I am writing this after spending last night as Consultant “on-call from home” as a resident shift. Due to a general sense of fear amongst the juniors and a relatively junior registrar, by midnight I figured it would be easier to just stay and hold the necessary hands. I did very little other than make coffee and listened to them make excellent medical decisions in the best interests of all the patients that came through - I suspect a cardboard cut-out and a coffee pot could have done an equally good job, but if it got morale heading back in the right direction, so be it.
I say this, because you are receiving caffeine-fuelled, sleep-deprived thoughts - and apologies for my grammar in advance.
Before I go on, I will start by saying that overall the case of the GMC vs Dr Hadiza Bawa-Gara is, at best, a distortion of justice that I have seen variably described as a travesty through to a full-blown miscarriage. It has also knocked back relationships between doctors of all grades and the GMC, to a point where we have juniors cancelling their direct debit to maintain their position on the medical register. I recognise that there are multiple issues about the use of reflection, support, scapegoating etc. I also hold robust personal views about why there should never have been a conviction of negligent manslaughter made. I strongly support all of that and I have been quite vocal wherever possible Twitter/Facebook/ Local news etc.
Now here’s the but…
I found myself slightly uneasy that I was 100% agreeing with Jeremy Hunt and the Bow Group – one of the oldest right wing think tanks in the country - on twitter for the first time in my life.
I then tried to see it from the GMC’s point of view, who not only have to answer to us but also to the general public. How would the average parent feel if the doctor looking after their child was the same doctor that had been convicted of negligent manslaughter only 12 months earlier? A part of me can see where they are coming from. Don’t get me wrong, I am a parent and I don’t know Dr Bawa-Garba, although I have it from someone that I trust that used to work with her, that she was great - an exemplary paediatrician - and on that I would confidently let her look after my child. But I suspect I am privileged with this knowledge. The population at large are not.
The GMC started this appeal because Dr Bawa-Garba was convicted of Negligent Manslaughter. This conviction, however, was not made by a jury of her peers, but of the general population; healthcare users who hopefully would never have to endure the pressures placed on Dr Bawa-Garba that night, and the majority of us at some time in our careers. All of the discussion about whether there is a racial or sex discriminatory component to this decision, on the background of other examples where doctors have confessed to and been supported through similar mistakes, leave out that crucial element. The mitigation of service demands, one person doing 3 people’s job in a failing system without appropriate senior support could not be truly appreciated. All of the same issues being raised now were present at the time of conviction: staff shortages, locum junior doctor not familiar with the local IT systems, patient who was recovering before he left the acute area, a system that allows un-prescribed drugs to be given, consultant who had been made aware of patient, treatment plan and was also satisfied with the progress and so on. Yet the outcry at that time was nowhere near as great. Were we distracted by junior contract issues, or was it just that the timing wasn’t right? Had the outcry come at the time of conviction the focus would have been on the short staffing, the under-resourced service, the fragmented IT department and the quashing of the criminal conviction.
Now, the outcry is directed at the GMC and the use of our appraisal documents, creating a bitter divide between doctors and our own regulatory body; a body which technically works for us, with a duty to maintain public safety and the standing of the profession in the community. In that light, we have already failed Dr Bawa-Garba by not speaking up when she was held responsible in the criminal courts for a tragic loss of life, that was multifactorial with more systemic failings than individual negligence. Actually, I am also starting to understand why the GMC took the actions it did.
Please don’t send hate mail, I do not approve of the use of personal reflections as evidence against someone. I do not think Dr Bawa-Garba should have been struck off, and I certainly do not believe that any individual in such circumstances should be held responsible for a loss of life within a system so broken, but before we declare war on ourselves, let's at least know what we’re fighting about.
Our focus now needs to move away from blame and recrimination. Clearly as a profession we need to pull together to encourage, indeed demand, a re-evaluation of the whole case to seek justice for Dr Bawa-Garba and for the parents who tragically lost their son. No amount of finger-pointing will restore the life of this child to his parents and nothing is going to ease their pain. But above all else, they must want to ensure that no other parent experiences their loss. This judgement will not answer the more important questions that may prevent a recurrence.
Was there a culture of fear in that trust at that time that led to the case not being appropriately escalated? Were there appropriate staff in place to cover the needs of the patients? Was it appropriate that a registrar should return from maternity leave to be the duty registrar? Today, many of these contributing factors are being addressed. There is a greater consultant presence in all clinical areas. Exception reporting highlights unsafe practice, with mechanisms in place to address recurrent themes. Doctors should be offered “back to work” programmes after prolonged absence from the wards, whether that be due to maternity leave, long-term sickness or periods out of programme for research and PhDs, although access to this is not yet universal. These systems are not fool-proof but aim to mitigate risk.
The GMC is working to revise the processes that led to a conviction of negligent manslaughter. This is not in any way an attempt to divert attention from their own actions, but what they are duty bound to do in order to protect us as doctors and ensure they are never again put in the position where they have to weigh their responsibilities to the practitioners who they serve against the public interest that they protect.
The BMA is making recommendations to their members regarding flagging up unsafe practices, reporting incidents and being cautious with their reflections, should they be used against the doctor. They have agreed legally binding protections with Health Education England (HEE) safeguarding junior doctors who raise concerns in the workplace from recriminations, one of their greatest successes for any trade union in the country.
