Abstract
‘Trust me I’m a doctor’, ‘your life in their hands’ – are you worried about getting the best treatment? Would you also be worried if you were a young bright student considering entering the long and arduous training into the medical profession? The Gosport Scandal, too much of the wrong medicine to the wrong people at the wrong time? The Bawa-Garba case, was it negligence or overwork of a dedicated young doctor? Two publicised cases, but actually there are many and the problems have been going on for a long time.
Can members of the medical profession be incompetent, negligent or wilfully do the wrong thing? Yes they are human beings, but actually the entry requirements and the long training time, much of it carefully observed, does mean that most are committed to doing their best; nonetheless it can happen. It is not for an editorial to try to determine who is right and who is wrong in particular cases. However, we can look at some of the factors that can cloud matters. Firstly the doctor, or indeed anybody, who thinks they cannot make a mistake is actually dangerous. Being able to change a plan when the indications arise is essential. Probably, everybody agrees that at the present time there is understaffing and considerable time pressures. ‘Routine’ thinking is quicker and easier and there is also quite considerable official pressure for ‘tick box’ approaches. Whilst this may work for a significant proportion of the problems to be dealt with, more uncommon problems and presentations are likely to get overlooked at least at first. There is also a dilemma: if there is insufficient time to give adequate attention to all admitted patients, do you give insufficient time to everyone or prioritise perhaps younger patients who have also conditions from which they are more likely to recover if treated properly. A different safety factor is having time to talk with colleagues. This gives a sort of internal monitoring and feedback on technique and methodology. Time pressures reduce this and there is also to some extent growing ethos of it not being appropriate.
Doctor–patient relationship and trust is all important but there are now pressures both from healthcare management and from the media. The latter unfortunately does not find value in reporting cases or services going really well and seeks to evoke horror in their audience. For many cases, reporting is such that the public does not really know what happened. The reader may wish to look again at the figures for Gosport. It is quite possible that some were treated inappropriately and could with better management have survived, to walk from the hospital. However, the implication that hundreds who died in the given period of time all fell within that category is likely to be misleading dramatisation. Management are also under great pressure, particularly to show that lack of time and resources, monitored by themselves, was not the cause of something going wrong. For both of these we are back once more to the ‘blame culture’. Even without the blame culture doctors are under huge pressure to do as much as they can with the staff and time available and still adhere to the Hippocratic oath which includes ‘premum non nocere’ – first do no harm. The GMC itself recognises the difficult issues and in March 2018 wrote publicly about the Bawa-Garba case: we are listening to what you’re saying about this case and we are in no doubt about the strength and depth of feeling that is being expressed. We are sorry that it has had such a significant impact on the profession and that as a result many of you are feeling upset and unsure about your practice and the environments in which you work. But that was never our intention and we know that we have a huge amount to do to rebuild the trust that we have lost.
Therefore, the tasks are how to maintain the confidence of properly trained doctors and nurses who do their best, but something goes wrong. How do we ensure clear monitoring of services to correctly identify malpractice at an early point and how do we clarify the distinction between these two?
Rather than enhance a ‘we and them’ climate we feel that it may be far better to invite those involved to look at the problems and see what solutions would help them. Possibly, the first answer would be more money in the NHS, and the NHS to publicly accept the responsibility for the effects of gross underfunding. The second may be for there to be less money spent/wasted on nonclinical management issues. Sadly, it is unlikely that either of these will happen. Hence thirdly, we would urge those involved, doctors, nurses and even lawyers, to suggest ways, that are practical and economic, in which medical staff can be supported and monitored in their practice so that even if they have fallen into unsafe ways because of the pressure on them, they can be helped to move back to what is safe. Could we for example prevent the professional isolation reported in the Bawa-Garba case?
We would therefore invite any healthcare or legal professionals to participate in a problem-solving debate by writing to the Medico-Legal Journal with papers or letters that contain constructive data and ideas rather than continually look fearfully over their shoulders.