Remedy

Remedy campaigns for the professional interests of doctors

Time to honour the Bristol whistleblower

By JJ Oliver - 1st September 2010 9:42 am

How would you feel if you moved to a new hospital and discovered that their mortality for the cases you were doing was twice the national average? Would you try to get things changed? And if you succeeded then would you expect to be treated as a saint or a sinner?

Twenty two years ago Dr Steve Bolsin found himself in this position when he took up a post in childrens heart surgery. After many years of struggle he got things changed - but at a huge cost to himself. Now it is time for British medicine to acknowledge the contribution of this unsung hero.

Dr Bolsin was appointed as a consultant anaesthetist in September 1988. Almost immediately he realised that there were problems in Bristol with the conduct of open heart surgery in children. He was particularly concerned about the long duration of surgery and bypass, and the consequent effect on postoperative outcomes. He soon raised this with his professor and his departmental chairman.

The Professor of Anaesthesia in Bristol recalls that Dr Bolsin had: “…expressed his concerns to me about problems in managing small babies following cardiac surgery… He was concerned that the mortality in this group of patients was much higher than he had been accustomed to… I advised him that rather than create waves with little credible evidence, he would be better advised to collect prospective data on babies and children who he anaesthetised for cardiac surgery in Bristol.”

Bolsin carefully audited the process, and continued to draw attention to the problems. In one of his letters he pointed out that the mortality for open-heart surgery in babies was “one of the highest in the country”. He expected that this letter would get a positive response. But instead of a commendation, he received a rebuke, and was sent away to collect more data.

Further data collected over the next three years showed the same patterns. He audited not only the anaesthesia and intensive care, but also at the work of the perfusionists and surgeons. The findings repeatedly demonstrated that there was a high mortality for children having major heart surgery.

At no stage was he told that he was wrong or mistaken in seeking to gather information, and he received assurances that the matter would be looked into. But nothing changed.

Between 1992 and 1995, he became progressively more desperate. He secured the help of senior doctors in other hospitals, the press and the Department of Health. For this he was rebuked, being told that he should not take information to ‘outsiders’ and that he should ‘keep his head down’. As the data he collected become more solid, his working environment became increasingly hostile.

A compounding factor was the uneasy relationship between anaesthetists and surgeons. He found that the surgeons ruled the roost, which made it difficult for any anaesthetist to appear critical of a surgeon.

After many years of adversity his data was finally acted upon. The death rates for children’s heart surgery in Bristol were dramatically reduced as a result of his determined efforts.

He also catalysed the development of a new process in medicine - clinical governance. It’s now used routinely to study and improve medical care across the country. And he was elected as the first national audit coordinator for the Association of Cardiothoracic Anaesthetists of Great Britain.

But here the tale turns sour. His career took a major nose dive, and he found himself unable to work in the UK. He eventually moved to Australia. He’s a forgotten hero of British medicine and, having recently had a quadruple bypass of his own, must wonder whether it was worth it.

The great and the good tell us that we should be impartial and committed, and that Good Medical Practice is based around the concept of integrity. The reality of whistleblowing is that the brave honest and committed doctors who attempt to change things risk professional suicide and spending the rest of their careers in the wilderness. Yet the smiling face of the Professor who Bolsin originally turned to for help is captured forever on an oil painting that hangs in the royal college.

Fortunately the British have a way to recognise and acknowledge the significant contributions that Dr Bolsin made to patient care. The Honours System exists for precisely this purpose. A group of his friends and supporters are now in the process of completing an application for him.

Remedy believes that the awards mechanism of the establishment should be used to bestow honour upon those who truly deserve it. We would wholeheartedly support this application, and invite our supporters to do the same. And there is a Twitter Group to support the campaign.

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Calling on the GMC to re-define misconduct

JJ Oliver, Remedy - 30th April 2010 2:15 pm

The Remedy judicial review being heard on 11 May could drive a coach and horses through the meaning of misconduct, and the meaning of unfitness to practice.

Doctors who are involved in management will be anxiously awaiting the verdict, since they may find themselves personally liable for their managerial decisions in future. And appeal lawyers across the country will be looking to the judgement to see whether the GMC has opened the floodgates for them.

Doctors are always happy to whinge about their managers, but serious action against doctors in management is rare. The GMC has only taken action in a handful of cases. One such case was that of Dr Roylance - the chief executive caught up in the Bristol babies cardiac surgery storm.

The MTAS recruitment process was a unique disaster. Some of the superlatives used at the time still stand out; it was described as the “biggest disaster” in a generation, and the anger it generated has still not subsided. So when Remedy wrote to the GMC asking for the senior doctors responsible for it to be referred to a fitness to practice committee then they hoped that the case would be duly investigated.

