On the General Medical Council !

Changing times, fashion and fabrication.

Reading GMC president Sir Donald Irvine's forward to the June 2000 review of the GMC since 1995 generated a sense of outrage. On colder reflection that still seems an appropriate word and response. The forward is a melange of vagaries about the alleged shortcomings of the medical profession. It huffs and puffs .....A[GMC] non-preparedness to tolerate unacceptable variations in the standards of provision and performance, nor put up with long queues and waiting times for access to essential services and suchlike pepper Changing times, changing culture.

Can one be forgiven for reminding Sir Donald that it is unwise to conflate the regulation of medical practitioners and their performance with the huge failings of the NHS as the underpinning monolithic political and financing healthcare system in the United Kingdom. The document, paid for by doctors, is a triumph of spin, not real, doctoring which rebukes practitioners for their past shameful performance (and ignores that major historian Roy Porter's description of, and monumental work on, medicine The Greatest Benefit to Mankind. Yes, we can stay that hand awhile from reaching out for the hemlock.

British medical practitioners have been and are still widely respected professionals both at home and abroad. It is the NHS system within which they are effectively forced to work that has so sadly failed the public.

In August 1997 this Society wrote to Sir Donald about then widespread anxieties of individual doctors and royal medical colleges concerning detrimental consequences for standards of patient care following especially the management-driven NHS reforms of Government White Paper Working for Patients (1989).We drew attention to paragraph 39, page 16 of The General Medical Council's Blue Book Professional Conduct and Discipline: Fitness to Practise' (1992) which declared

".....Apart from a doctor's personal responsibility to patients, doctors who undertake to manage , to direct, or to perform clinical work for organisations offering private (our emphasis) medical services should satisfy themselves that those organisations provide adequate clinical and therapeutic facilities for the services offered..."

We could no longer see good reason why only doctors practising outside the NHS, rather than all practitioners, should be singled out in this particular way. Indeed, many doctors in our specialty have found their responsibility in securing a safe and competent treatment environment well nigh impossible without recourse to extra-contractual referral to colleagues working in hospitals in the independent sector (a practice which continues frequently to the dismay of relatives and friends travelling long distances to visit patients).

Likewise, we think it probable that in underscoring those independent sector doctors' medical responsibilities the doctors concerned would have welcomed the GMC caveat paragraph as perhaps also empowering them, commensurate only with the adequate discharging of their professional duties and responsibilities, in their (doctors') legitimate insistence on adequate facilities protecting their patients in a private healthcare setting.

There has been grave concerns expressed by The Royal College of Psychiatrists about hospital bed reductions in some districts of bed occupancy levels of 130%.i.e. 130 patients to 100 beds. Clinicians and their Royal College have long recognised and publicised that psychiatric units have virtually no `cold` patient admissions or waiting lists because of the nature of the specialty : that almost invariably hospital admissions are on an emergency basis (not necessarily under the aegis of The Mental Health Act 1983) ; that in order to meet this situation hospital bed occupancy in acute units needs to run at annualised average levels of around 70% to allow for the fluctuating pattern of emergency need. Despite this, successive Governments have failed to halt declining staffed bed numbers from 150,000 in1955 to 67,000 in 1987 and to 42,000 in 1994 in England and Wales. Alas, no therapeutic advances in inpatient psychiatric treatment or innovation in community care can be held, in our view, as justifying such massive reduction in this essential component of good psychiatric practice.The general medical/surgical sector has suffered no less.

Understandably, the secular eye cannot readily distinguish between deficiencies generated in healthcare systems by political NHS policy (over which doctors have had systemically reduced influence) from those directly attributable to medical professional shortcomings. These are commingled by the most obvious involvement of that practitioner whose immediate patients suffer and the practitioner rather than the policy is more obviously blameable in the public and media limelight. This is not to suggest that practitioners are always without fault as that would constitute a preposterous claim in everyday clinical practice which by its very nature involves serious risks and benefits balance for patients. Indubitably, doctors ability to act as best medical advocate for their patients has been further inhibited by refusal of many NHS Trusts (supported by central Government) to restore Clause 330 of Whitley Council Terms and Conditions of Employment for Hospital Medical 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.

We suggested (and remember this was 1997):

(a) that the content of Paragraph 39 of the GMC 1992 `Blue Book` should apply to all registered medical practitioners, and not just those providing treatment in private health organisations and

(b) that government be pressed to re-instate Paragraph 330 of the Terms and Conditions of service for Hospital Medical Staff whether employed by NHS Health Authorities or Trusts so that a practitioner shall be free, as before, 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 be formally tabled for discussion by the GMC.

We believed that effectively addressing these two related issues could in itself revive flogging doctor morale and strengthen their patient advocacy.

Sir Donald's courteous reply in 1997 complimented the Society on its very cogently argued case for including guidance which placed responsibility on all registered medical practitioners as we suggested. But then somewhat bafflingly he felt unable to follow it because we would be placing a duty on many doctors, particularly junior doctors within the NHS, which it would not be in their powers to fulfil: inexplicable, because there are junior doctors in independent hospitals also and anyway the special position of consultants in hospitals and family doctors in the community could readily be the medical umbrella protecting the special position of trainees.

And reinstating that Paragraph 330 of the Terms and Conditions of service for Hospital Medical Staff!

Well, the president attempted to reassure us..... You may be interested to follow up on reports in the press in September 1997 that the health minister, Mr Alan Milburn, has ordered the removal of all "gagging" clauses in NHS employment contracts. Accordingly for three long years, the Society has mounted a permanent watch for those porcine forms in flight across the firmament.

Dermot Ward