David Oliver: Is abuse towards doctors in government roles unfair?BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1796 (Published 06 May 2020) Cite this as: BMJ 2020;369:m1796
All rapid responses
I have a lot of sympathy with Gabriel Scally's argument. And the article he and colleagues published in the BMJ recently setting out the serial failings in the government policy response to the Covid-19 Pandemic should be required reading for anyone interested in what has gone wrong so far - partly due to advice and actions from medics and scientists in roles within government and its executive agencies and arm's length non departmental bodies . There have been any number of lengthy, well attributed and referenced discussions of failings over testing, PPE, preparedness and speed of response and of ham fisted public communications (including my own only last week in this journal)
I was very clear in my short column that there had been mistakes on behalf of the various medics in these roles and they should not be exempt from criticism. Though until all documents and minutes are released we won't know the full extent of any advice given or decisions taken by the medics as opposed to ministers and senior officials.
As a former national clinical director on secondment to the Department of Health before the creation of NHS England/Improvement and Public Health England i understand the challenges posed by being on a Civil Service Contract and part of the collective responsibility of government decision making and working relationships with civil servants, ministers and special advisors. . And in my various professional leadership roles since, i have also seen close up the lobbying and influencing and pressure from the other
As Prof Scally correctly surmises, my intention was to warn against personally abusive attacks and accusations of political capture, lack of professional integrity or acting in bad faith. This is a very different matter from exempting people from legitimate criticism. These roles are seductive because of their influence and profile, and closeness to the levers of power and potential opportunities which may then arise and because they afford a real opportunity to make a difference to national policy. And because of these trappings they are hard to walk away from even though most people in them could find another job tomorrow.
In the case of Public Health England and the CMO and CSA then the Civil Service code applies, although NHSE/I have a little more freedom to be critical of government and distance themselves from decisions. It would be hard to stay in post and therefore able to make a difference by publicly briefing against the government. (Even though politicians and special advisors clearly brief against the medics and scientists off the record or try to pass the buck for decisions)
However, there have been woefully few senior doctors or nurses who have publicly resigned from these roles over the past two decades when decisions have been taken against their advice or better judgement and over their heads/behind their backs. For instance, why did no senior nurses walk over the scrapping of nursing student bursaries or the work on safe staffing levels?
Even since i submitted my column, i have come closer to Scally's view of events. For instance, as a geriatrician working closely with social care and care homes i could not have stood by at and allowed the Health Secretary to assert at a downing street briefing that he had thrown a protective ring around care homes without publicly disagreeing, contradicting and then having to resign
I do think personal, professional integrity leave doctors in government roles with lines that they personally don't think can be crossed
My plea was for abuse not to be personal or hateful or accusatory and for critics to realise how hard such roles can be and for people to realise that it is better to have clinicians in these roles than not. If the current crop were all replaced by equally credible experts, the new incumbents would face the same challenges of working in a highly politicised environment where many of the decisions and advice happen away from the public domain and where rules prevent outspokenness.
And some of the individuals like Prof Whitty the CMO were widely respected just before the pandemic and have not become different people overnight.
However, i certainly don't think jobs attracting salaries close to £200k and with considerable prestige attached should be exempt from criticism - so long as we play the ball, not the person.
[1[ Scally G et al BMJ 15th May 2020. https://www.bmj.com/content/369/bmj.m1932.abstract
 Oliver D. The Covid Pandemic Shows the need for good government communications, BMJ 15th May 2020
Competing interests: No competing interests
I noted the statement, "Criticism of doctor– advisors is unfair" at the top of the opinion piece by David Oliver in the paper edition of the BMJ and was surprised to find it published online under a different title, "Is abuse towards doctors in government roles unfair?". I would never dream of defending abuse of people under any circumstances, so the answer to the question that Dr Oliver poses in respect of abuse, is a resounding, 'Yes, always'. If, however, the question he is posing is about 'criticism', then my answer, in this case, is, 'No, it is fair to criticise'.
The handling of the coronavirus crisis has been extraordinarily inept by any objective judgement. The death toll speaks for itself; unfortunately. It could be argued that it is wrong to expect the current CMO and Chief Scientist, neither of whom are from a public health background, to handle a major public heath emergency competently. But some of the decision making has been so disastrously wrong that it is clear that public health advice has either not been sought or has been ignored.
