As the post nuclear option Heremy Junt/BMA contract row rumbles on behind the scenes – the top hit on google news today for junior doctor contract is a three day old blog post on Conservative Home by a psychiatrist sorely in need of Photoshop if ever there was one, and the BMA’s ‘latest update’ is weeks old, a thoughtful post by JT reminds us that the opposing comedy duo of Junt and the BMA Junta are not the only threats to junior doctors. The SPECTRE known for the time being as NICE, the National Institute for Clinician Evisceration, has produced yet more guidelines on statins. Commendably dense with the rhetoric of patient choice, the general thrust is nonetheless on upping the uptake. JT’s gripe is three fold. The first is that clinical guidelines, statistical tools, algorithms, call them what you will, become wet paper bags when they attempt to contain the complexity of real life. The second is that guidelines alongside variations of payment by result tends to get, well, results, ie more people on statins, without care for whether they want them or need them. The third, touched on more briefly, but just as important, is that, up against the hour glass of surgery time, thoughtful deliberation never stood a chance. It is the dead duck floating feet defiantly up, but head drowned in the time-hoopered barrel of clinical complexity.
News last week that there were 17 deaths in or following police custody in 2014/15 in England and Wales has rekindled outrage at the scandal and led to the usual political wails. Theresa May, announcing an inquiry into the deaths, said they ‘represented failure’. Well, that’s one way of putting it. Others rallied round ‘one death is a death too many’. Had Stilton been asked for comments, he would have said the deaths ‘absolutely represented failure,’ and that ‘one death absolutely is a death too many’. Sotto voce, he may have added, ‘we absolutely have been here before,’ because of course the GMC has had a hand in the death of similar annual numbers of doctors under FTP investigation, but from a far smaller population at risk. We should also note Stilton does not count year-and-a-day deaths, ie those occurring after FTP investigation. As a killing machine, or if you prefer a negligent machine that allows deaths, the GMC is far more lethal than the police. For once Stilton would be in error to say the GMC absolutely is more lethal, were he ever to admit such a thing, because in absolute published numbers the police are equal to, or slightly ahead of the GMC, but in relative, pro rata, terms, the GMC’s FTP processes are more lethal than police custody processes. If the police’s grim reaper is a scythe on open land, the GMC’s grim reaper drives a combine harvester down narrow streets.
Good medical practice, perhaps, but bad English. Absolutely Stilton’s announcement of his latest hair shirt guidance for doctors, absolutely jointly produced with the Nursing and Midwifery Council so that it applies to nurses and midwives as well, is focused, if that is not too strong a word, on the duty of candour, more generally understood as the duty to be honest. It tells clinicians, with a ringing third degree participle prolapse, that ‘When something goes wrong with a patient’s care, doctors, nurses and midwives should: speak to the patient, or those close to them, as soon as possible after they realise what has happened.’ Wily clinicians, and those liable to be bent by their learned friends, are thereby provided with a useful loophole. So long as the patient hasn’t realised something went wrong, there is no need for the clinician to embarrass themselves. Piling Pelion on Ossa, the next point reverses the prolapse. Clinicians, the announcement says, should ‘apologise to the patient – explain what happened, what can be done if they have suffered harm and what will be done to prevent someone else being harmed in the future’. From where Dr No is sitting, it seems they absolutely don’t know who they are, and if they don’t know who they are, the what hope can there be for the rest of us knowing who we are, let alone what we should do?
The other day we had David Cameron getting pumped up about a seven day NHS. Pumped up is the New Tory, but a lot of old hats were still put on pegs, some hats more moth-eaten than others. JC (of the Department of Health Sunshine Band) was wheeled onto the Today programme, sounding about as pumped up as a flat tyre. Despite the ill wind blowing today through NHS General Practice, with more vacancies than currants in a bun, the government’s prescription is five thousand more GPs. Quite which wind these GPs will arrive by has yet to be explained. Historically, the NHS has outsourced, or at least gained, extra doctors from abroad. Pigs, after all, can always fly, if they are pumped up enough.
Two days ago Dr No got another fun email from the GMC. Unlike the recent email from O Chair – ‘I’m Terry, and I’m your buddy!’ – the latest email is GMC News, March 2015, e-bulletin edition. Dr No passed on the email’s ‘Forward to a friend’ link – if friends are forwarding GMC emails to you, you need to check out who your friends are, and if you are forwarding GMC emails to your friends, you need to check out whether you’ve actually got any friends. He also declined to click the link offering Dr No the opportunity to check his registration online, on the grounds that he already knew his registration status. He learnt, from the GMC News e-bulletin headline, that there was ‘Strong support for proposals to improve patient protection and public confidence in doctors’, which turned out to be another eight out of ten cat owners who replied story. He also learnt that the theme for this year’s GMC conference, hashtag #GMCconf for those who can’t – perhaps because they are busy forwarding GMC emails to friends – make the regulator’s annual gangbang in person, is ‘creating a culture of openness, safety and compassion’. Coming from an organisation which, at least in the conduct of its fitness to practice procedures, is known for its opacity, recklessness and indifference, this struck Dr No as a bit rich.
