on the disposal form the cause of death, which the medical referee must “definitely ascertain.” A reference to radioactive implants is now included, but its completion is not a statutory requirement.
The one major recent change to the regulations has been positively unhelpful. Astonishingly, it is designed to exclude senior hospital pathologists from any involvement in the cremation process, even though the results of a necropsy are the most satisfactory objective evidence on the confirmatory medical certificate. No confirmatory certificate is required in such cases. Instead a new single question on the initial medical certificate inquiring whether a necropsy has been done incorporates five qualifying clauses which the junior doctors who usually complete it find unusually difficult to understand.
What can be done? In the BMA survey medical referees themselves emphasised the need for induction and continuing training to promote common standards. A requirement to meet the costs of any necropsy requested by the medical referee would help to resolve the occasional problem when the cause of death is disputed, or when none of the doctors eligible to sign the requisite certificates is available. More effective supervision by the Home Office is urgently required, including random inspectorial visits to crematoriums. Differing necropsy rates and quality standards need identification and explanation. Thirteen crematoriums dispose of fewer than 1000 bodies a year; one as few as 219. The choice is simple: either the system should be made effective or it should be abandoned. The latter is an extremely hazardous option, but to do nothing is even worse. Despite the claims of cremation authorities that they expect no difficulty in recruiting medical referees, the present system is about to collapse under the impending manpower crisis.