‘Great to see a single-handed enthusiastic GP with a rolling programme of audit – keep up the good work!’
Such was the report of an audit inspection of the practice of former Hyde GP Harold Shipman, who hanged himself in Wakefield prison this week. It was carried out in January 1998, some nine months before the arrest that led to his conviction for killing 15 patients, in January 2000. According to the first report of the official inquiry, still continuing in Manchester under the chairmanship of Dame Janet Smith, he was probably responsible for at least 200 more murders.
It is ironic that despite the failure of audit inspection to reveal any of the grisly secrets of Shipman’s practice, his case has become the focus of proposals for further programmes of audit of which he was such an enthusiastic supporter. His death is unlikely to deter the introduction of a range of measures into primary health care, justified by the peculiar circumstance that Britain’s most prolific serial killer was a GP.
The fact that Shipman’s crimes remained undetected for so long is a grotesquely backhanded compliment to the culture of trust that prevails between doctors and their patients. Until the summer of 1998 – when his crude forgery of the will of his last victim, former mayor of Hyde Kathleen Grundy, was noticed by her solicitor daughter – none of his patients ever suspected him.
Even when the circumstances in which some of his patients died were quite extraordinary, their relatives never considered the possibility that their GP, whom they regarded as a committed and caring doctor, was responsible. Indeed, Shipman’s style of practice, perhaps somewhat autocratic and paternalistic for cosmopolitan tastes (though conducted from a modern, computerised, well-organised surgery) tended to reinforce his image as a traditional, single-handed, small-town GP.
It is true that Shipman could not have achieved his grim success as a serial killer if he had not also been a GP. But this does not mean that it is a sensible response to his crimes to introduce radical changes in medical practice. Yet this is the main purpose of the second stage of the ongoing Shipman inquiry, which is considering matters such as the prescription of controlled drugs (used in large quantities by Shipman to kill his patients), the procedures for completing death certificates and cremation forms, the regulation of single-handed GPs, the role of the coroner and the responsibilities of local health authorities.
Proposals in these areas are justified by the claim that they may ‘prevent another Shipman’. But given that Shipman is the first mass murderer to emerge in the 170 years since general practice was established, we are unlikely to see another in the near future. We can also be sure that no preventive measure introduced in response to such a bizarre set of events is likely to detect a serial killer of the future.
Yet, according to primary care Professor Richard Baker, whose inquiry into Shipman’s clinical practice revealed his zeal for audit, ‘it is a priority to detect serial killings as early as possible’ (1). Though this used to be considered a priority for the police, it is now destined to become a priority for audit in primary care (though perhaps not yet a performance indicator). Recognising that future serial killers may not exactly follow Shipman’s methods, Professor Baker emphasises that ‘monitoring should be designed for the early detection of aberrant behaviour more generally, as reflected in mortality patterns’.
The problem here is that death is the end point of life as well as an outcome of therapeutic – or homicidal – intervention. It may be the result of good medical practice just as much as bad medical practice. Crude mortality rates are unlikely either to reveal substandard practice or to expose a serial killer.
A doctor’s behaviour would have to be very seriously aberrant before it started to affect practice mortality rates. A recent study proposes a model that would have detected Shipman’s excessive death rate some 12 months before his arrest in 1998 (2). But by that time he had already killed more than 100 people. The same model further suggested that some 32 other local GPs were also achieving excessive death rates and hence also required investigation as potential serial killers.
Given the scale of the atrocities he committed, it is understandable that Shipman’s death has provoked anger among the relatives of his victims. Perhaps his demise will allow them, in time, to move on. To reorganise medical practice in the name of its most notorious practitioner would be a bizarre – and irrational – tribute.
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)).
Policing the medical profession, by Dr Michael Fitzpatrick
Second opinion, by Dr Michael Fitzpatrick
(1) British Medical Journal, 2003; 326: 274-6
(2) Lancet 2003; 362: 485-91
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