It’s a matter of conjecture whether Stilton wants more complaints to the GMC. Last year, he was all for it. The GMC’s State of the Profession report for 2014, published on 8th October 2014, noted ‘regulators…are seeing a rise in complaints…much easier to raise a complaint. This is all to be welcomed…’. The ellipses cover many words but the meaning is unaltered. By 11th February 2015, only four months later, writing in BMJ Careers, he said ‘We do not “welcome” the huge increase in complaints’. It is not clear why “welcome” is in quotes but that aside the two positions seem rather at odds with each other. Perhaps they have the heating at GMC Towers set rather high, and Stilton is starting to overheat. Or maybe it’s complaint blowback, be careful what you ask for. Welcoming complaints, the GMC got more than it bargained for.
Just as forecasters talk of a ‘fog situation’ or a ‘snow event’, so do medical educators now talk of the ‘shape of training’. Why the accessory words are needed is beyond Dr No, but then again he is not all that surprised because the recent Shape of Training Review – hashtag ShoT or in this parish bashtag ROT – was led by a certain eminence situation, one Prof Sir David Greenaway, a distinguished looking egg-head and leading light from the science that makes astrology look good. The #ShoT review’s publication situation was treated by and large as a no news situation – maybe being #ShoT didn’t help – though for some reason the BBC did cover it, and of course our dear friend the Ferret Fancier has been poking holes in the review for some time. One of the Ferret Fancier’s notable achievements has been, on appeal, to get an order for the release of certain GMC minutes of #ShoT/DoH meetings, which the GMC had previously determined should most definitely remain as an ongoing non-situation.
In a curious move, because to many it will suggest the GMC perceives itself to be on the back foot, Stilton yesterday had published in Pulse an article in which he attempts to portray the GMC as a listening organisation which ‘accepts there is a lot more to do’. Or, to put it another way, on the matter of its regulatory functions, the Council accepts this is ‘an area where more can be done’. Pulse’s standfirst boldly promises an explanation of ‘how the body is ‘improving fitness-to-practise regulations’ – this being, after all, and as the Council accepts, ‘an area where more can be done’ – but in the body the article fails to keep its promise. Instead, Stilton delivers a peevish nit-picking lawyerly rebuff to two recent articles, and a bizarre waffle on why GMC punishments are not punishments. These, however, are diversions. The real message, the payload, part-hidden as it is, is much darker. It is that age old defence against charges of involvement in state sponsored evil that has become known, since the Nuremberg trials, as the Eichmann Defence: ‘only following orders’.
Once upon a time there was a turkey farm that grew so large that no one had ever seen one so vast. There were so many turkeys that, over time, the turkeys began to specialise in what they did. There were turkey-surgeons with white plumage, who operated on other turkeys. There were turkey-physicians, with fancy black and white plumage not unlike a human frock coat, who were called in when no one knew what to do. The turkey-physicians didn’t know what to do either, but were very good at making it look as if they did, which made everyone feel better. There were turkey-apothecaries, always busy in their brown aprons, handing out this pill and that potion. Over time, the turkey-apothecaries renamed themselves turkey-GPs, which made them feel more important, but no one else was fooled, and the turkey-GPs carried on doing what the turkey-apothecaries had always done, the over-worked under-appreciated back bone of Turkey Farm. There were even mad turkeys, as they were affectionately known, whose plumage tended to look as if they had been dragged through a hedge backwards, whose job it was to lock up deranged turkeys. No one liked locking up fellow turkeys, but sometimes it had to be done, and it was the mad turkeys who did it.
Any lingering hope that Parliament’s Health Committee could hold the GMC to account at its annual accountability hearing earlier this week over doctor suicides while under GMC FtP investigation has now disappeared as sand in the desert. Though delayed for a few days, the transcript of the hearing is now available online. It makes grim and depressing reading. On the matter of FtP doctor suicides, the Chair of the committee – a doctor – came to the proceedings with a regrettably light grasp, if that is not too strong a term, on the facts. Stilton, the GMC pongo who answered the questions on these deaths, turned out to have an even lighter grasp. Indeed, so poor were these grasps that Dr No has no hesitation in saying that they were, and are, an insult to democratic process.