The GMC will undoubtedly be interested in the debate over Baroness Warnock's views on euthanasia for patients with dementia. http://py111.wordpress.com/2008/10/19/warnock-on-euthanasia/    Baroness Warnock has been vilified by many for her views and it is highly unlikely that she would have dared to express her opinions if she was a registered doctor. There is no doubt that she would have been reported to the GMC and thus intimidated.

 

Despite the instant reaction of critics the issue of euthanasia and dementia does need to be addressed.

 

Goddard agrees with the esteemed ethicist  that people in end-stage dementia deserve something better than dying from thirst when they could be eased away from their suffering. And undoubtedly many do suffer.

 

He disagrees that we should take into account the cost to the NHS or to the family. There are two very separate issues (in Warnock’s pronouncement - as in NHS policy-making) – one is about rationing the other is about the relief of suffering. The two must not be confused. They should not be debated together.

 

These two issues are at the heart of the fundamental debate about the state of the NHS today.

 

Professor Goddard believes that one hard issue at a time is plenty. In the true end-stage of dementia the patient cannot eat or drink, is unaware of their surroundings and family and is only aware of their suffering. This may last for a ghastly few weeks but as such only costs very little. “The rationing side of the argument can be ignored. The more important issue is whether or not patients deserve to have the best analgesia when that is all that is left for them”.

 

In the past doctors were able to give diamorphine  (heroin) and morphine to their patients. In fact opium from which these derive, has been used to ease the suffering of the dying for millennia. These drugs are still available for patients who are having hospice care but such care is mainly provided for those suffering from cancer. The need for palliative care for other terminally ill patients is understood but this does not mean that it is available. That dementia patients deserve the same access to palliative care as people with cancer is not a new concept but the money for such care is just not there and much care of patients in the end-stage of dementia is provided in NHS hospitals and in private nursing homes. It is in these places that patients with dementia die of thirst at the end of a protracted period of suffering. This is partly because the geriatricians and the GPs, working in a team are afraid to prescribe drugs such as diamorphine which will reduce suffering but are also likely to shorten the life of the patient. They are afraid because it is highly possible that another member of the team will report them to the GMC.  Thus the fear of such referral prevents the doctor from providing the best care for the patient. The family of the patient are rarely involved in these discussions in any meaningful way.

 

Few would disagree that suffering patients should be able to have diamorphine. Yet the association of the drug with drug-addiction, the use of diamorphine by the mass-murderer Shipman and the increased willingness for other members of the care team to "rat" on the doctor mean that the medical profession is playing safe and avoiding the issue by allowing the patients to die of thirst. Thus defensive medicine is restricting access to a drug that has been a boon for humanity for over 5,000 years.

A headline in the July copy of the GMC today magazine of the General Medical Council states that “Good Medical Practice is…. Getting on with your colleagues”

At first glance this agrees with the duties of a doctor laid down previously. Working with colleagues in the ways that best serve patients' interests would surely include “getting on with your colleagues”. Or does it? 

These days the term “Colleagues” includes anybody in the healthcare team. Thus it must include non-medical and medically-trained managers as well as the clinical staff who work with the doctor to provide care for the patient. ‘Teamwork’ is so beloved of New Labour. Fine if all are in agreement with ethical, noble, beneficial aims. But teams can be far more easily swayed by external influence/herd movement than an individual can. Teams cannot take responsibility, are not accountable (practically or legally). Individuals can and are. Frequently doctors find that they are clashing with managers over the provision of care for patients. The debate over euthanasia highlights the use or denial of use of powerful pain-killers for fear of referral to the GMC. There are many other ways in which possible referral to the GMC intimidates doctors.

 

It is probable that a minority of patients really believe that doctors today make patients their first concern. Much honest research is needed on this - NHS's self-congratulatory efforts are not really believable. Doctors are seen as one big club, like masons who all close ranks under threat.

 

But why are doctors perceived as behaving in this way?

 

One of the most common problems is the denial of life-saving drugs, either because of the post-code (wrong side of the road) or because the Primary Care Trust or NICE (National Institute for Health and Clinical Excellence) have refused to sanction the drug. As Stephen Pollard states in his website, (www.stephenpollard.net/000985.html) “Even the most cursory look at NICE's methodology and purpose shows precisely how it ends up denying treatments to patients which they would otherwise have had. The list of drugs which NICE now refuses to sanction is almost endless:

 

Last year NICE said that irinotecan and oxaliplatin should not be used as first line treatment for advanced colorectal cancer, even though they are licensed for this in the UK with an established drug 5FU. They added that a third drug, raltitrexed, should only be used in clinical trials. The real reason? The newer drugs cost £1,200 per patient a year, compared to the £70 of more traditional treatments.