There are many issues that still remain to be resolved, and there seems little point in having one of the best “whistle-blowing” policies in the country if there are not the resources to rectify the problems that are highlighted. The GMC has clearly stated that working within an unsafe environment is not an excuse for poor practice. It is unclear what is expected of us should we arrive to a shift where a colleague is off sick; should we continue to work to the best of our ability attempting to stretch ourselves in order to offer some service to everyone, or should we offer an optimal service to a few, turning away the rest? The latter option is alien to the majority of us, however, it appears to be what is being advocated.
Further, we know both from work within the BMA and data from sources such as the National Training Survey that rota gaps are widespread and have a significant impact on patient safety. How can a mandate not to work within unsafe environments align with working within these rotas? Should there be mass resignations, which will in turn further attenuate patient safety? Reflection on difficult cases or situations at work is generally accepted as crucial for patient safety, however, this case has raised real concerns about what should be included. It is essential that Royal Colleges produce clear guidance on this subject, and the BMA is approaching colleges alongside trainee organisations to ensure that this happens as a matter of urgency.
Most importantly we have to stand together as a profession, with the BMA, the GMC, the Royal Colleges and the NHS Employers to make it clear, we will continue to serve our patients to the best of our ability within the constraints that we find ourselves in today’s NHS, because without it many more parents will suffer.
I know I’m rambling now, blame the caffeine - so I’ll shut up.
Looking forward to being shouted down
David Strain is MASC lead for postgraduate training
Very thought provoking piece David. I think that we as a profession and NHS need to reflect on the culture change that needs to occur that means frontline staff need to feel empowered to report unsafe practices. We often learn from an early stage of the profession practices that are ultimately destructive and harmful to ourselves, our profession, the NHS and ultimately our patients.
I wrote about it here:
"Actually, I am also starting to understand why the GMC took the actions it did"
And yet you never really flesh this point out fully.
Dont defend the indefensible
Please see www.crowdjustice.com/.../ for another perspective.
The question is did the GMC really have to push for complete erasure? I think not....: thesoulfuldoctor.co.uk/.../
"...Despite the judge noting and agreeing with the MPT that it is right that the maintenance of public confidence and standards do not mean that “it is necessary to sacrifice the career of an otherwise competent and useful doctor who presents as no danger to the public in order to satisfy a demand for blame and punishment” – this is exactly what has happened! "
The GMC had said several times in the BHG case that it had to do what it did to maintain public confidence in the profession, and in the high standards of the profession. Correct me if i am wrong, but HBGs lawyer in court said public confidence maintenance does not mean pandering to populist opinion but rather the informed balanced, reasonable public’s opinion. How true.
Many of the public have little or no idea of the truth on the shop floor in hospitals or primary care. Take these two articles below as an example:
Expert urges doctors to report themselves to GMC:
I will thus argue, coupled will all the horrors stories we hear in the educated media about the NHS, that public confidence (the informed, reasonable, public that is to say) was already affected due to institutional failures for years!
If you read doctors forum sites like doctors.net.uk,it is replete with threads that working under high risk severely understaffed conditions is rampant and many, many ,drs have witnessed such tragic occurrences themselves or near missus. One may not often hear of these occurrences because all junior drs want a good reference so they don’t often complain and just crack on, but also they know it’s often down to system pressure and not individual failings!
A case in point, in primary care we get given 10 minutes to see patients which involves taking a good history, examine, consider differential diagnosis, advise treatment, counsel on treatment options inc side effects ad alternatives, arrange tests if needed AND document everything so i don’t get sued! You can imagine then that it’s almost as if we are being set up to trip! Furthermore it’s somewhat hypocritical to be taught great and wonderful consultation styles in our training but as soon as we graduate we get ushered into very severely time squeezed consultations where we cannot practice what we preach! Furthermore it’s an insult: we take 10 years to train to be a GP and the system forces us to underperform; we are being treated like monkeys!
Now if you add other stakeholders who call for public confidence in the profession and maintenance of high standards in the profession, how is that possible working in such a system, when the systems itself severely affects and dents public confidence and trust-emphasis on the reasonable and informed public that is?
All the patients i have spoken to about what i have to cram into the 10 minutes are both shocked and appalled, they are just ignorant of the situation, they only know a bit, just like the jury who convicted Dr Garba
Hence we really need to call the system out, instead! The NHS chiefs need to put more money into the ailing health service. For years the general public have being drip fed repeated failings of the NHS but compassion fatigue means that psychologically the public have no energy or will to say or do much to change the NHS for the better by themselves!
Some members of staff reported to my ES that they had smelled alcohol around my room one week. My ES brought it up a few weeks later - all I could think of was that I had seen a patient who reeked of drink on one of those days. ES discusses with TPD and an occupational health referral is done on the advice of HR with the reason for referral box containing: "..he has shared that he used alcohol as a coping strategy for stress in the past.." ... !! Just because I did a reflection over a year ago about coping with stress the bad way, and how I would cope with it the good way in the future... I think this problem is already alive and well in the NHS and is used to devastating effect. I cant help but notice some doctors are silent on the issue.