Consent Concerns
On May 19, the Health Service Journal reported that the Care Quality Commission and NHS England have written to the General Medical Council stating that the current system for securing patient consent for treatment is open to abuse. Allegations are being investigated that some doctors have retrospectively altered consent forms to cover up mistakes, and although patients should routinely be given copies of their completed consent forms, many of them aren’t. The GMC will doubtless look into this as a matter of urgency (i.e. within the next decade). The issue is not just whether forms are filled correctly, copied to patients or retrospectively altered, but whether doctors have time to properly gain the consent of patients in an over-burdened NHS. Improper consent was central to the Bristol cardiac disaster, which the Eye exposed in 1992. The results for complex child heart surgery were demonstrably worse in Bristol than at other units at that time, but there was no defined minimal standards forcing them to stop. The surgeons were only found guilty of serious professional misconduct because they had deceived parents in the process of consent, by quoting national average success rates for operations, rather than their own, far worse, figures.
MD has also exposed wide variation in consent procedures for prosthetic hips (Eyes passim). Patients should be told at consent for a newly produced hip or indeed any hip that has been modified (however slightly), that there is no outcome data to support their use in real life (rather than lab tests), and they should be offered a tested alternative approved by NICE. As one patient told MD: ‘One surgeon recommended a metal-on-metal hip. I asked him what the alternatives were but he said this one was the best and newest, and was much less likely to wear out, whatever I did. I didn’t fancy something new that hadn’t been used in humans before, so I asked for another opinion. The second surgeon recommended a very old fashioned Exeter hip. He said I shouldn’t go anywhere near a metal-on-metal hip. He said the potential risks were far too high and I didn’t need to take them at my age. He said I needed a tried and tested hip with great results that was just right for a man of sixty-eight. My new hip works a treat and I was so relieved when I read about all the metal hips that have failed. How can two surgeons a few miles apart give you such different opinions?’
The catastrophic failure of hip prostheses such as the ASR has led to mass litigation and misery, much of which might have been prevented if patients had been given proper informed consent and the choice of a proven alternative hip. For three years, MD has been trying to discover whether the parents of disabled children at Alder Hey hospital undergoing routine surgery for stomach acid reflux have been properly consented. One surgeon undertakes an outdated procedure that involves cutting the vagus nerve and performing a pyloroplasty. This is not recommended by NICE nor international experts in the field, exposes the children to significant risks and has been at the centre of whistleblowing concerns raised by two experienced paediatric surgeons who worked at the trust. The GMC, CQC and NHS England are all aware of these concerns, particularly the lack of hard data to support the operation and questions as to whether parents have been made aware of this. On 24.10.14, Sir Bruce Keogh, Medical Director of NHS England, wrote to MD to say that he had asked Professor Mike Richards, chief inspector of hospitals at the CQC to investigate. Professor Richards assures MD the CQC are taking the matter ‘very seriously’ and have gone back to the hospital to ask for more information. In the NHS, ‘consent’ is rushed through in minutes, but investigating serious problems with consent can take years. In the meantime, read your consent forms carefully, insist on a copy, and ask about the benefits and risks of operating, and the evidence behind them. Watchful waiting is sometimes better than surgery.
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Following MD’s advice that terminally ill patients should be seen at least every two weeks by a doctor to avoid any problems when registering the death, several GPs have written to point out that they are not obliged to visit a terminally ill patient every 2 weeks, and that if a patient dies having not been seen by a doctor in that time it can usually be sorted out by a phone conversation with the coroner, without needing a post mortem. This is indeed usually the case, although not always, as the experience of several Eye readers testifies. MD has just experienced superb NHS end of life care for a relative who died in Sherston, Wiltshire – compassionate, collaborative and competent. Thank you.
MD’s book, Staying Alive – How to get the Best rom the NHS – is available here