 

Later in the year NICE said that there was “insufficient evidence” to recommend the use of a new cancer medicine which has clearly proved its efficacy in the treatment of patients in two of the three phases of chronic myeloid leukaemia. The medicine has been licensed for all three phases in 65 countries around the world: but not, thanks to NICE, in the UK.

 

Relenza for influenza, beta interferon for multiple sclerosis, herceptin for breast cancer: on and on the list goes, all on the basis of supposed “clinical excellence” and all, in reality, based on a desire to save money.”

 

Now, this sort of interference in medical care really annoys doctors. It particularly irritates the doctors who care most about their patients. When they are told that they cannot prescribe the treatment that they consider is best for the patient they believe, not unreasonably, that they are not acting in accordance with the GMC guidance to“make the care of your patient your first concern”.

So they will argue, as an advocate of the patient, with the managers and with the participants in organisations such as NICE.  At which point they are in danger of being accused of not “Getting on with your colleagues”.

 

Alternatively a doctor may discover that a number of his immediate medical colleagues are sub-standard in an area of their practice. He may try to substantiate this by medical audit : analyzing the results with the help of statistics. Or he may go to a more senior colleague with his concerns.  Whatever way the whistleblower tries to address the problem he will find that he is not “Getting on with your colleagues”.

 

At this point the crusading doctor may well be sent to the Occupational Health Department by his line-manager. The doctor he sees there may well tell him that he is stressed and that he is talking too loudly. “If you do not reduce the loudness of your tone I will have to put you in front of the Fitness to Practice Panel of the GMC”  is the sort of thing the poor doctor may be told.

 

Having started off with the welfare of his patient at heart the doctor has now become a patient himself and is in danger of being suspended by his employers and struck off the register by the GMC.

 

Patients and their relatives get this approach from the NHS also. Ask about the validity of the treatment offered and you’re marked as a ‘non-compliant patient’ or an awkward relative. Complain about the filth lying on the floor in the ward and you are made to feel that it is you who is out of step.   Exactly the same tactics. If that moderate pejorative doesn't work, they go to next level: 'mental health' issues - exactly as doctors hauled before the GMC.

 

The employers are becoming more aware of the ways in which they can manipulate the GMC, or even just the threat of the GMC, to their advantage. The occupational health doctors are, too often, in a compromised position. They are employed by the NHS to look after the workforce but managers will insist on interfering and putting the employer’s viewpoint about individual cases.

 

The crusading doctor is likely to be frightened by the suggestion that he should be put in front of the GMC.

 

Why is this happening?  In the post-Shipman world of medicine things are not as they used to be. The GMC is acting more harshly to avoid criticism from government and is very soon to bring in yearly revalidation for all doctors.

 

In his book The History of medicine, money and politics: riding the rollercoaster of state medicine Professor Goddard argues that whilst the judge who presided over the Shipman enquiry may consider the GMC to be an old pals’ club most of the doctors do not consider that to be the case at all. Moreover if the GMC does decide that the doctor is not guilty there is now, following the formation of The Council for Healthcare Regulatory Excellence in 2003, the possibility of double jeopardy.

 

Just the threat of referral to the GMC is very often all that is needed to “ keep a doctor in line”.  Hospital Consultants have been threatened in this manner when they have shouted at the incompetent management once too often. The effect is very worrying….. some decide to retire rather than be threatened by both management and the GMC and there has been at least one suicide.

 

Professor Goddard commented “I have spoken at length, written letters in support and acted as expert witness for a number doctors who were attacked in this manner.  All have found referral to the GMC to be a totally unpleasant experience.”

 

Of course it does not necessarily end there.  Patients and employers have always had the right to take the case to the courts if they felt the GMC had got it wrong and been too lenient. The doctor could do the same if he felt the GMC was too harsh.

 

However since April 2003 medical professionals also have to worry about The Council for Healthcare Regulatory Excellence (CHRE) (Footnote[1]). This organization has been set above the regulatory bodies of nine clinical professional groups including the doctors and nurses…..and their remit is to check whether the regulatory bodies have been too lenient and to make the punishment harder if the CHRE considers that they have.

 

Never the opposite.

