Why didn’t doctors do something?

Dr Dermot J Ward  

The question was posed by BMJ Deputy Editor Dr Tony Delamothe in a thoughtful piece “Repeat after me: “Mid-Staffordshire”. (BMJ/16 January 2010/vol 340/ p 132).  He lists 4 reported medical scandals (1) Alder Hey (retention of children’s organs, (2) Bristol ( children’s heart surgery) (3) Shipman (serial killer) (4) Mid Staffordshire (emergency services) and challenges the reader to identify the odd one out. It is Mid Staffordshire because it occurred in the 21st century, the other 3 in the 20th. But there is more.

He mentions the estimated death tolls associated with the four. Alder Hey had none, Bristol 30-35, Shipman (probably) 250 and Mid Staffordshire 400-1200. Then he identified an anomaly associated with the inquiry into each. The first three have generated media attention lasting for years. This has been in stark contrast to that surrounding Mid Staffordshire which already only 10 months after the computed large death losses has virtually disappeared off the media radar. (Since that publication it has returned to late February 2010 media scrutiny).

He notes also that whereas the Shipman inquiry yielded 2500 pages, Mid Staffordshire NHS Foundation Trust (truly a misnomer there) inquiry grossed a mere 172.  

He dilates on the importance of systems failures in administration, management and nursing but it is only of the medical professionals he asks ‘Why didn’t the doctors do something?’ As there appears to be a public memory defect over Mid Staffordshire perhaps in asking that question there is a suggestion of a medium to long term memory deficit implicit in that question. Let me submit a skeletal answer, but  before doing so as recently as 18.02.2010 Rebecca Smith Medical Editor of The Daily Telegraph headlined ‘Culture of fear puts targets before patients, advisers tell NHS’and states that ‘politically driven policies were put before patients according to previously unseen reports from three independent international health organisations for the Department of Health. The information had been obtained under the Freedom of Information Act. The Telegraph is about 10 column inches but is packed with hugely important findings.

And now back to the past and that promised answer to Dr Delamothe’s question. Deliberate sidelining of doctors (this applies particularly to hospital practitioners) began in 1983 with NHS Management Inquiry (Griffith Report) which introduced line management headed by a [non-medical]chief executive. This displaced senior doctors and matron assisted by a hospital secretary and with that, imposed non-medical managers implanting forward planning as dictated by their political masters. The quondam natural leaders and innovators in medical policy were pushed to the periphery.

In 1989 Working for Patients white paper on secondary care created, inter alia, hospital Trusts and began the removal of consultant NHS work contracts from health authority regions to local trusts. That government publication incidentally confirmed ‘...the key role of the consultant in the NHS in terms of their 24 hour responsibility for patient care. It is they who are the leaders of teams, responsible for all aspects of the clinical care of patients under their charge.’ However, as duties and responsibilities for patient were so clearly described, simultaneously the commensurate  medical authority required to discharge those responsibilities adequately was undermined at a stroke by removal of a freedom of speech clause 330 from Whitley Terms and Conditions of Service for Hospital Staff whereby:-

“A practitioner shall be free, without prior consent of the employing authority, to publish books, articles, etc., and to deliver any lecture or speak, whether on matters arising out of his or her hospital service or not.”  

In 1987 Richard Smith, then editor of the BMJ (v295; 1633-4), had already adumbrated an increasingly ominous climate pervading that near monopoly employer of doctors, the NHS, in his milestone article, ”Twenty steps towards a ‘closed society’ on health” and the new phenomenon og gagging doctors and concern for freedom of speech. By 1994 that usually prosaically reassuring BMJ was moved to publish a series of four related pieces under a generic title ‘The rise of Stalinism in the NHS’ (v309:1640) witnessing that senior doctors and nurses ‘were convinced the NHS was beginning an organisation in which people were terrified to speak the truth’.  Opposition in the House of Commons objected to Clause 330 removal from new trust working contracts and sought reassurance that a similar clause would be re-inserted in trust contracts. This was rejected by government as were observations of a similar nature made by the British Medical association, our doctors’ trade union. Perhaps because of its formal attachment to ‘the NHS’ as putative most effective healthcare delivery system of a national health service its (BMA’s) it’s activities have tended to be characterised by mere observational disapproval with a reliable outcome of impotence rather than a vigorously effective.

It is difficult to recall such a massive gap between original aspiration and reality as that embedded in the NHS and what that healthcare system has delivered to the population as exemplified by Mid Staffordshire under the crucial management of politicians. What is also remarkable is what good clinical care doctors and their teams have achieved despite NHS politician-driven maladministration interference in their day to day work.

Perhaps the above points go some way towards answering Tony Delamothe’s pertinent question. My query is why didn’t the BMA doctors’ trade union, do more to preserve freedom of speech for doctors; to expose and oppose that corrosive gagging and secrecy?