But the GMC politely declined the opportunity to hold such an inquiry. At this point Remedy reached for their lawyers, and challenged the GMC to defend themselves in court.

The case raises significant issues well beyond the events of 2007. At the heart of it lies the prickly and complex issue of what constitutes unfitness to practice. What sort of actions outside the clinical arena will render a doctor unfit to practice as a medical practitioner? The GMC have defended themselves on the grounds that: 

Whatever the conduct of [The Proposed Defendants] with regard to MTAS, I do not consider that it can sensibly be said to impinge on their fitness to practise as medical practitioners.

Yet this seems to be at odds with many previous rulings. There are many doctors who have been removed from the medical register for what has been referred to as “bringing the profession into disrepute” and for “conduct unbecoming of a doctor”. And if, for example, the doctors under investigation had knowingly breached the laws affecting international medical graduates then would the GMC still be arguing that this had no effect on their ability to work as doctors?

There has never been a case of deficient professional performance brought against a doctor for managerial issues. If Remedy is successful then this verdict will send a cold chill down the spines of medical directors and doctors working for health authorities - especially in an era of financial uncertainty.

The case is being heard in the High Court on 11 May - five days after the general election. Remedy has created a Facebook group for supporters of their case. If you agree with us, please attend court or, failing that, express your support.

This verdict is going to be studied by medico-legal bodies for many years to come.

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“A major blow against limiting doctors’ rights”

By Richard Marks, Remedy's head of policy - 26th January 2010 3:25 pm

Remedy is delighted that our legal team has forced the government to delay their plans to exempt deaneries from employment agency legislation.

This is of significant importance to any doctors caught up in the recruitment process, who would have been deprived of many employment rights by these proposals. The legislation governing the conduct of employment agencies was passed by Parliament in order to give protection to vulnerable workers.

A government consultation in early 2009  stated that they ‘consider that [Deaneries] operate as employment agencies within the definition contained in the Act’ and that they wished to introduce an exemption. Their reasons for doing so were unclear.

The Act gives the power to introduce exemptions by regulation, subject to consultation, and a consultation took place in the summer. Both Remedy and the BMA opposed the change, arguing that it was not in the best interest of doctors. But the government announced in November 2009 that the respondents on the issue of postgraduate deaneries ‘mainly comprised a number of Deaneries who were in support of the proposal’. They also stated that they had been presented with  ’evidence that the potential consequences could be to seriously hinder the recruitment and training arrangements for junior doctors with a subsequent impact on both costs and staffing for the NHS’.

Remedy believes that the consultation was not carried out properly. We had no idea what the ‘potential consequences’ were, and we have had no opportunity to comment on them, or on the evidence which is referred to.
Our lawyers sent a Letter Before Action to Lord Peter Mandelson on 11 December, challenging the veracity of the consultation.

In their reply, the government solicitors agreed to re-consult on whether or not to introduce the exemption. They offered  to consult specifically in areas around training and recruitment. No date has been set for this re-consultation.

The status quo has been maintained, and the proposed exemption has been delayed - possibly indefinitely. We are very grateful to our legal team at Blackstones and Leigh Day in securing this result.

This delivers a major blow against a concerted effort by government to limit the employment rights of doctors. We anticipate further attempts in the future and will do everything to resist them if they are unfair.

Doctors should enjoy the same level of protection against abuse as other parts of the workforce.

The government has also agreed to negotiate a code of conduct for deaneries, and Remedy has been asked to join these negotiations alongside the BMA. We have drafted our thoughts on this and are now seeking the views of our supporters.

Our views on the implications of Employment Agency legislation and the issues that we feel need to be addressed can be read on the Remedy website. 

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Recriminations begin over swine flu vaccine

By Richard Marks, head of policy of Remedy - 9th January 2010 6:40 pm

At the beginning of the summer it looked as if we could be on the brink of a major health epidemic that could bring the country to its knees. A huge machine went to work preparing for the impending cataclysm. Six months later the swine flu epidemic has been a bit of a damp squib, and the medical profession looks as if it has been ‘crying wolf’ yet again.

Millions of pounds were spent on vaccines and antivirals and a great deal of anxiety has been generated. So was this incompetence? And, are we going to point the finger of blame at someone?

The retrospectoscope is a great and wonderful tool. Looking back to the summer there was a very real threat of a new strain of a virus, which had the potential to spread rapidly across the world. Attempts at containment were unlikely to succeed. In addition, there was evidence from South America showing that this new virus had the potential to be highly virulent, and worst case scenarios suggested that up to 65,000 people could have died.

