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Wednesday, 2 February, 2000, 13:03 GMT
Forum: Doctors and patients
For many years, Harold Shipman succeeded in killing his patients with impunity and in a way which suggests serious flaws in the systems that should protect patients from unscrupulous doctors.
But those responsible for regulating the medical profession argue that this could not happen again because of new checks now in place.
Dr Simon Fradd, a member of the General Medical Council, the British Medical Association's committee for GPs and chairman of the Doctor-Patient Partnership, answers your questions on the doctors' watchdog.
Why do the Royal Colleges and the BMA appear so intent on protecting doctors before protecting the public?
This question saddens me because it is very far from the truth. All the bodies representing doctors are extremely distressed by the actions of Harold Shipman. He has brought dishonour on an honourable profession. The BMA and the Royal College of General Practitioners have both called for an immediate enquiry so that we can ensure that such evil behaviour cannot occur again.
Some years ago I was removed from a GP's list since I upset the GP by speaking my mind. I did not immediately go to another GP but I waited until I needed medical attention. When I suffered an accident and was in much pain I went to five different GPs who would not add me to their list nor treat me because I had upset "one of their profession". It was made clear to me, "upset one of us and you upset us all." I was forced to go to the hospital casualty department for treatment. This power and commitment to each other is a dangerous thing, it can be used to cover up malpractice. It's common knowledge that GP's do try to get rid of problem patients, hopefully, not too many will go as far as Shipman. If I may refer to doctors employed by the DSS: the power to deprive people of benefit is widely misused, if they can do this, when there is so much medical evidence available, but which is somehow swept aside, what can these people do in the confinement of their own single practice? Is enough being done to safeguard patients from GPs such as Shipman?
The answer to the last point must be no not enough is being done to protect from the likes of Harold Shipman or he would not have been able to get away with it. However it is essential for all patients and doctors that public confidence is restored and all changes necessary to achieve this must be implemented. Deciding what measures are appropriate is a matter for the independent enquiry.
I feel the association of removing patients with Dr Shipman's actions is distasteful. However, the relationship between the family doctor and the patient is fundamental to a sense of wellbeing and good health in the patient. In the same way that the public must continue to have the right to change doctors, so must the doctor have the right to say when the relationship has broken down.
The DSS employs their own doctors to assess eligibility of individuals for long term benefits. This responsibility is out with that of the patient's GP. The terms of reference for DSS doctors are laid down by Government.
The House of Lords Science and Technology Select Committee in their 7th report - 'Resistance to Antibiotics' - stated that "the greatest bulk of imprudent use of antimicrobials in human medicine in the UK is the prescription of antibacterials by GPs for self-limiting or viral infections' (7th Report HL Paper 81-I 1988). In other words GPs are prescribing (on demand) antibiotics for viral infections which as any schoolboy scientist knows do not work for viral infections. This is only one example - how can we trust doctors when they cannot even get the basics right?
Do you think there should be stricter guidelines under which doctors can give medicine to patients, so they can be checked?
It is true that the prescribing of antibiotics for viral infections has been commonplace. This is in part historical. Before antibiotics, infections were one of the commonest causes of death, especially in children. The idea of bacterial resistance, particularly being passed down the food chain is a relatively new one. Doctors have been reducing their prescribing of antibiotics dramatically over the last few years. We now need to make sure the public understand why this is so.
Medicine is constantly evolving. Over a relatively short period of time what was best practice can become exactly the opposite. It is not sufficient for doctors simply to claim they keep up to date and expect the public to take this on trust. For this reason the General Medical Council is introducing revalidation - a system of 'MOT tests' for doctors. The changes to the NHS mean every GP practice has to have someone responsible for checking that knowledge and standards are kept up. This is known as clinical governance.
If my understanding of the information I know about this case is correct, then it appears to me that the GMC did not pass on information about Harold Shipman to the police, who were making enquiries at the time. This strikes me as a conflict of interest for the GMC, to release 'confidential' information about a doctor or to comply with the law. I also get the same impression between the GMC and the government; the GMC decides what they want to tell the government. When are the GMC going to become more accountable?
This case shows that there have certainly been weaknesses in the system of self-regulation in the past. Some of these weaknesses reflect the legislation under which the GMC works. It took 2 years to receive Parliamentary time to introduce powers for the GMC to deal with cases of poorly performing doctors as well as those who were sick or committed serious professional misconduct. Shipman's drug offences would be dealt with quite differently today.
The GMC now has some 40% lay members. This is vital to the Council's accountability. Lay people are involved in screening complaints as well as sitting on adjudication panels.
Findings of the performance committees are in the public domain. It needs to be decided whether the responsibility should be for the GMC to actively give out this information or whether the police, health authorities and employers should check out if a doctor has ever been found guilty of an offence. In this case I understand the information was not requested of the GMC.
The system of revalidation is the most significant. Doctors will have to regularly prove their abilities in order to retain the right to practice.
Many people in the UK will now be frightened to visit their GPs. How may more Dr Shipman's might there be out there? No one knows. It is not enough to dismiss this case as a one off. We've all known GPs whom we thought were uncaring. The public need concrete reassurance. I would suggest a one off investigation immediately into all GPs in the UK. One of the ways Dr Shipman was found out what the statistically high death rate of his patients. A similar analysis could be undertaken comparing each GP's practice with the norm for their area and abnormal death rates followed up and investigated carefully. Your comments?
I totally agree that it is not enough to assume that Shipman is a one off. Public confidence has to be re-established urgently. That is why I welcome the announcement of a full, urgent inquiry to identify areas where improvements can be made. There is much statistical data on GPs which is regularly monitored. The process must be checked to make sure that someone is actually checking these statistics.
There will be other safeguards that can and must be developed. The Government has already announced its intention to look at the return of dangerous drugs, death certification and notification of deaths to the coroner.
Do you think that publishing doctor or surgery "performance figures" would help identify "problem doctors"?
I do not think this will be helpful. Harold Shipman would appear to have been a competent but evil doctor. There is the problem of what statistics indicate a good doctor or identify "problem doctors". The revalidation system sets out clearly what constitutes an excellent GP and an unacceptable one,
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