Rate my as a doctor, but don’t blame me for a service in crisis

Health secretary Jeremy Hunt’s plan to name and shame GPs who fail to spot cancer by placing a red flag next to their practice on the NHS website has been rightly slammed. However, MD is strongly in favour of patients and relatives rating their NHS care, and encourages his to do so. There is good evidence that people who have a good experience of NHS care, and feel listened to and included in decisions about their care, get better results. Putting this information in the public domain provides important feedback to the NHS and individual staff, and guides patients where to go to find kind, competent care.

Publishing patient experience information in real time, as many hospitals are starting to do, is a good smoke alarm to step in and stop poor care before too much harm is done, and a great was of praising excellent care. Some sites such as Patient Opinion allow you to have a conversation with a willing GP practice or hospital and try and sort out problems. In some instances, this has happened commendably quickly. On the website MD uses, every word a patient or carer writes is published unedited. Doctors aren’t in the business of always giving patients what they want, and occasional patients are vexatious. But the overwhelming majority provide honest feedback on their experience of care and what could be done to improve it. If all the NHS did was listen and act on this feedback, it would improve the service far more than any political reform.

One problem with Hunt’s plan is that politicians and NHS bureaucrats are simply not trusted to provide accurate fair ratings in the same way patients are. Wrongly flagging up a practice as providing substandard cancer diagnosis could have serious psychological and legal consequences. And for the few doctors who are making fundamental errors that would fail your medical finals, a regulator should have stepped in to support and retrain them long before a red flag appears on a website.

The main reason MD gets such positive ratings in the care of young people with chronic fatigue syndrome, is that I have 90 minute consultations. Difficult diagnoses cannot be done in 10 minutes. GPs are under ridiculous pressure to manage demand and be competent in ridiculously short consultations, and patients are having to wait dangerously long times for specialist referrals, and increasingly having the referral refused. Young people with serious mental health problems are currently being denied access to the specialist care they need. Some Child and Adolescent Mental Health Services (CAMHS) are in meltdown, many staff have gone off sick and those that remain have to ‘choose’ between a child who has been self-harming for a year and a child who has been self-harming for a week. The latter may respond best to treatment, the former will be absolutely desperate. The one who doesn’t get seen gets bounced back to the GP, who has to pick up the pieces.

One of the reasons I stopped general practice is I just don’t find it safe. There is huge pressure not to refer because of the financial difficulties of the NHS, and an increasing number of referrals are refused. So to be publicly outed for not investigating sooner could lead to a huge increase in hospital referrals, and yet more refusals. One in three patients will at some stage get cancer, just as one in three will get diabetes, one in three will die with dementia and 1 in 4 currently have a mental health problem. There are all sorts of delays in the diagnoses of many of these diseases, but no evidence that blaming GPs on the brink of a breakdown will improve the care that patients get. On the IWGC website, the vast majority of ratings for NHS staff are very positive. Some staff dislike the idea of a commercial organisation collecting and publishing this information, others feel it is more likely to be accurate than letting the NHS do it, with its history of IT errors, gaming and cover-ups. I certainly wouldn’t trust any data Jeremy Hunt fed to the Daily Mail. For transparency and accountability to work in the NHS, staff have to believe in it.

Cardiac surgeons have put outcome data in the public domain for years. Surgeon Ben Bridgwater’s University Hospital of South Manchester web page shows his photo, his qualifications, his CV, his cardiac surgery and activity results, the national results for cardiac surgery, advice on how to interpret the graphs, what patients think about him, and how this patient experience information is measured. In specialties when there are clear outcomes and fair comparative measures, others should follow suit. General practice is murkier because it’s about managing uncertainty under pressure, and trying to have a sense of what might be the more serious diagnosis that needs urgent referral amongst the day’s 50 consultations. The NICE website publishes clear criteria about which symptoms and signs should qualify for an urgent two week cancer referral. The Macmillan website clearly describes suspected cancer symptoms. Diagnosis is an imperfect science, and 15% turn out not to be wrong. Patients should ask ‘What else could it be? How would I know? And what should I do if symptoms don’t improve or persist?’ If you get another opinion, you might be very surprised how different it is. And far more useful than waiting two years for a red flag to appear on the website.

Inquiring into the GMC

Jeremy Hunt has rightly ordered an inquiry into NHS whistleblowing, to be chaired by Robert Francis QC. He cannot hope to fulfil his promise of no more health service cover-ups without understanding why and how the numerous cover-ups in the past have happened. And this inquiry must reach every level of the NHS, to show how high up the chain the denial, incompetence, amnesia and wilful blindness has gone. MD has long since given up on the General Medical Council as having any meaningful role in calling doctors to account or protecting patients from avoidable harm. The Eye reported Dr David Elliman, a consultant paediatrician at Great Ormond Street to the GMC on September 30, 2011, alleging that he failed to act appropriately on whistleblowing concerns that might have prevented the death of Baby Peter Connelley. The GMC is still investigating. And the GMC is still pondering its initial decision not to hold an inquiry into the conduct of Dr Barbara Hakin, now deputy CEO of NHS England, in not responding appropriately to the patient safety concerns of whistleblower Gary Walker (Eyes passim). This referral is now two years old.