Those responsible for planning services across the country are in an unenviable opinion. If they under react and under plan then they risk leaving the country vulnerable to a great plague that will cause untold misery and grief. If they over react then they will be accused of unnecessarily crying wolf and wasting money. And if they look indecisive then they appear weak.

Swine flu has been a global problem and the planners in this country will have looked carefully at what the rest of the world was doing. And it looks like everyone else got it about as wrong as we did. Well actually some of them got it even more wrong. The French, for example, bought 94 million doses of vaccine - more than the population of the country - and they only used 5m of them.  Now they are desperately trying to unload their excess stock.

And figures published in Le Monde showed that some other parts of Western Europe bought enough vaccine to immunise their whole population twice over. The US and Canada also bought considerably more than they have used, with Canada recently donating 5m surplus doses to Mexico.

There are some that think we have drawn a line under this too quickly. Flu epidemics come in threes, and we still haven’t seen the end of it. The WHO is still warning that it will be a year before the crisis is over. So maybe before we rush to put our excess vaccines onto eBay we should just wait a little longer. 

Doctors are naturally cautious and I think most of us think that the government largely got it right. It is far better to slightly overreact rather than the opposite. I think the majority of taxpayers would agree with this too.

However the green-ink conspiracy theorists have been on the case and are pointing their fingers at the drug companies. They are suggesting that some of the independent experts sitting on WHO committees have financial links with the pharmaceutical industry. And one blog posting goes further and points the finger at an individual. 

Should we believe the conspiracy theorists? Probably not. The allegations may well turn out to be totally without merit or validity. Whenever a mistake is made then there is always someone ready to leap forward and claim that there is a conspiracy at work. But, with such large sums of money at stake, we do need to be reassured about what went on.

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The real truth about the UK’s drugs policy

By Richard Marks, head of policy at Remedy UK - 6th November 2009 10:24 am

Drugs policy is not about science, health or balancing of risks. It is all about politics and the careers of politicians. That seems to be the inescapable conclusion of the events which unfolded over the past week. And what is most amazing is the brazen manner in which politicians come out with this and still expect our gratitude and respect.

Drug and substance abuse is bad. We should not underestimate the harm that some drugs do; as doctors we see evidence of this on a day to day basis. As human beings we see it all too often in friends, family and colleagues. Most of us feel that society should take some sort of collective action in order to restrict the use of these harmful substances, in some way.

Most of us are also comfortable with the idea that these restrictions should be graded across a spectrum. So some drugs are freely available (such as caffeine), others should be restricted in some way (alcohol or tobacco) and others should be made unavailable. Those that are unavailable are also graded so that the penalties for using the more harmful are more severe than the penalties for the less harmful.

In an ideal world, then, the decision of how to grade any individual drug would be based on the harm the drug does, and the harm to casual users, to addicts and the vulnerable, and to society as a whole. Quantifying and balancing these risks is a difficult science, requiring a range of scientific and sociological disciplines to work together to seek an answer.

But after the scientists have done their job and quantified the risks, and assuming their findings are valid and correct, then surely the job of the politician would be to rubber-stamp them. But this is where the whole model falls apart, and where an almighty row has erupted. Because even when the scientists have measured the risks to the nth degree, the politicians still think that they know better. They want scientific advice and government policy to be two separate concepts. 

And while Alan Johnson wriggles in the limelight and takes the flak, Her Majesty’s opposition is ready to leap to his defence. Writing in The Times this week Lord Young, the former conservative minister, is anxious to defend the right of politicians to ignore advice whenever it suits them. “The Minister will have other considerations to take into account” is his explanation. He argues so forcefully that it almost sounds credible.

But what other considerations does the minister have to take into account in setting drugs policy? If the scientific advisors have done their job properly and thoroughly there should be no stone unturned. A moment’s thought and the “consideration” that Lord Young refers to becomes obvious. It is of course, the political implications, and the repercussions on the career of the minister and his government.

So there you have it. But why stop at drugs? This argument extends to every corner of government policy, including the running of the NHS. And what I find so astonishing about this affair is that there has been no pretence of a cover up story.

For those of us brought up to believe in the scientific method, and that somewhere out there lies the truth if only we could find it, this all comes as a bit of a shock. I always thought the people upstairs knew what they were doing, and were acting on the basis of the best information available to them. Scientists like to believe in the purity and absoluteness of scientific fact.

But maybe I’m just being a little naïve. Groucho Marx understood the problem much better than me. “I have principles”, he said. “And if you don’t like them, well I have others.”