 

If they can make things harsher, can they not also change the decisions if the original judgement was too harsh and make things more lenient…thus creating a balance? Their reply is that this is not in their remit and is in any case unnecessary since the professional can always go to court about it….. a ridiculous reply since the patients could also always do the same.

 

Thus the GMC is likely to be used as a tool to suppress dissent amongst doctors.  The GMC may be completely unaware of this problem and believe that the doctors sent in front of them are the right ones. As the NHS slides into decline, when compared with other health services in the developed world, there will be many more doctors and nurses standing up to be counted and even some caring managers who feel that the NHS has become too politicised. They will reach the point that they feel they must disagree with the so-called managerial colleagues or point out the ways in which cost-cutting is adversely affecting the patient care provided by medical colleagues. They will be controlled by an increasingly draconian regime using all means at its disposal to silence the dissenting practitioners and the GMC will be used against the doctors in many cases.

 

Whistle-blowing doctors have posted comments on Internet “blogs” about outrageous behaviour by NHS managers and senior doctors acting in a managerial way. These courageous individuals have also been referred to the GMC and their freedom to comment and right to work have been curtailed.

 

The Council for Healthcare Regulatory Excellence could be a force for good if it was allowed to act as an appeal body for whistle-blowing doctors who are unfairly treated by their employers of by the GMC. But this is not in their remit.

 

Even better would be to truly protect the whistleblowers. The Public Interest Disclosure Act 1998 is supposed to protect employees who disclose the fact that they have witnessed wrongdoing. However “the employment laws were specifically introduced to encourage genuine whistleblowers to come forward and expose matters of public concern without fear of reprisals.  Employees should take particular care when making the disclosure to a person who is not their employer; since more stringent conditions then apply.”

 

/www.rjw.co.uk/library/articles/uk-bodies-move-to-protect-whistleblowers

 

The doctors are likely to find that it is the managers representing their politicised employers who they are disagreeing with and that disclosure of their concerns to their employers results in no action whatsoever. Thus they become angry (and risk the GMC) or tell an outside body and risk instant dismissal. Either way round it is the most caring of the practitioners who are removed from the workplace and the care of the patients suffers because of this.

 

A similar problem has arisen with surgery. The paediatric cardiac surgery scandal in Bristol led to a Public Inquiry. Eventually one of the two surgeons involved was struck off by the GMC. The other was suspended by the GMC and later sacked by his NHS Trust. 

 

One result is that many surgeons will not operate these days on cases that have a poor chance of an optimal outcome.  This means that some patients, who are otherwise bound to die, may not get the slim chance that surgery could offer. With the publication of league tables of surgical mortality, the lesson of careful case selection is spreading widely. It would be comforting to believe that, if the only chance, perhaps a slim one, lay with surgery the surgeons would be prepared to have a go.

In our brave, new world this is probably not the case.

 

But it does not stop with the administration of medicine or the application of surgery. Diagnostic tests are also problematical. Doctors have frequently been reported to the GMC because they missed abnormalities on scans and x-rays. Their overall results may have been within the normal range but just a few errors are sufficient to make a case against a doctor. What is not understood in this context is that all tests involve a level of error and that in radiology this error rate runs between 2% and 30%. Doctors have been forbidden by the GMC from working in fields of radiology such as breast screening when their results overall were at least as good and possibly better than the average in the UK. Once again the GMC not only harmed the doctors involved but also damaged health care in this country. The Council for Healthcare Regulatory Excellence will only make things worse in these paranoid and politically correct days and the doctors will not dare to speak out for fear of being sacked , struck off or both.

 

This all adds up to a sorry tale of intimidation harming healthcare and the GMC are right in the middle of this muddle.

 

The GMC is undergoing an enormous change as I write this. A completely re-constituted GMC will be taking over very soon. As a last gasp the old GMC is taking away the age exemption for the annual retention fee and bringing in a new licence for all doctors who wish to practice medicine. “In about a year from now, the GMC will introduce the licence to practise and, from that point forwards, the medical register will show whether a doctor is a licensed medical practitioner or holds registration only.”

www.gmc-uk.org/publications/gmc_today/gmc_today_oct08/licensing.asp

 

The new council’s members will take office from January 2009 and consist of 24 members, of whom 12 are lay and 12 are medical. They have been selected by the Appointments Commission who are an “independent organisation” responsible, on behalf of the Secretary of State, for making such appointments. The question here is similar to the one we used to ask of the old Monopolies Commission (why is there only one monopolies commission?)

 

So who selected the Appointments Commission?