On the 13th of March Sir Patrick Vallance spoke on air about the 'aim' being to build up 'herd immunity'. Dr Oliver refers to, 'occasional slips, such as Vallance mentioning “herd immunity”.' It was immediately clear to people with even a basic public health understanding that it was a disastrous strategy, and it is equally clear that it was no 'slip'.
The Civil Service Code is very clear about how civil servant should behave in areas of political controversy, as indeed the coronavirus is. It states that civil servants must, "act in a way which deserves and retains the confidence of ministers, while at the same time ensuring that you will be able to establish the same relationship with those whom you may be required to serve in some future government". I believe that both by participating in Downing Street press conferences, which make controversial political announcements prior to them being made to, let alone discussed by, parliament, and by arguing for approaches and measures that are politically controversial, doctors who are civil servants are being misused and are operating outside the civil service code.
The question now facing England is, as the death toll mounts and as the decision making so far is being steadily revealed as flawed, who should be the team that leads the country into the next phase of this crisis and who should they have as their advisors?
Competing interests: No competing interests
Taking up one of Dr Oliver’s points:
Doctors in part medical, part managerial posts have always straddled an uncomfortable saddle.
The bottom line is: your medical responsibility is supreme.
You do not knuckle under the “superior manager”.
You may choose to resign.
You may choose to be made redundant.
You may choose to be kicked out. In the interests of the NHS.
True, the National Health Service chokes freedom of expression. You have to choose EXIT sometimes.
The Civil Service always wants conformity.
The doctors in the civil service can decide to stand for independence even if it leads to EXIT.
“We have always been guided by scientific advice,” say the ministers.
Let us have clarity. Clear as distilled water. Not clear as mud. Have the ministers always been guided by the Chief Medical Officer?
Competing interests: Ever free, aware of the cost
Epidemiology – what`s that?
Epidemiology can be `a closed book` to the average person who, not unsurprisingly, is more likely to look at disease from their own individual point of view. The man-in-the-street, or should I say the `citizen behind-closed-front door`, was, until they had the benefit of the daily U.K. Prime Minister`s Briefing,  televised daily at 5 p.m., unlikely to have ever seen graphs showing daily updated data about populations, or led to consider trends, or curves. They are now, although they may not realise it, being introduced to epidemiology, benefiting from daily mini-tutorials, thanks to this progressive updating presented by a trio of leading figures: a politician; a leading scientific adviser; and a leading medical officer. This trio, in turn, are then questioned by a selected number of leading journalists/medical journalists. As far as I am aware, this is a totally new format, devised to keep the public abreast of the latest daily developments at home and abroad concerning the coronavirus pandemic and its effect on mankind, by having explanations of graphic data to show the effects of the lockdown strategy on slowing the spread of the virus. Citizens, encouraged to stand back to see what effect the lockdown is having to combat the disease on their fellow U.K. citizens as a whole, and in other nations with similar or different strategies and timelines, are also being given the incentive, not only to consider populations rather than individuals, but also encouragement to continue to comply with the lockdown strategy for the good of the whole community.
This format has many advantages and potentially beneficial consequences. At this time of crisis, when everybody is striving to collaborate against a common threat, we are able to witness a trio of knowledgeable, high-powered individuals, combining to co-ordinate their expertise, so that we, the public, can appraise the here-and-now of the world-wide march of this virus as it indiscriminately ravages different cultures, different ethnicities, different climates, affecting young and old, rich and poor, privileged and downtrodden, bringing misery to many, as it rapidly and insidiously infects by unseen means. Humankind is the victim of this unseen assassin: it is time for a united effort. It is not a time for `them and us`; Labour or Tory; Art versus Science. It is a time to pool best efforts and approaches, to bring disparate ideas together, to try to understand the behaviour of this virulence and deal with it. Perhaps a time too, to observe not just the virus, but human behaviours, both generally and specifically, as revealed in and by these daily televised press briefings, where prevailing huge uncertainties prevent provision of exact answers to so many questions. It is not a time for one-upmanship, to score points, or to blame, or point to past insufficiencies unless they are instructive. So urgent is the threat, so devastating the disease, now is the time to put all energies into coping with the present and work together to create a better more just future. Hindsight can be applied later.