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Doctor and nurse regulators divided over swine flu

By Richard Marks, head of policy at Remedy - 1st October 2009 10:08 am

One of the many worries about a swine flu pandemic is the effect it would have on the case mix inside hospitals. If we were overrun with seriously ill children then traditional paediatric ITU services could be swamped. There has been plenty of warning over this, plenty of constructive thought and a good deal of local planning.

The net result will involve a major rearrangement of how health care staff are deployed if the worst-case scenarios come true - hospitals might consider cancelling non-urgent surgery and moving staff around in order to cope with the changing patterns of disease. Even staff not directly affected by swine flu may be affected by repercussions of this. The exact way that this will pan out in practice is not yet known.

Earlier in the year the GMC issued some fairly sensible advice on this. It states that doctors may be asked to work outside their normal scope of practice, and some doctors who have retired, or who are not working in the profession, may be asked to return to work. They strongly encourage doctors to respond positively to such requests.

“Doctors need to feel confident that they are working within agreed standards and principles of practice, and will not be subject to criticism because of the difficult decisions they are forced to make, or the standards of care provided during a pandemic,” it says.

The GMC guidance goes on to explicitly state that: “In an emergency, wherever it arises, you must offer assistance, taking account of your own safety, your competence, and the availability of other options for care. In a pandemic, this means that you may work outside your normal field of practice, either in providing care to patients with influenza, or patients with other conditions.”

However the Nursing and Midwifery Council have taken a contrary view, which is encapsulated in the cliched phrase: “We’re not happy”. In their website guidance on swine flu, modified earlier this month, they write that: “All nurses and midwives are expected to practise within their competency level…If faced with any aspect of practice that is either outside their area of registration or beyond their competency level, they must seek supervision or advice from a competent practitioner…Nurses and midwives are able to extend their scope of practice, within the healthcare legal framework, but must ensure that they have the knowledge and skills to do so in a competent manner. If competency levels are not adequate, support and supervision must be sought from a competent practitioner.”

This guidance makes it clear that nurses who are forced by circumstances to work outside their comfort zone cannot expect any support from their regulators if they get into trouble. In the meantime they have written to 90,000 nurses who are out of practice, asking them if they would like to return to work to “address any potential staffing shortages which may occur in the event of a surge in the swine flu pandemic.”

The mixed messages that this is sending out are confusing.

Most nurses I talk to are very aware of the possible clinical problems. If the brown stuff started to hit the fan then they would do what seemed most appropriate at the time. As individuals they would want to do their level best and do what needed to be done. The disconnection between the nurses on the ground and their regulators needs to be explained.

To me this issue highlights a major cultural difference between doctors and nurses and their attitude to risk and diversity.

Read MPS advice on swine flu practice.

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WTD compliance exists on paper but not in reality

By Richard Marks, Remedy's head of policy - 9th September 2009 7:46 pm

So, what a surprise. The Remedy survey of the first month of the WTD showed that many of the trusts that were compliant on paper were not compliant in real life.

Three reasons stood out for this. One was the widespread gaps and vacancies, which have encouraged and even required moonlighting and extra shifts. Secondly, there has been the effects on training, which mostly happens during the day. And, thirdly, there has been the dogged professionalism and committment to their jobs which baffles some of the bean-counters in Whitehall.

Many of the politicians hark back to a time during the last century, when doctors worked hundreds of hours a week. They use this as a pious justification of the new regime, invoking such arguments as “patients should not be treated by tired doctors”. They ignore the inconvenient fact that patients sometimes get ill at night.

The problems we have identified have been recognised for some time. Last year a pilot in Galway published in Surgeon showed that SHOs on a supposedly WTD-compliant rota ended up working more hours than they were rostered for, and they failed to comply with the regulations. The SHOs also noticed a deterioration in the quantity or quality of training, and 81% of them felt that patient care deteriorated.

The Royal College of Physicians also expressed concern. A survey carried out by them in February 2009 showed that two thirds of WTD compliant rotas for medical SpRs reported major problems, and that respondents reported significant reductions in the quality of patient care and in training. They also commented on the problems with locum cover. But, strangely, both of these studies showed an increase in the quality of life for doctors.

So why are the respondents so unhappy?

Medicine is not a normal job. Every sixth former is warned when they apply to medical school that medicine is a vocation, and that it demands a lifetime of commitment. Those that accept this particular gauntlet do so on the understanding that they will be treated by society as experts in their field. And here is where we have come unstuck. The WTD was intended to protect factory workers from exploitation. Was it ever intended to cover professionals?

Remedy believes that the WTD was always going to be bad for training and bad for health care, and should have been opposed more vigorously by the politicians. We put out a plan, the Barbados plan, which relied on doctors taking the voluntary opt-out. There is an element of sour grapes in our call.

