Society of Clinical Psychiatrists AGM November 2013 -  Chairman's Address

 

This NHS year has been egregiously outstanding. The Health and Social Care Bill 2012 is yet another topdown reorganisation atop the fifteen over the past 30 years: claims that the NHS is “broken” abound; the Francis Report confirmed upwards of 1000 avoidable deaths from patient neglect especially in nursing care, a scale never before seen in the NHS; the inadequacy of the hospital and care homes “Inspections”. Then there was the revelation that the chief executive of the NHS in England and Wales, Sir David Nicholson, who had prior to that elevation been for a couple of years chief executive of the Mid-Staffordshire Foundation Hospital Trust, confessing his complete ignorance of any wrongdoing during or after that management posting.

Journalist Charles Moore’s powerful piece on the Francis Report (Let’s face the truth about our uncaring, selfish and cruel NHS, Daily Telegraph, February 9) should be compulsory reading for complacently shocked politicians and their appointed senior managers of the NHS. Anyone who has worked in the NHS over the past 20-30 years in virtually any capacity other than as business managers, has been aware of deteriorating hospital patient care standards. He made it clear that Sir David should resign from his post as NHS Chief Executive and indeed he is due to do so in a month or two. It is sobering to recall that in the opening ceremony of the 2012 London Olympics the NHS was being vaunted as a world microcosm of unique healthcare excellence. Any excellence so depicted lay in the talented imaginative fiction of Danny Boyle’s artistic creation. 

Despite Sir David’s appalling performance, and freely admitted ignorance of his deficiencies in any NHS office, he still claimed he was the person to see through the latest NHS reorganisation. Astonishingly, PM David Cameron supported his claim. No less astonishing was QC Robert Francis’s Report failure to name any person culpably responsible for that shameful behaviour that so neglected and demeaned those unfortunate helpless patients. (Four doctors were named and reported to the GMC but that body subsequently decided there was no case against them. (This would not have been the first time that doctors were being scapegoated successfully or not).

Quite possibly the need for a vigorous  medical profession has never been as strong as it is now and many will have endorsed the sentiment on revalidation expressed by Dr Peter Magauran of Newchapel  Surrey when in an elegant but elegiac 2004 letter to BMA NEWS he wrote:

Revalidation: “I regard the great professions as vocations for life. The priesthood and the law do not rely on the equivalent of CPD [continuing professional development] points to give them meaning. Imagine a parish priest removed by his Bishop. not because of a disciplinary matter, but because he had not attended sufficient courses. Imagine George Carman (a famed barrister) – who I’ve had the privilege of coming up against – being told that his license was being revoked because his CPD points were inadequate...” Dr Magauran declared further, “unfortunately, the medical profession has got caught up in a maelstrom of its own making from which I see little hope of extrication”. Just how prescient he was is borne out by comment from an anonymous NHS hospital specialist in Irish Medical Times (18.10.2013) titled A stark admonition to emigrating doctors which is reproduced below by kind permission of its Editor.    

“A stark admonition to emigrating doctors

I’m aware of the great difficulties in medicine in Ireland and that many Irish graduates are leaving for various reasons. Traditionally Britain has been a prime destination for Irish emigration and thus the reason for this article.

A word of warning is needed for Irish and non-Irish graduates thinking of coming to the UK. If you are thinking of moving to the UK, my advice would be not to. Don’t even think about it.

Twenty years ago I would have encouraged doctors to come to the UK. The medical world is now on a different planet. There has been so much change in the last 20 years that the profession is almost unrecognisable. Morale is rock bottom and doctors are under pressure from several different angles.

Many medical schools now do not teach the basic sciences like physiology, biochemistry and anatomy. Problem-based learning is the order of the day from the start. In some colleges there are actually no specific subjects. Recently I asked a medical student what subjects he was sitting exams in last year – he could not say. So things are broken from the very start. Clinical exams are not as they used to be. Actors are used and marking is subjective.

