Policing the medical profession

• ‘A community has lost a good doctor, a family has lost a husband, a father, over what? Just hysteria. It’s like a force of evil came into the house and took over, and ended up with someone destroying themselves.’ Julie Evans, whose husband Philip, a GP in South Wales committed suicide in June after becoming depressed as a result of a complaint about his treatment of a patient who died suddenly. (Guardian, 22 November)

For Mrs Evans, ‘Philip was the classic victim of the blame culture that now pervades our society’. The widespread conviction that when something goes wrong somebody must be to blame undoubtedly has a corrosive effect on social relationships, particularly those between doctors and patients. Mrs Evans singles out the NHS complaints procedure that encouraged the bereaved family to channel their anger against their doctor, while subjecting him to ‘daunting and harrowing’ delays and inquisitions, with damaging leaks to the local press. As a result, Dr Evans lost confidence and self-belief, both of which are, as his wife rightly observes, ‘prerequisites of a good doctor’. He became depressed, contacted the British Medical Association’s counselling phoneline, and ultimately threw himself over the cliffs at Rhosilli on the Gower peninsula.

But, as the statement by outgoing General Medical Council (GMC) president Sir Donald Irvine quoted above indicates, the problems facing today’s doctors go much further than the damage inflicted by bureaucratic and insensitive complaints procedures and sensation-hungry newspapers. With an abrasive attack on ‘a minority’ of doctors whose professional practices are ‘dangerous, offensive or otherwise unacceptable’, Irvine wants to rally public support for a comprehensive programme through which all doctors will be obliged to demonstrate their fitness to practise. He also wants to put the ‘patient instead of the professional’ at the heart of the health service, insisting that patients should be the ‘ultimate arbiter of NHS quality’.

Irvine’s populist rhetoric finds a ready resonance with a public opinion already inflamed by reports about Harold Shipman, the scandals at the Bristol children’s heart surgery unit and Alder Hey hospital in Liverpool, and an apparently endless series of stories of abusive and incompetent doctors emerging from the hearings of the GMC.

Who could object to patients having a bigger say in the NHS and doctors being taken down a peg or two and forced to keep abreast of new developments? Well, I believe that both patients and doctors should object. A closer look at these proposals suggests that both are likely to be the losers in a new culture of state control over medical practice.

In addition to the complaints procedures that now flourish at every level of the health service, the government has recently announced plans to introduce a comprehensive system of patient advocacy in every hospital trust. Though there has been some controversy over this scheme to displace the long-established community health councils with a more bureaucratic and centralised system, the plans appear to be moving ahead.

At the level of the GMC, lay representation has grown rapidly, effectively bringing the self-regulation of the medical profession to an end. Though reformers seem to assume that patient advocates and lay members provide some representation of the public, the fact that they are appointed by the authorities or the government means that they are more an instrument of official control than a mechanism of democratic accountability. Following the pattern of appointments to other such bodies, lay appointees are likely to be cronies of Tony or one of his lieutenants, selected for their loyalty to government policy.

Irvine’s enthusiasm for consumer sovereignty reflects a lack of understanding of the limitations of market forces in the regulation of professional relationships – and a lack of understanding of the history of the medical profession. In the nineteenth century, physicians regarded the market as a threat to both income and status, as they were forced to compete with diverse unscrupulous practitioners, and also to deal with attempts to turn them into mere employees. In response, doctors – in common with other aspiring professionals – tried to distinguish themselves from tradesmen and businessmen by claiming a commitment to a higher cause than vulgar commercial interests. As Paul Starr, historian of doctors in America, puts it:

‘In justifying the public’s trust, professionals have set higher standards of conduct for themselves than the minimal rules governing the marketplace and maintained that they can be judged under those standards only by each other, not by laymen.’ (1)

Whereas the market ideal is that the consumer rules, the ideal of a profession ‘calls for the sovereignty of its members’ independent, authoritative judgement’. From this perspective, a quack is a practitioner who tries to please his customers rather than his colleagues.

The call for the ’empowerment’ of patients is presented as a radical challenge to the medical profession, or at least to what Irvine characterises as its ‘deeply conservative rearguard’. In fact, it amounts to the surrender of the autonomy of the medical profession to state control and the surrender of its standards to the dictates of the market. But as many casualties of Britain’s private medical sector can confirm, the notion that ‘the customer is always right’ is not a reliable guarantee of quality in healthcare.

The fact that it is possible for a doctor to continue to practice for decades after qualification without ever opening a book or taking any other steps to keep up to date has long seemed indefensible. The difficulty lies in devising a system of appraisal that provides a meaningful guarantee of competence. Though this problem has occupied some of the greatest minds in the medical world over the past decade it is still far from being resolved. Who is qualified to assess doctors’ competence? Can doctors who opt to assess other doctors rather than continuing clinical work be considered reliable assessors? By what criteria should doctors be assessed? Who should draw up these criteria? What if a particular doctor considers them inappropriate to their practice?

All these questions, and many more – notably on the question of resources for appraisal when health service resources, especially in terms of medical personnel, are already overstretched – have dogged discussions over proposed systems of revalidation.

It is striking that the current debate assumes that public confidence in the medical profession depends on the introduction of a new system of regulation. From a historical perspective this is curious, because over the past century and more the prestige of the medical profession has risen dramatically, largely independently of the role of the GMC, which has long been a remote and ineffectual body, concerned largely with policing ‘bad’ doctors.

But just as public confidence in the medical profession was little affected by periodic scandals about corrupt or lecherous doctors, neither did it depend on the vigorous pursuit of such rogues by the GMC. The prestige of the medical profession had quite different – and until the past decade – quite secure foundations in the successes of scientific medicine and in the vitality of the doctor-patient relationship. The key change of recent years is that long-tolerated variations in styles of and standards of medical practice have suddenly been judged to be ‘unacceptable’. This judgement was made, at least in the first instance, not by the public or by the media, but by doctors themselves.

The independent general practitioner (GP), competent on qualification, symbolised the confidence of the medical profession in the nineteenth century. By contrast, the ‘never quite competent’ GP, one who requires continuous formal instruction and regulation, mentoring and monitoring, support and counselling, symbolises the abject state of the profession today. Far from being arrogant, paternalistic and complacent, today’s doctors have been so humbled that there is a risk that sentiments of self-doubt and insecurity will result in demoralised and defensive practice and seriously undermine their capacity to care for patients.

According to the mother of Michael Oliver, Dr Evans visited the family after his death and ‘got down on his hands and knees’ to apologise. Though this is disputed by Mrs Evans, it provides an apt image of the current plight of the medical profession and a striking contrast to the caricature offered by Donald Irvine.

Dr Michael Fitzpatrick is the author of MMR and Autism, Routledge, 2004 (buy this book from Amazon (UK) or Amazon (USA)); and The Tyranny of Health: Doctors and the Regulation of Lifestyle, Routledge, 2000 (buy this book from Amazon UK or Amazon USA). He is also a contributor to Alternative Medicine: Should We Swallow It? Hodder Murray, 2002 (buy this book from Amazon (UK) or Amazon (USA)).

Read on:

Bristol Inquiry: key questions, by Dr Michael Fitzpatrick

The high price of Alder Hey, by Dr Michael Fitzpatrick

(1) The Social Transformation of American Medicine, Paul Starr, 1982