The overwhelming impression is that the GMC delays difficult cases so long in the hope complainants will withdraw their complaints. This is certainly the experience of Dr Peter Wilmshurst, the Godfather of NHS whistleblowers (see Shoot the Messenger ), who has dedicated his life to holding those who lie about the results of medical research to account. ‘I have two cases before the GMC and five that the GMC recently refused to act upon. The Assistant Registrar has audited the five cases and found that in 2, the GMC’s handling of the cases was materially flawed and in the remaining 3 it may have been materially flawed, but the GMC decided not to look further into those 3 cases. In those 5 cases, which the GMC will not reopen, the Assistant Registrar decided that the decisions of the Case Examiners (to dismiss the cases) was wrong and the wrong decisions were because of incorrect advice from the GMC’s expert, a medical qualified professor of law and medical ethics. The Assistant Registrar said that the GMC’s expert failed to consider some allegations in those cases, and with respect to allegations that he did consider the advice of the GMC’s expert was ambiguous and contradictory and the Assistant Registrar says that the GMC cannot understand some aspects of the advice from their own expert.’

‘With respect to the two ongoing cases, one follows complaints that I made in 2008 which the GMC has tried repeatedly to get out of dealing with. The latest stunt has been to threaten me with a High Court hearing unless I comply fully with the GMC’s disclosure requests. Initially the GMC’s lawyers asked me to disclose legally privileged court documents and had I done so I would have broken the law. The GMC’s lawyers must have known that they were asking me to break the law. I had to engage a lawyer to bat that off. Next they asked me to disclose the medical records of over 400 patients and witnesses in the case. The GMC has the right to those documents but does not have the right to ask me for them. I would be in trouble had I disclosed them.

I informed the GMC’s lawyers of the fact that they should have known that they are entitled to have the records but must apply though the relevant hospital medical records department for the documents. In the 15 months since I told the GMC this, they have made no attempt to get the records. I believe that again the GMC was wasting my time and attempting to get me to do something wrong. However the GMC subsequently asked me to disclose other documents, which I have been compelled to disclose. Those are over 6,000 documents, consisting of over 34,000 pages that I have spent many hundreds of hours copying and emailing to the GMC. Had I refused to do so the GMC threatened me with a High Court hearing and said that they would drop the charges against the dishonest doctor that I had reported. He has previously appeared before the GMC for other offences of dishonesty that were found proved.

GMC disclosures are not covered by the Legal Procedures Rules, which apply to maintaining confidentiality of disclosed documents in court proceedings. Those given disclosed documents by the GMC (i.e the charged doctor) can do what they wish with the disclosed documents and those documents that I disclosed include patient information, which will be given to a doctor that has a record of dishonesty and research misconduct. The GMC will give no reassurance about their confidentiality.

The other on-going case involves complaints from another and me about a medical member of the GMC Council. We specifically allege that the doctor silenced and detrimentally treated whistleblowers, including those who raised concerns about Mid-Staffs. I best say no more at this stage, except that once again the GMC is trying to bog me down with an unreasonable disclosure request.’

If someone as ethical, knowledgeable and determined at Wilmshurst struggles to get any form of timely accountability from the GMC, it shows how pointless and soul-destroying the exercise can be for patients and carers. A further kick in the teeth for Wilmshurst emerged when surgeon Anjan Kumar Banerjee was awarded an MBE in the Queen’s Birthday Honours List for ‘services to patient safety.’

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Wilmshurst reported Banerjee to the GMC twice. On the first occasion he was suspended from the Medical Register for falsifying medical research and on the second occasion he was erased from the Medical Register for “lack of probity” (he defrauded patients and medical insurers) and for “substandard medical practice”, which involved him performing inappropriate operations, particularly on private patients. Amongst the GMC’s determinations was that he lied to patients with cancer about the length of NHS waiting lists to induce them to go privately. He was struck off the Medical Register for 6 years, then allowed back on.

Banerjee was made a Fellow of the Royal College of Physicians in Edinburgh for the first time when he was awaiting his GMC hearing, at which time he was suspended from his hospital, under investigation by the police because of his financial misconduct and under investigation by the Royal College of Surgeons because of concerns about his clinical skill. Despite the fact that he is a surgeon and not a physician, he was re-elected to the RCP Edinburgh after returning to the Register. He has also been elected to Fellowships of the Royal College of Surgeons in Glasgow and Royal College of Surgeons in Edinburgh since going back on the Medical Register. The Royal College of Surgeon in England withdrew his Fellowship in England after the GMC adjudications, allegedly because they were so angry that he had presented false data during his Hunterian Professorship lecture (the most prestigious lectures of that College). Banerjee continues to claim the Master of Surgery qualification from the University of London even though the investigation by Professor Michael Farthing for the University showed that the data used for the thesis that was submitted for that degree was also false. Banerjee is now apparently also on the Board of Examiner for the Faculty of Pharmaceutical Medicine of the Royal College of Physicians.

As Wilmshurst puts it: ‘I am in favour of rehabilitation of offenders, but I found the speed of Banerjee’s rehabilitation surprising. If you add to this the fact that the GMC also found a professor guilty of serious professional misconduct for his involvement in research misconduct and he was then invited to  give a prestigious named lecture at the Royal College of Physicians in April this year,  and the fact that a gynaecologist was given a Silver Clinical Excellence Award by the Advisory Committee on Clinical Excellence Awards only 18 months after being placed on the Sex Offenders Register, I cannot help asking whether the rewards in medicine are going to the wrong doctors.’