At postgraduate GP level, the use of actors in clinical exams has caused huge problems for non-British doctors (international medical graduates), so much so that a recent attempt has been made by the British Association of Physicians of Indian Origin (BAPIO) to take a judicial review against the Royal College of General Practitioners. These doctors are allowed to sit this exam three times and if they do not pass they are then referred to the General Medical Council (GMC). Many lives have been very adversely affected by this. This is only one example.

Relentless interference

Medicine is being affected over and over by political decisions at Westminster and in the devolved nations (Northern Ireland, Wales and Scotland). This is relentless and affects regulation (changes to the GMC and the Care Quality Commission), working conditions and finance. Recently salaries have dropped and the latest proposals in general practice are that surgeries open for longer and seven days a week.

GPs are answerable to the local organisation, usually the health board or trust, as well as to the Performers List. This is a list of doctors maintained by the health board of GPs able to work in its area. Until recently you needed to be on the Performer’s List in every health board you worked. This ‘list’ can impose restrictions on a doctor.

Prof Steve Field has just been appointed to head up the GP section of the Care Quality Commission and he has said that GP surgeries will be fined or closed if they fail to live up to certain standards.

Doctors in the UK are now seen as potential or probable criminals. This arises in reaction to events like Shipman and the German doctor who made a prescribing error which resulted in the death of a patient. However, the almost criminalising of doctors is a reason or an excuse for bringing in the draconian changes that have been introduced, such as the changes at the GMC, and the setting up of the Medical Practitioners Tribunal Service and revalidation.


Broken medical system

In hospitals the relationship between doctors has changed and now there are no ‘teams’. Patients are not assigned to a particular doctor and this causes a lot of trouble, with tales of ‘lost patients’. The role of the nurse has changed and this is largely put down to their university training.

There has been a proliferation of nurse specialists, consultants and practitioners. Sometimes patients do not know who they are talking to and some think the nurse is the doctor.

This is shameful. Nurse practitioners are doing a lot of work that was the realm of the doctor and this includes surgery and endoscopy. This naturally means that doctor training is affected, whatever about the service itself.

The role of the nurse has now largely been taken up by healthcare assistants.

The standard of care within hospitals is often dismal and there have been huge scandals here, such as the death of the husband of Ann Clwyd MP, following which she headed up an inquiry into nursing standards. There have been recent reports about failings in the care of the elderly. The list is endless.

One thing worth mentioning came out last week. At the Glan Clwyd Hospital in north Wales, there were 96 cases of C.difficile from January to May this year. The medical system in the UK is broken. Medicine as a profession has been eroded. Doctors are leaving the UK and many are retiring early.

If you are unhappy in Ireland, do not come to the UK. Go somewhere where you can work as a doctor, be appreciated and have a reasonable salary. Here, you will be seen as a potential criminal and regulated to death in the system that is broken.

In a nutshell, no non-UK doctor should come anywhere near the UK or the NHS.”


That is truly a sad comment on the NHS and below are some recommendations which, if implemented, could repair and recover some of the lost patient treatment competencies and the essential confidence and authority of a medical profession which in any healthcare system remains its greatest asset and hope.   

1.      NHS business management system as imposed  on the NHS in 1983 and its subsequent development has actively damaged it by its inherent inappropriateness as outlined above. The immediate evidence, Mid Staffs, is but the large tip of an understandably larger Iceberg of patient neglect.  

1.      A freedom-of-speech clause in consultant contracts, abolished in 1989, should be restored. The present national health service is redolent of the now thoroughly discredited old Soviet healthcare system, an observation originally made by Mr Michael Portillo. Had that freedom-of-speech clause (incidentally a more legally appropriate and proportionate description than colloquial “whistleblower”) been retained the anonymity of the consultant author above would have been unnecessary.   

