Don’t Look Back in Anger
Friday 2 February 2018
It’s been a curious topsy-turvy sort of fortnight, not least when I found myself driving to work last Friday and nodding in appreciation at what Jeremy Hunt was saying on the Today programme. I’ll expand a little more on that bombshell later, but it felt that for a brief moment that the whole of the medical profession, commentators, Jezza and politicians of every hue could unite on a health story. It was just desperately sad that what united them was a human tragedy for a family, the professional standing of a junior colleague at the very sharpest of sharp ends, and what many viewed as the damaging and over-reaching actions of the General Medical Council.
Last week saw me at the Council offices on Monday for Chairs and Chief Exec’s meetings, and on Tuesday I had to rush from the surgery to our evening confederation meeting. A letter arrived a few days later telling me that on the way there I’d secured a £60 fine for ‘contravening a bus gate order for prohibition of driving in a bus lane’ in Bathpool. Huh? There were fewer of us at the racecourse than expected, but we had a cosy informal chat about everything, having done passable justice to the huge vat of chicken curry. After four portions the synapses were starting to wilt. This Monday, I went with one of the practice managers to the NHS Somerset offices to negotiate further tweaks to the SPQS specification for 2018/19, and we’ve also been discussing with the CCG the ‘Improved Access’ scheme for this year. Practices should be receiving letters about both schemes shortly. We’ve also had the quarterly South West Regional LMCs meeting, where we get to hear of the situation around the patch (bottom line: overall, we’re doing ok in Somerset), and on Wednesday, we gathered at Monks Yard for the first of three facilitated development sessions for the Somerset GP Board.
This is going to be critical work as we try to get our heads around what it means to work for the board, rather than in our other roles, be they LMC, SPH, CCG or a GP associate director at a trust. We’ll all need a culture shift, and there’s a sense we need something solid to get our teeth into, to give us some purpose and direction. We intend that the SGPB should play an integral and central part in the upcoming Clinical Services Review, and work to develop the ‘at scale’ collaborative agenda.
February isn’t a month I particularly look forward to (apart, obviously and emphatically, from Mrs Chair’s birthday). It means my appraisal is looming, and I’ll already be a month late, as I always am, sending expenses stuff to the accountant. This is my last revalidation appraisal, and I’ve only got one, or possibly two appraisals left in my career after this, so I still need to make some sort of effort. I’ve done all the requisite patient and colleague surveys (cheques in the post), listed as much of my learning and reflections as my tattered wits allow, and have now reached the stage where I need to push the ‘fin’ button before I write something that I’ll regret. It’s a pretty crap time of year to have to unveil what’s really going through your head. As Mr Gallagher says: “Slip inside the eye of your mind, don't you know you might find a better place to play?”
What to put in my PDP for next year? It’s well known amongst my colleagues that I don’t do feet. They generate an irrational, disproportionate response, for which I had a couple of theories. In anatomy, we’d started at the top, and although I can still name all the branches of the internal carotid artery, and describe the course of the lingual nerve in intimate detail, my enthusiasm, attendance, or both, must have waned somewhere around the knee, and the tarsus has remained a mystery for the whole of my career. I’m also aware of my reaction to the distant and distinctive creak of the Zimmer edging towards my room, accompanied by Mrs Wobble, who I’ve done my damnedest to keep alive, upright and mobile over the past 30 years. I’ve bunged the pharmacopeia at her every system, and here she is now to tell me about her painful feet. Anyway- it turns out that I was wrong. One of our long-retired nurses recently jemmied open one of my temporal lobes, reminding me of the time she’d asked me to help remove the shoes of a reclusive elderly gent, which had remained in situ for at least 15 years, and become welded to his feet. There was much heaving and chiselling, and then more, but different, heaving. Is it too late in my career to add ‘feet’ to my PDP for next year? Assuredly, yes.
My podiaphobic PDP was also looking a bit paediapenic, so I’d booked myself onto an SGPET Q and A session last week with Claire Salter, one of the bright young paediatric registrars who does Primary care clinics in the West Somerset area. The meeting was at the Carew Arms in Crowcombe, but it wasn’t my first learning experience there.
