Letter

Competence, not crime, is the real issue

Dear healthmatters—Your editorial in issue 39 was perplexing. Is Dr Shipman’s criminal behaviour really an appropriate stick with which to beat the whole medical profession in a drive to impose a more uniformly high standard of care? Dr. Shipman’s patients and colleagues generally held him in high esteem, and as far as I am aware there never was any question of Shipman’s clinical competence, rather the opposite. The deaths of his patients were not the result of errors but of deliberate killing for motives as yet unclear.

Could his patients have been protected by more regulation? None of the current performance monitoring schemes is likely to have led to early detection.

Later you advocate that NHS management should ensure (sic) positive engagement of practitioners in quality improvement locally. How will that motivate clinicians in an atmosphere where the central NHS administration, including ministers, has so little trust in them? You rightly point out that failure to conform to current management directives does not necessarily lead to malpractice, but in the same sentence you refer to professional lobbies interested in promoting conflict – what is the link?

The issues you raise are nevertheless important.

• The public desires humane and skilled doctors who can communicate with their patients, and accountability as protection from malpractice. Are these goals not being achieved because there is at present insufficient regulatory bureaucracy in the NHS? Is reducing clinicians’ autonomy in their interactions with patients – by imposing frequent appraisal and revalidation – the ideal way to improve the competence of practitioners? If so, is this not a proposition which needs to be put to the test? How does one encourage genuine whistleblowers while distinguishing them from colleagues who bear a grudge? With revalidation, how can one be certain that what it is possible to audit constitutes what it is essential to monitor? Who will carry it out? How much of the extra money going in to the NHS is this process going to consume?
• How does one motivate professionals, and what action can be taken to protect the public against those whose psychological morbidity interferes with their work, or whose motivation has lapsed? You refer to high levels of psychological morbidity in the medical profession, presumably increased alcohol and drug abuse, suicide, etc. Unless we assume that people with psychological problems are attracted to a career in medicine, this must be the result of the experience of being a doctor and rank alongside the numbers giving up in their early years or taking increasingly early retirement. These issues should be tackled in a preventative rather than punitive manner by looking at workload, stress, and ‘ownership’ of one’s professional activity, which all impact on motivation and job satisfaction.
• Should the balance of professional activity change with seniority, so that in specialties with high stress levels or where new techniques are frequently introduced, those who cannot retrain can concentrate on doing those things they remain experts at?

British doctors used to be renowned internationally for their high level of professional idealism. Alas, morale has now fallen so low as to constitute a crisis. The medical profession’s bad press and the attitude of the present and previous governments in labelling doctors as a reactionary, self-interested, high-spending group of civil servants who have to be thoroughly regulated is unlikely to be restorative. Your editorial does little to contribute to solutions.