1.      The restoration of essential consultant authority commensurate with their duties, responsibility and accountability in recognition of their central importance in secondary medical  healthcare delivery to patients. Simple measures revived from past long established good practise such as family doctor referral, where necessary, to a named consultant and whose name would appear at the head of that patient’s hospital bed. 

1.      Restoration generally, at hospital level, of senior consultant, matron and hospital secretary/administrator triumvirate; the senior consultant being elected by peers for a limited period to be decided. The custom and practise of the ward sister or charge nurse accompanying the consultant on ward rounds should return, where it has ceased, as routine order of the day. Furthermore, the practise whereby, in some areas, family doctors have been referring patients to a “team” rather than to a named consultant should cease forthwith. It is unsafe and a patient so referred may never see a consultant for proper diagnosis and appropriate treatment plan. 

1.      Crown Immunity was introduced in the early1990s for all NHS doctors without effective opposition. Prior to that doctors held individual medical defence insurance. This conferred on doctors the security of independent individualised protective legal cover for each doctor so insured. The reason the profession objected was it could mean that the local health authority could be prepared to settle  out of court in a charge of alleged negligence or misconduct against a doctor because it might be less costly than pursuing it through the courts. If such were the case there could be no formal clarification of an innocent doctors reputation. Restoration to the individual medical defence insurance position would further reinforce the necessary doctor confidence and legal security which is so essential to effective patient care.   

1.      The treatment of “whistleblowers” on observed NHS system failure exposure has been both disgraceful for the whistleblower and wastefully expensive for the taxpayer. Recently, consumer affairs journalist of the year  Ian Cowie, (Daily Telegraph, Whistleblowers should be rewarded, not ruined” Feb 23,2013) published a thoughtful piece (mostly he writes on financial matters) of legislation changes in the US whereby whistleblowers are financially rewarded. That is certainly a path worth exploring in the NHS  healthcare context.      

1.      The ‘friends and family test', whereby patients will be asked whether they would recommend NHS services to people they know, is being rolled out and is sadly typical of backward government thinking. While it is important that patient complaints and dissatisfaction are appropriately addressed this Society considers that the changes we urgently recommend by improving patient clinical care would so improve the services that the number and sorts of complaints exposed in the Francis Report would be much less likely to occur. There is a parallel here with W Edwards Deming’s Total Quality Management (TQM) which the US toyed with for some years in its post-war motor industry and discarded. Essentially, it involved the goal of production process perfection from the earliest to the final phase, aiming at elimination of end-failings rather than inefficient and expensive post production expensive corrections. Following the US rejection Deming, a mathematician and statistician, then sold it to the Japanese with spectacularly successful results in its motor industry while in Detroit, US motoring industry descended into near total destruction from which only now is it showing some signs of emerging. 

1.      Reinstatement of tax relief on health insurance premiums. This, was introduced by Mrs Thatcher’s government. Its abolition  was one of the first acts of the new Labour Government in 1997. The person who takes out such insurance is more a latter day saint than someone to be despised (this has applied particularly to Labour politics). He or she has paid their so-called insurance stamp (though such insurance fund does not exist), and thereby shortens the waiting queue of those less fortunate and contributes overall more to investment in healthcare.  

1.      Restoration of Community Health Councils (CHCs) in England. The key function of the CHCs has been to represent the interests of the public in local grass-roots  health service in their district. Abolished in 2003 by the Blair government they continued in Wales for reasons never properly explained by Mr Blair. 

These observations (together with the Society’s formal overview of the Francis Report published on the Society’s website) are made in a spirit of hopefulness and as a counterbalance to political superficial waffle about transparency when opacity seems a more appropriate description. I wish it would have struck a more optimistic note but I would then have been a mere unrespected Danny Boyle.

Let me end with thanks to our Honorary Secretary, Press Office and our Webmaster for their continuing invaluable support for the Society.

 

Dr Dermot Ward FRCPI, FRCPsych  Chairman SCP