Unlike Eton, where standing in the school is largely determined by the gilding and cut of your waistcoat, corridor kudos in my era at Kings (Taunton) was gained by the louche supping of milk from a pint bottle, marking you out as a member of the first rugby or cross-country teams. The runners had to re-qualify every week for their free pinta by coming in the first eight home in the weekly ‘milk runs’. Our coach was a sado-comedian, and twice a term we’d be bussed out to Crowcombe Court, then a boys’ boarding school, for a ‘milk run’ up Crowcombe Hill to the cattle grid, circuit training at the top, and then back to the school for tea. One spring day in 1976, perhaps anticipating a significant attrition rate on the hill, Kings sent only a couple of cars to pick the survivors up. Those of us left behind were told to wait at the Carew Arms, their school being understandably keen to get us off the premises. It was my first time in a pub without an adult, and my learning points were: a) Strangers buying alcohol for penniless teenagers in shorts was acceptable in the 70’s, b) Colt-45 Malt Liquor was stunningly horrid, and c) the coach had meant us to wait outside the pub (‘obviously, Bray’).
42 years later and I’m back for more learning. It was good to catch up with old friends and meet colleagues from a different bit of the county, and we heard from Claire just how hectic Musgrove had been for all departments over the past few weeks. We discussed lots of hot topics, including the lack of health visitors, psychiatric and feeding problems, and Claire provided a useful list of on-line resources. Learning points from my second evening at the Carew Arms included that tachycardia is not to be ignored, the GPs in West Somerset give parenteral antibiotics more often than we do (understandably given their remoteness), and that Dr Salter probably doesn’t take too many prisoners on the hockey pitch.
I know that a very nice lady from the GMC will peruse this blog; she’s ‘liked’ it in the past, although at the time I questioned whether she was tagging it for further action. In the first 1000 words I’ve admitted to a motoring offence, gluttony, under-age drinking, hinted at bribery and admitted my aversion to feet (although my appraiser will shortly be reading in my CPD log about ankle replacements, Achilles tendon rupture, Charcot feet and Lisfranc fracture-dislocations, as well as quite a lot north of the ankle). But what about the stuff that happens in the consulting room- the difficult and dysfunctional consultations, my near-misses and mistakes which I will undoubtedly make? How happy am I to put these in any e-learning portfolio, or bare all in my appraisal documentation after the events of last week?
Another paediatric registrar, Dr Hadiza Bawa-Garba, made headlines last week, her name having become synonymous with a tragic case where multiple failings across the whole system contributed to the death of a 6-year-old with Downs syndrome, Jack Adcock. Accounts of what happened, and the catalogue of errors that day, make for horrific reading, and yet I bet most of us will have found ourselves, or known of friends, in situations very similar to those described at some stage in our careers. Disasters of any sort rarely have a single cause, and it would be hard to imagine a more toxic combination of factors than meshed together here. We’ve just been more fortunate than Dr Bawa-Garba, and the consensus of most medics, at least, is that she’s been hung out to dry and is paying the price for the failings of the system.
Much of the anger was directed at the GMC, who had appealed the decision of the Medical Practitioner Tribunal Service to suspend her for 12 months. They won that appeal last week, and she was struck off the register. She had previously been convicted of manslaughter in 2015 and given a two-year suspended sentence. It had been reported that evidence from her reflective e-journal had been used against her, although the MPS subsequently denied this. What was used, however, was evidence from her consultant following ‘reflective discussions’ between them when they reviewed the case afterwards. This will clearly risk doctors being less willing to admit to mistakes, or to discuss them openly, a point recognised and clearly stated by Mr Hunt in that radio interview.
The media were quick to point out the gap between the reaction of medics on social media, aghast at what they saw as the unfairness of the situation, and the patient groups, accusing medics of wanting to cover each other’s backs. The situation is even more complicated than that. Legal opinion is that the confounding factors would have been taken into account at the manslaughter trial, and once the verdict there was guilty- implying that the factors were insufficient to significantly affect her actions, there was no way that a ‘tribunal’, could rule them back into consideration- in other words, she had to be struck off once that verdict was returned. But what does that say about the role of a jury trial here? How could they understand the complexities of the horror-show that unfolded that day? Some commentators have also raised the race card, and the police have this week been asked to consider corporate manslaughter charges against the hospital Trust.
The personal tragedies remain, however, and whilst the name ‘Bawa-Garba’ attracts the headlines, the real victims in all this are Jack and his family. Given the carnage of the past month or so, there will never be a better time than now to highlight just how dangerous a seriously under-resourced service can become, and doctors have to be free to speak out if a system is unsafe, and reflect openly should mistakes occur.
I’m looking back, and I’m angry.