We now get frequent emails from members who tell us that they are working longer hours than they should be, and are not being adequately paid. This is the worst possible position, and one may have been cynically exploited. 

When the reduction in junior doctors hours was first proposed then it immediately raised the question of who would do the work that had previously been done by junior doctors? Would it be consultants? Would it be a sub-consultant or a staff grade, or an new-fangled rebadged middle-grade doctor? Or would it be nurses and nurse practitioners? As the years ticked away the answers to these questions remained unknown, and the career and manpower planning that was needed to implement one of these solutions fell by the wayside.

We now need an urgent answer to that question. Because the Remedy survey suggests that the work previously done by junior doctors is now being done by unpaid junior doctors.

Read the Remedy WTD survey in full. 

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Remedy need your views on the WTD now

By Richard Marks, head of policy - 28th August 2009 10:03 am

How has the Working Time Directive affected you? Has your work-life balance improved? Has your training improved or got worse?

Remedy is trying to find out how the first month of the directive has worked out across the country, and would appreciate your feedback. Please respond before 30 August to the Remedy Survey. 

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Why haven’t we planned training after the WTD?

By Richard Marks, head of policy - 18th August 2009 10:45 am

The WTD was a long time coming. Together with MMC it is completely changing the lives and working patterns of junior doctors. Yet, as 1 August implementation date recedes into the past, we still feel strangely unprepared.

Meeting after meeting about the WTD ended with shaking of heads and shrugged shoulders. How can we provide a service to patients under these conditions? How can we train doctors in such a short period?

The answers to both of these questions are fairly simple and are interlinked. It would be easy to provide training under the new regime if only there were no requirement to provide service. And it would be easy to provide service if there were no requirement to train.

At this point in the argument someone invariably points out that service and training are inextricably linked. Well, to a point. Most specialties now have introduced the concept of a curriculum; a series of clinical cases and experiences that the doctor-in-training needs to see and gain experience of. But the curriculum does not mirror service requirements.

For example, a surgeon-in-training may need to do ten cases of operation X and ten cases of operation Y to satisfy the curriculum. But operation X may be twice as common as operation Y, and he may end up doing too many of these cases. I think it becomes helpful to talk of intra-curricular training and extra-curricular training to distinguish the two situations.

So, we could devise schemes whereby trainees would only spend time getting the experiences that were necessary for the curriculum. This would allow us to reduce their hours-in-training considerably.

Who, then, would do the work necessary to run the service? Would this work fall to staff grades, consultants, sub-consultants or nurses? Would hospitals that cannot deliver the relevant parts of the curriculum still get trainees?

Questions like this provoke apoplexy amongst junior and senior doctors and to the various groups and corporate bodies across medicine, and discussions hit a brick wall. None of these options are remotely palatable to large parts of the profession, and none of the groundwork has been done to enable any of these to take place.

But until the question of the extra-curricular work has been addressed then there can be no progress. So the question I am left puzzling over is why we find ourselves ten years down the line unable to solve this dilemma.

Is it because nobody in medicine has the leadership or authority to reach a decision? Is it because none of these alternatives are acceptable and we all have our heads buried in the sand?

Something is going to have to give way soon. We cannot spend the next ten years playing a game of chicken.

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A strange way to introduce a WTD opt-out

By Matt Jameson Evans, co-chair of Remedy - 12th August 2009 11:46 am

A couple of days before the changeover and in the midst of a media frenzy about WTD a page appeared on NHS Employers website. It outlines the use of the individual opt-out for doctors - with a sample agreement for anyone to download.

Anyone familiar with Remedy’s campaign on the opt-out might think we would be breaking out the Prosecco after two long years of sidestepping on the issue by the Department of Health. Over 300 million quid has been spent on finding solutions to the 48 hour week in the last year, but the only one that was free, legal and required no resources other some active promotion was repeatedly brushed under the political carpet.

Yet the Prosecco remains under lock and key in the Remedy drinks cabinet. The only way the individual opt-out can work is if the nettle is grasped and implementation is coordinated properly.

The opt-out fails if it is used coercively by trusts or consultants. Without direction and a rigid set of rules ensuring real freedom of choice (a choice we know about two thirds of doctors want) it is also illegal.

A short opt-out session should have been included in every August induction this year outlining and delivering free choice. Instead it appears like a raspberry in the face of common sense, on a website few doctors ever visit, with no guidelines for employers on how to mix a 56 and 48 hour week rota and with a big question mark on what exactly the individual doctors are supposed to do with it.

Remedy is conducting a survey on how many doctors were offered an opt-out at the beginning of August. Please follow the results in the coming weeks.

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