As we are all in this together it is necessarily important for people to grasp the fundamentals of the scientific process,  especially those who are in the public eye: journalists, commentators, opinion leaders not versed in research methods. It is tempting to publicly air beliefs, suppositions and anecdotes indiscriminately, but all too often such utterances are construed as fact through repetition. It is good, in the midst of this crisis, to observe the careful use of language employed by those on the podia in the daily Prime Minister`s Briefing, nuancing the degrees of uncertainty that abound in connection with researching and planning how to deal with this utterly new virulent infection racing round the globe. Differentiating between the known unknowns and the unknown unknowns is an art as well as a science, demanding an expertise that few possess and most have never even considered. Dealing with how to cope with planning a safe route for a country`s citizens depends on rigorous and well run systems to gather data incrementally, day by day, in order to interpret how the virus is behaving both in individual people but also in various settings, situations, geographical areas, each having a multiplicity of different activities and influences. Anyone demanding details of precise future actions based on this current fragile data base is insensitive. Better that they should attempt to understand epidemiological methods and thus the enormity of the task, supporting those with the skills to formulate the best strategies, to prioritise the research questions and how they should be asked.
Perseverance in the face of extreme uncertainty is arduous; the experiential fact of uncertainty is incontrovertible.   Persevere we must. Dealing with uncertainty is difficult, [1, Chapter 4] but embrace it we must. 
 David Oliver. Is abuse towards doctors in government roles unfair? BMJ 2020;369:m1796 https://doi.org/10.1136/bmj.m1796
 Evans I, Thornton H, Chalmers I, Glasziou P. Testing treatments: better research for better healthcare – Second Edition. Pinter and Martin, London. 2011. ISBN 978-1-905177-48-6 Free download from www.testingtreatments.org/the-book/
 N.H. Keeble. Introduction (1984) in John Bunyan`s Pilgrim`s Progress. Oxford University Press. 1966.
 Refractor. Uncertainty. The Lancet. Volume 358. December 15 2001.
 Arabella L. Simpkin. Embracing uncertainty: could there be a blueprint from covid 19? BMJ Opinion 16th April 2020. https://blogs.bmj.com/bmj/2020/04/16/embracing-uncertainty-could-there-b...
Competing interests: No competing interests
I thank all three respondents so far, for their considered replies.
I note their professional backgrounds.
I don't say much about my own career on my BMJ profile, but I have at various times been a national clinical director seconded to the Department of Health (before the split from NHS England) and so on a civil service contract, working with ministers and officials; a fellow and a trustee at two of the main health policy think tanks; a president and vice president of my own speciality society and royal college and a medical features journalist often commenting on or explaining policy and communicatons.
Having seen the role of clinicians in government and arm's length bodies from all these perspectives, I am well aware of the realpolitik and the pressures and the sometimes strained and constrained relations with ministers.
My only alluding towards the end of a 600 word OpEd piece to the tactics of hiding behind then blaming the scientists and medics does not mean I have "failed to grasp" anything, I just happened to be focussing on a different aspect of the issue.
In fact in my piece in this week's BMJ  I have been very clear about serial failings in government communications and transparency or honesty.
I was also very clear in the article they are responding to that there had been failings, there were legitimate questions and criticisms.
However, like it or not, PHE is an executive arm of the Department of Health and Social Care, making its leaders de facto civil servants, as are the CMO, Chief Scientific Advisor and their deputies. NHS England/NHS Improvement is a non-departmental body not bound by the same rules and at times Sir Simon Stevens, its CEO, has been openly and repeatedly critical of the government and contradicted ministers and Number 10. However, it would be hard for NHSE/I to function (including its Medical Director and Chief Nursing Officer) if repeatedly undermining positions in public.
I would much rather we had senior doctors, nurses and allied health professionals in these national roles than not. However, I do think we could benefit from more transparency about advice given (both by them and by scientific advisory groups like SAGE in the way it already is for, say, NeRVTAG. And more explicit protection for senior appointees' ability to be a challenging and independent voice.
I also do worry about the scientists and medics being trotted out as some kind of human shield for ministers at briefings or media appearances.
I acknolwedge that it can be very seductive and prestigious being in these roles and hard to walk away from them. And I think each individual will have a line of personal integrity that they feel cannot be crossed and compels them to resign and speak out.
However I suspect that equally high calibre individuals could be appointed to post and still face some of the abusive, highly personal remarks and accusations of bad faith and dishonesty and political "capture" which the current incumbents have faced. And it is to this which I object.
 Oliver D. The Covid-19 pandemic illustrates the importance of good government communications. https://www.bmj.com/content/369/bmj.m1863
Competing interests: No competing interests
In brief, I completely endorse Mr Wilson (11 May).
I would only ad : please look at my Rapid Responses since early February and see whether the Government took note of what its medical officers would have read. If they did, why was any government action delayed by more than a month? If the delay was Political, then the CMO should not shelter the Minister.
