SCP AGM CHAIRMAN’S ADDRESS 2007

Dr Dermot Ward

I must begin this address on a most sad note at the sudden death of our stalwart friend and the SCP’s  most diligent Honorary Secretary Dr Michael Twomey on 21^st September only some days after our last Execute  meeting. Our hearts  go out in deepest sympathy to his wife Anne, family and many friends. Despite her bereavement Anne has bravely assisted us in picking up some SCP paper pieces which better informed our meeting and for which we are deeply grateful and now, not without respectful silence and reluctance, we move on now to our AGM business.

Notwithstanding pleasing headlines, to doctors that is, in the serious national dailies such as “We should treat our doctors like gods” - author/journalist Andrew O’Hagan and “Leave our doctors alone, Sir Liam” – journalist Liz Hunt on the egregious England Chief Medical Officer (aka its ‘most senior  doctor’), locally and nationally the NHS is boiling, not just simmering, as public and professionals strive to preserve such health services as they have. This is although new premier Gordon Brown’s promised handing power back to the public and medical professionals.

In my Chichester base stand at any busy roundabout and you will notice flags streaming from car windows rather as football supporter cars might sport flags emblazoned with favoured team colours. But here favour exhorts all to‘Save St Richard’s’ – the local DGH. Many believe that despite ostentatious ‘public consultation’ its fate has already been stealthily sealed: that it will lose its greatly valued A&E, maternity and paediatric services within a massive revamping of services by a monolithic faceless South East Coast Strategic Health Authority covering a massive population involving Sussex and Kent. We are not alone.

I cannot recall a time when the general population took to street marching and open public meetings in such large numbers in protest against plans they fear will undermine their local and national health system. The average England person is slow to anger but when so provoked, can show an unexpected intensity of hostile response. Their abiding default setting is live and let live. But when something seems rotten, is felt to be unfair, then those accidental tourist politicians in the NHS should take note.

There is just one DGH consultant in post who has spoken out publicly against the threatened trimming of services. I don’t think younger doctors quite realise (unless they have had reason to approach SCP’s  Suspended Doctors Group)  how cowed – I do not exaggerate - senior hospital doctors are by management: how their right to speak out and influence policy has been constructively diminished to near vanishing point. Previously legal clauses in hospital doctors terms and condition of service and which ensured proper professional right to publish or speak out publicly were abolished by the previous administration.

The centre - Government – also draws widespread opprobrium for its Modernising Medical Careers (MMC) policy and the shambolic Medical Training Application service (MTAS) imbroglio that engulfed and is convulsing postgraduate training over the four thousand places shortfall since August 1 for home-grown trainees. Already there is an established exodus of trainees to Australia and New Zealand while imports of foreign doctors, some with little understanding of British culture are seduced in to plug gaps and face an uncertain future in our national health service while perhaps depriving their own homeland of much needed doctors.

 The BMA, and I remain a member, has it seems, failed the profession over many years as it endorsed its allegiance to the envy-of-the-world NHS and effectively colluded with politicians in well nigh asphyxiation of an honourable and rightly proud great and once self regulated profession. It (BMA) seems to comment almost as detached observer, rather than vigorously opposing where appropriate. Both revealing and puzzling are some recent resignations. On March 31 a Professor Alan Crockard (‘an eminent neurosurgeon‘, I’d never heard of till then) resigned. It was revealed he had been the government appointed hotshot responsible for the thoroughly discredited,  MTAS for appointing trainees..

His defence was that he became increasingly aware that he ‘was given responsibility but less and less authority’. This could so easily become the England’s medical profession’s mantra. Doctors, including neurosurgeons, are not stupid. Yet for a whole year before that medical voices (including the SCP), appealed to, and roared at, the deaf Academy of Royal Medical Colleges not to cede to government its (Academy of Medical Colleges) own power to decide medical training programmes and thus allowed itself to endorse poodle tenth rate government medical policy leading to trainee and training chaos.              

Then on 20^th May the chairman of the BMA for the previous 4 years, Mr James Johnson, fell on his sword because, he alleged, as a consequence of his attempt to defend government’s Chief Medical Officer , Sir Liam Donaldson. The latter is sometimes described as ‘England’s most senior doctor. Let nobody be in any doubt: diminish the medical profession and, as night follows day, patient care will be damaged; patients will suffer. 

Now I respect the work of public health doctors as much as the next medical man or woman. But this particular physician who has probably not formally treated a patient in upwards of twenty or thirty years has advised that the GMC Fitness to Practice body should operate on civil court’s level of proof – balance of probability – rather than that of criminal courts’ ‘beyond reasonable doubt.’ This has profound litigation implications for doctors. He also pushed for the MMC changes which so incensed the profession that there has been talk of expelling him from the BMA (now there’s a threat). He (England’s ‘most senior doctor’) is in effect more a straightforward civil servant who will do his political masters’ bidding, whatever ‘modernisation’ they dream up and which might reasonably be expected to complete the evisceration of the medical profession and undermine good patient care as we have known it.

