SCP 50^th ANNIVERSARY AGM CHAIRMAN’S ADDRESS 2008

Dr Dermot Ward 

The NHS is 60 years old this year. Somewhat less well known is that this year is the 50^th birthday of the Society of Clinical Psychiatrists. But I want to return briefly to our late and much lamented Honorary Secretary, Dr Michael Twomey who died suddenly just over one year ago. Only days before his death he sent me photocopied extracts from the Royal College of Psychiatrists Gaskell 1991 publication 150 Years of British Psychiatry1841-1991 edited by German E Berrios and Hugh Freeman. In that was a chapter on The Establishement of the Royal College written by John Howells, formerly ,Director, Institute of Family Psychiatry in Ipswich.

As a member of the SCP he had been a vigorous supporter of the College’s establishment and indeed 20 years earlier had written the SCP monograph Royal College of Psychiatrists. On page119 of the Gaskell book Michael had underscored ‘Psychiatrists seemed to have parity with fellow [NHS] consultants, but control of their clinical work lay with the medical superintendents. It was the need to achieve clinical freedom that led to the formation of the Society of clinical Psychiatrists since the RMPA Royal Medico-Psychological Association (RMPA) was dominated by medical superintendents. Opportunity came with the Mental Health Act 1959, when, through the Society’s influence, the power of admission and discharge was given to  the responsible medical office, that is , the consultant. ‘When this was passed through Parliament a medical Member of Parliament waved his order paper in the air and shouted  “at last we have got rid of them”! As actor Michael Caine might say “No’ many people know that”!  Thank you again, to Michael (Twomey) .

That Caine quote helps to segue into the historical anomalies surrounding the genesis of the the NHS. George Watson, a Fellow of St John’s College, Cambridge and author of The Lost Literature of Socialism, reminds us that in the last years of a long life which ended in 1963, William Beveridge viewed with dismay the welfare state he was said to have built. Although the first director of the London School of Economics, 1919  (his day job was forever a civil servant) his fame rested on his Report published in 1942, Social Insurance and Allied Services and made Beveridge famous as the father of the welfare state – though he had never held elected office. But the nature of his achievement has been misinterpreted since 1948 when the NHS began.

The public still mistakenly believe that the welfare state is due to Labour and harder still to persuade them that Beveridge wanted something else. Labour was the last of the three parties to accept the Report: both Liberals and Conservatives accepted it at once; the Conservatives led by perhaps the most daring exponent of Asquith’s welfare state of 1908-14, Winston Churchill. Labour opposed it bitterly as Beveridge detailed in his memoir Power and Influence. He declared , bemused, “I find myself at times described as the author of the welfare state on account of  my proposals in the Beveridge Report”.  The term doesn’t appear there, “nor as far as I know , none of the proposals of mine”. Beveridge believed in a private health sector and was never in favour of socialised medicine. I mustn’t go on. But the detail is even more fascinating than that.

Fast-forward to 2008 and some of its more remarkable features in NHS, UK monopoly medicine and let’s first focus on psychiatric services. In last years address I finally mentioned a heartening  July 2007 BJP editorial, What is the heartland of psychiatry by Dr (now Prof) Guy Goodwin and Prof  John Geddes both at Cambridge’s Warneford Unit. Many will have read it. Rightly or wrongly at the time I saw it as exposing the deliberate eclipsing of medical influence – one telling example was 1997’s National Service Framework for Mental Health (DoH); its surprisingly detailed recommendations on services for severe mental illness in England and that ‘psychiatrists were notable only by their exclusion fro the process whereby the Framework was developed’.

There were many other important points.   However, in the same journal in July last there appeared another most significant paper Wake-up call for British psychiatry with 37 signatories (including Goodwin and Geddes)  spearheaded by Prof Nick Craddock of Cardiff. It is critical of psychiatric illness/’mental health’ confusion, insists on psychiatric patients’ right to expect more than non-specific social support: that patients referred by their general practitioner should be assessed by a named psychiatrist rather than a anonymous team and indeed in correspondence with Dr Goodwin he agrees that this milestone ‘Wake-up’ paper was triggered by the ‘Heartland’ one. The ‘Wake-up’ authors express a hope that the Royal College and the United Kingdom NHS will be favourably influenced by this paper.  At this point just let’s say it is work in progress and wish all well as their aims coincide with those of this Society.                           

But now to the broader canvas. Psychiatrists are not the only specialists that have been demoralised, disempowered and perhaps even suborned is not to strong in some instances. I was saddened to read a paper in the Psychiatric Bulletin (Nov 08) ‘Early intervention in psychosis’ under a paragraph heading ‘Implications’ stating  firstly ‘Still the results that early intervention in psychosis based on Department of Health guidelines can lead to significant cost savings”. This was then followed by some details of possible benefit to patients rather than the State’s exchequer. Shouldn’t a medical ethical morality mention patient benefit/disadvantage first:not money and patient benefit second.