The CHIEF MEDICAL,OFFICER is the only officer who can advise on medical matters. His deputies advise on his behalf. The Chief Scientific Officer cannot take over the rights and responsibilities of the Chief Medical Officer who reports direct to the Minister.
I also ask:
Has any “ Special Advisor” sought information from or given directions (nudge, hint) to any staff of the Chief Medical Officer at any stage?
Competing interests: Old man, influenced by what he has experienced and what he has seen of previous Chief Medical Officers.
While I sympathise with Professor David Oliver’s comments concerning the roles of the doctors and scientists advising government during the coronavirus crisis, he fails to grasp, until the very end of his piece, what is happening and thus he does not discuss the failing which is leading to his potential endpoint.
He says in his last sentence:
What seriously concerns me is ministers repeatedly saying that they’re “following the scientific advice.” I do hope that they won’t seek to dump blame on appointees who are not electorally accountable.
David Oliver is evidently concerned that the scientists and doctors are now “between a rock and a hard place”. I would suggest that they suffer from a collective failure to comprehend the cumulative effect of what has been happening.
Undisclosed advice in the early days of this crisis was a concern but was accepted in the urgency of the situation and its “unprecedented” nature (the parentheses reflect the over-use of the word). Assurances that government was being open were not challenged. As failure added to failure over PPE there was a distinct shift. Failings which went back years came to light. At times the scientists appeared to be going beyond the advisory role into making excuses for decisions which did not necessarily have a scientific or medical context.
Once on that slippery slope there is no clawing back. Take Professor Stephen Powis, Medical Director of NHS England, when responding to a question from Channel 4 about the testing of date-expired PPE at the daily No10 Briefing on 7th March. In a 40 second waffled response (there were 18 er/erms) he did not even address the question. As the question was about Public Health England practice and policy and he is not a PHE director, he probably did not know the answer. He did not say so. Was he infected by the political belief that it is a failure to admit to not knowing? It was a policy question (failing to release information) so he could have passed it to the politician leading the Briefing. He did not. From a politician’s viewpoint he had absolved them from any responsibility for the question and as far as I was concerned his personal credibility collapsed.
The public presentation of the government’s approach to the crisis has become a shambles compounded by the lack of clarity of the roles of the scientists. The fact that Professor Chris Whitty (CMO) and Sir Patrick Vallance (CSA) now appear infrequently suggests they are happy to distance themselves as far as they can from this shambles. Their deputies have to be spokespeople for many branches of science and seem to share it around quite liberally. It took a superb interview between Andrew Marr and Professor Sir David Spiegelhalter on Sunday 10th March to describe what seems to be happening.
“… this is not a trustworthy presentation of statistics and its such a missed opportunity. The public … are hungry for details and facts … yet they get fed this what I call number theatre which seems to be co-ordinated by a Number 10 communications team rather than genuinely trying to inform people about what’s going on.”
The scientists are losing our respect because of their political enslavement. It is time to separate, let the politicians do the politics and make a mess of it if they must. It is the job of scientists to advise, not to try to rescue them. If they cannot spot the difference they will end up as the ones to blame, as Professor Oliver fears. They must talk about the science separately, in a less charged non-political environment and with complete transparency.
Roger Wilson is a cancer patient and advocate. In his professional life he was a journalist and TV producer. He is a member of the NCRI Consumer Forum and Honorary President of Sarcoma Patients Euronet. He chairs the Patient Panel of the European Organisation for the Research & Treatment of Cancer (EORTC). He was awarded the CBE in 2011 for services to healthcare.
Competing interests: No competing interests
1 (Referred to in the article's title but not the text) 'abuse' is never justified. 'Fairness' does not enter into it, abuse is always inappropriate and any decent organisation has well documented processes for preventing it and handling it when it does occur. Any organisation that fails to investigate and where necessary take action on alleged cases of abuse within it is guilty of a serious failure. The same applies to misogyny.
2 No politician's or civil servant's actions are above examination and where appropriate it is fair and legitimate for these actions to be criticised in a professional and polite manner. Whether or not there is a crisis or emergency or whatever is irrelevant.
3 It is incumbent on all arms of government in a democracy to be as open and transparent as possible about decision making, including the evidence and logic on which the decisions are based and the identity of the decision makers. Politicians and civil servants should remember at all times that they are the servants not the masters of the citizenry.
Competing interests: No competing interests