One surgeon  with medicopolitical sense, consistency, and dare I say bravery, Mr David Nunn,  has observed that 15 years ago government thought it a good idea for consultants to do clinics in GP surgeries. The problem with that was that doctors were taken away from their hospitals, reducing the level of cover, increasing the level of risk for patients. And, it eventually emerged , the unhelpful Working for Patients (1989) policy which  profoundly the working environment of hospital consultants during the later Thatcher years was, it emerged, the brainchild of a single GP. Subsequently he was struck off the medical register for drug addiction.

This brings me to the rapid rise of Professor Sir Ara Darzi now Lord Darzi, another, as I understand it, noted surgeon and I’m sure no drug addict. When they were new brooms, PM Gordon Brown and his Health Secretary Alan Johnson had declared not exactly a moratorium (“a breathing space”) on more reorganisation/modernisation of the NHS etc but, lo, Lord Darzi is now a Health Minister appointed by Health Secretary Alan Johnson and is expected to produce, yes you are right, a new health service reorganisation. It appears that the good lord favours the development of ‘super hospitals’ over DGHs which would then be downgraded to cottage hospital level. He has been lauded for his listening skills but Dr Ian Verber, a consultant paediatrician at the University of North Tees, in a letter to Hospital Doctor responding to earlier claims applauding Lord Darzi’s ‘listening skills’ suggested and I quote Dr Verber “that the noble lord’s listening skills atrophied at the time of his appointment to government. Nothing says (says Dr Verber) could be further from the truth. Sir Ara (as he then was) was asked to make recommendations on the reconfiguration of services on Teeside in 2005.

“He did visit but did not think it necessary to talk to paediatricians, paediatric anaesthetists or paediatric surgeons. His recommendations included the establishment of a centre of excellence in obstetrics in a hospital without neonatal intensive care, paediatric anaesthesia or paediatric surgery; the provision of paediatric surgery and trauma services on a site with no paediatric medical in-patients; and the splitting up of adult vascular surgery on to more than one site.

“none of these recommendations was workable and each was repudiated by the independent reconfiguration panel which was brought in to sort out the mess.

“A happy ending for Teeside but as for the architect of this shambles – a seat in the House of Lords and appointment as chief adviser to the Department of health. You couldn’t make it up.” Effective health delivery systems and a politician cherry picked individual one-man-band have proved a capricious mixture in the past.

The NHS is now Europe’s odd-man-out and over the past fifteen years the formerly Marxist states have moved to pluralistic healthcare systems in which private and public, together with a true insurance component, complement each other and in which state funding is not assumed to imply state management. Cuba is the last country to share the British model and that is unlikely to survive Fidel Castro’s departure.

But what of psychiatry itself? Apart from the SCP’s publication contribution to the MMC debacle and debate in the JRSM we once more took advantage of the overcrowding in prisons. What seems insufficiently appreciated is that district mental hospital bed numbers in England and Wales have been drastically cut from from 160 000 in 1960 to 32 000 in 2003 . Last year Chief Inspector of Prisons Anne Owers commented publicly on prison overcrowding and claimed that “jails are reaping the harvest“ of the closure of mental hospitals because thousands of psychiatric patients are being incarcerated rather than being treated.

Back in 1939 Lionel Penrose demonstrated a negative correlation between prison population, homicide rates and availability of hospital beds. Political force majeure has in effect denied this gravity for decades. We continue to be concerned about ‘teams’ and leadership in the day to day clinical setting and the exclusion by the DoH of psychiatrist input into its 1999 National Framework Service for Mental Health: the virtual extirpation of ‘mental illness’ and its replacement with that less effectual coverall ‘mental health problems’; the associated dumbing-down of psychiatric treatment potential by GP’s, those who find that no longer do their referring letters addressed to a particular consultant reach target but are arbitrarily referred to a member of the ‘MDT’. There is therefore no qualified medical report response which was a valued contribution to their ongoing psychiatric professional updating. As one publication put it the GP was ‘referring into a void’.

Let me end this perhaps unusually long address on a cheering note. It is inspired by an editorial in the September 2007 British Journal of Psychiatry written jointly by Dr Guy Goodwin and Professor John Geddes from the Dept of Psychiatry at Warneford Hospital. Its title, for those who may not have read it, is What is the heartland of psychiatry? It puts serious flesh on much of the skeletal thinking of this Society. I cannot see it disappointing any psychiatrist who cares about psychiatry and the future for patients. It reminds one that there can be a time of hope.