I was somewhat mollified to see that that the lead author was a ‘consultant clinical psychologist’. But the jounal in question is a medical one. There were six authors four of whom were psychologists. The disciplines of the other two were unclear (something not uncommon in author detail in such publications in recent times).  

Returning to the wider NHS, gives little comfort unless one is a medical masochist.  The activities of the The Lord Darzi  bring to mind the Woody Allen 1983 hilarious film Zelig. Briefly, Woody’s pseudo documentary was about a fictional 1920s media sensation, Leonard Zelig, a human chameleon who develops an ability to take on the characteristics of anyone he happens to be with at the time. Darzi crops up everywhere. On one day he is attempting to inflict massive changed on general practice – not least his polyclinics with which the King’s Fund report ‘Will polyclinics deliver integrated care’ is unimpressed and rightly concerned about additional distances for patients to travel. Then his services were employed by his political masters to announce a government u-turn on its manifesto pledges since 1997 to abolish mixed sex wards. This despite being both unsafe and unsavoury (ICUs perhaps excepted) especially for women. February of this year saw his repeat u-turn this time over what had been the ringfencing of funding for medical training. There appears to be no NHS problem so bad that The Lord Darzi cannot make worse. I could go on but unlike Woody’s Zelig this man is not funny. However, let’s leave him for now.

NHS Direct was finally rumbled also early this year as a waste of taxpayers’ money costing £25 per phone call as it was shown to send up to 60% of callers to their GPor A&E. The ban on top-up drug payments  was eventually lifted after the National Cancer Director declared the practice of withdrawing NHS care if a patient chose to buy additional treatment was ‘unfair’.  Many of us would consider ‘unfair’ to be unfitting compared with ,say, moral backwardness in a medical context. Similarly reprehensible was the decision to deport a visitor living in the UK on a visa who during that time developed a cancer for which treatment was commenced. She was deported to her home country when her visa expired in mid treatment where she died a short time later. This was quite shameful. You could say it was ‘unfair’, again inadequate as a description rather more legalistic than moral  She was patently a different case to those health tourists who abuse the healthcare system.

Then there is the GMC, our own creature, paid for by doctors and once upon a time our self regulating and fitness to practise body. It is now patently unfit for those  purposes.  Sample its decision to abandon criminal level of required proof  - beyond reasonable doubt – in alleged serious misconduct in favour of the lesser burden of proof in civil law – balance of probability, in fitness to practise hearings. It further astonished us by its financial assault on retired doctors when it reintroduced payment of the Annual Retention Fee which for goodness knows how many years was the order of the day. This was done in the name of avoiding discrimination. ‘Unfairness’ again? Unfortunately the GMC does not take doctors’ pension  into account. Doctors’ subscriptions are tax allowable against earnings so the retired doctor pays more because of being a pensioner.  Isn’t that unfair discrimination? The BMA sent it to Judicial Review which unbelievably upheld GMC policy.

In 2004 the GMC was taken to the High Court by a man with a neurodegenerative disease who accused it of wrongly advising doctors regarding end-of-life medical care. He claimed that the advice given by the then GMC would facilitate doctors withdrawing life support when a patient became no longer able to indicate consent or approval. The High Court found in his favour. A triumphalist Daily Telgraph editorial waxed lyrical on the ‘rising star’ judge properly putting the medical profession in its place. I wrote a challenging letter published in the Telegraph which naturally was rubbished (my essential crime, so it went , was my perceived doctor paternalism) in that newspaper via a letter from ‘The Dying Man’, as the case came to be known.

On appeal the judges overturning the High Court ruling, said the case should never have come to court in the first place, that doctors were aware that if they did what the dying man feared they would be charged with murder. It is salutary to reflect that courts do not guaranteed justice, only the possibility therof. The GMC (or BMA) should use our collective moneys as happened in that case to appeal the retired doctors Judicial Review decision. Clearly, a wake-up call to all doctors in the NHS is also somewhat overdue.                       

Finally,  let me thank  the Society’s Honorary Secretary and Treasurer, Dr Mike Haslam, for his untiring work on our behalf. Dr John Harding Price, indomitable as ever, serves us so well as our Press Officer and of course Dr Peter Tomlin, in his new role as President of the Suspended Doctors Group, and Dr Ray Parsons as its Honorary Secretary both serve the Society and the SDG faithfully. We are indeed fortunate and hope to be hearing more from them today.