Wendy Savage MBBCh(Cantab) FRCOG MSc (Public Health) Hon DSc
October 2006
Proposals to strengthen the system to assure and improve the performance of
doctors and to protect the safety of patients.
Response to Dame Janet Smith’s criticisms in her enquiry report into the murderous
Dr Harold Shipman
44 recommendations grouped under headings:
Effective and fair fitness to practise procedures
Assure and improve the quality of practise
Address the need for better information for public bodies and employers
Structure and governance of GMC
Tenor of document seems at odds with the work Liam Donaldson has done before
The background information in the documents is useful but the recommendations
do not all seem to follow logically. Dame Janet Smith seems out of step with
most commentators who consider Harold Shipman to be an extraordinary anomalous
doctor. As the CMO has quoted the Osbornes ‘HS would have passed any appraisal
of fitness to practise with flying colours ‘ BMJ 2005 330:546. Donaldson has
concentrated on getting away from ‘shame and blame’ and understanding the importance
of systems failures, understanding why things went wrong and rehabilitation.
Clifford Ayling GP 1970-1980s
Poor handling of complaints and inefficient communication between organisations
Richard Neale O&G consultant 1985 NHS management gave reference. GMC President
made erroneous decision when he returned from Canada then GMC lost file as did
police until 1994
Kerr and Haslam Psychiatrists.1970-80s Complaints not believed - whistleblower
treated badly
The other examples given of shocking cases are old but the basic problems was
not so much with the GMC in the sexual abuse cases but with local systems of
management of complaints and reluctance of boards to take the patients’ complaints
seriously combined with a culture in which the consultants was unchallenged.
Times have changed and I do not think that this would happen today. In Ayling’s
case his partners accepted his denials (as in a similar case, Green, a GP in
the Midlands) where other agencies such as police and social services failed
to consult each other. Again I think the public awareness of sexual abuse is
much higher and GPs are much more accountable today than in the 1970s and 80s.
In the GMC the President no longer screens all complaints as was done in 1985
and the system is much more clear-cut with case-examiners medical and lay looking
at each case which does not go forward after caseworkers have weeded out cases
according to strict criteria. Again in the Neale case the role of NHS management
who gave him a reference which enabled him to get locum jobs was nothing to
do with the GMC.
Education-oversees undergraduate education-visits medical schools. 1993 Tomorrow’s
doctors changed curriculum-for better
Registration 170,000 on register weekly updates and queries run into thousands
Standards and Ethics 1995 Duties of a doctor. Good Medical practice Welcomed
by all
Fitness to practise Investigation and Adjudication separated 2004 new system
Although those members of the general public who understand that the GMC is
the regulatory body for the medical profession and do not confuse this with
the BMA (which is done by even highly educated people) tend to think of the
fitness to practise aspects and do not know about the other roles of the organisation.
Education to PMETB Why? No evidence
GMC to do investigation new quango to do adjudication? Why not the other way
round? GMC maintains register so should be body to strike off. Two thirds of
complaints not GMC material so should be dealt with by ?HCC
GMC affiliates in every ‘Trust’ – why?
Civil standard of proof to replace criminal ?
British doctors are respected throughout the world and there is no evidence
to suggest that the GMC’s supervision of medical schools which are inspected
every 5 years is unsatisfactory. As far as the proposals to leave investigation
with the GMC and have a new body to adjudicate is concerned this seems to me
to be the wrong way round. The proportion of complaints to the GMC which are
not serious enough to go forward to a case examiner is two-thirds. In my view
it would be better for some other body such as the Health Care Commission to
be the portal for complaints about doctors (and other staff) and for them to
investigate and refer serious cases to the GMC. The GMC associates are already
trained and operate without reference to GMC Council members who already act
like a Board although they are also on specific committees to deal with the
various functions. The newly organised GMC has only been fully operational since
November 2004 after major re-organisation in 2003 and should be given a chance
to bed down. The idea of having a GMC trained affiliate in each Trust seems
unnecessarily onerous and bureaucratic and expensive. Although about 1 in 200
NHS doctors is referred to the NCAS each year this is because Trusts have been
required to consult with the NCAS before suspending doctors. In 85% of cases
alternatives to suspension are found (which raises questions about the threshold
for suspension and the culture of management) and only 10% go through a full
assessment ie 1 in 2000 doctors. If appraisal is done properly these problems
would be picked up earlier and this system is still in its infancy.
I do not think that an expensively trained doctors working in what is virtually
an NHS monopoly should be struck off without clear proof that he is not fit
to remain on the register. The arguments for the civil standard are not well
made.
The proposals are heavy handed, unnecessary in view of the changes that have
taken place in the last decade such as
Audit
Appraisal
‘Clinical governance’
Proposed system of revalidation
They may destroy professionalism will be expensive, time consuming and may fail.
The vast majority of doctors are conscientious, keep up to date and are more
trusted than politicians . As Baroness Onora O’Neill said in her Reith lectures,
and also quoted by Donaldson, ‘The efforts to prevent the abuse of trust are
gigantic, relentless and expensive, and their results are always less than perfect.
It is worth reading these lectures published as ‘A Question of Trust’ by Cambridge
University Press as her analysis of the situation is excellent. Revalidation
would have started in April last year and it was always seen as an evolving
mechanism but owing to Dame Janet’s criticisms this idea has been put on hold.
I reject the airline pilot analogy-doctors are not only self motivated to keep
up to date they work in teams and their work is informally scrutinised by many
people. We do not need to construct a whole new system to detect poor practice.
If appraisal and NHS management did their job, patients would be protected.
One could see that the NHSE’s response to the Shipman report was to deflect
criticism away from the failings of the NHS on to the GMC-which arguably was
not within Dame Janet’s terms of reference!
last updated 16/10/06