Thursday, 18 April 2013

The GMC on Francis - not clear

Following up on my synopsis of the implications of the Francis report, here is the GMC's response to the key recommendations relating to medical training:

" 155. The General Medical Council should set out a standard requirement for routine visits to each local
education provider

GMC - We are committed to a thorough and consistent inspection regime and we are addressing all of the issues raised in points a-d of this recommendation in our review of quality assurance in education.

161. Training visits should make an important contribution to the protection of patients.

a. Obtaining information directly from trainees should remain a valuable source of information – but it should not be the only method used.
b. Visits to, and observation of, the actual training environment would enable visitors to detect poor practice from which both patients and trainees should be sheltered.
c. The opportunity can be taken to share and disseminate good practice with trainers and management.
Visits of this nature will encourage the transparency that is so vital to the preservation of minimum standards.

GMC - We agree that visits/inspections are an important tool for assuring high quality training and protection of patients, and they form a major part of our existing quality assurance programme. The education QA review is looking at how we can strengthen the role of visits/inspections and at how we report on them. In the meantime, from the summer of 2013, where we have validated any concern about an educational setting we will publish that information on our website."

I am slightly concerned by the GMC's comments for several reasons. Firstly they have not stated that they will reinstated routine training visits to all local providers as Francis has recommended. Secondly they refer to their 'education QA' in their answer to both key Francis recommendations, as if their review is the ultimate truth and that this may overrule Francis.  Thirdly in their answer to 161, they state that visits form a 'major part' of the current system, this is worrying as it is exactly this system that failed at Stafford and that will fail again unless the GMC comes out of its state of denial.

Perhaps I am just paranoid, maybe, but I am deeply concerned that the GMC is going to ignore the key piece of advice from Francis, that being the reinstatement of routine workplace visits for all providers of medical training.  We need to hold the GMC to account on this, perhaps they will take it all on board and I will be proven to be a paranoid fool, but perhaps not, and if so we need to have anticipated this fact.

Wednesday, 17 April 2013

The Francis report and what it should mean for medical training - part 3

Now to part 3, in parts 1 and 2 I have highlighted Francis' key observations relating to training, that being the failing regulatory system.  The key recommendation is that routine visits to all local providers should be reinstated:

"The General Medical Council should set out a standard requirement for routine visits to each local education provider, and programme in accordance with the following principles:

- The Postgraduate Dean should be responsible for managing the process at the level of the Local Educational Training Board, as part of overall deanery functions.
- The Royal Colleges should be enlisted to support such visits and to provide the relevant specialist expertise
where required.
- There should be lay or patient representation on visits to ensure that patient interests are maintained as the
- Such visits should be informed by all other sources of information and, if relevant, coordinated with the work of the Care Quality Commission and other forms of review."

Francis also makes it clear that the DH must support this process and that the system must take these routine regulatory visits into account:

"- The Department of Health should provide appropriate resources to ensure that an effective programme of monitoring training by visits can be carried out.  All healthcare organisations must be required to release healthcare professionals to support the visits programme. It should also be recognised that the benefits in professional development and dissemination of good practice are of significant value.
- The system for approving and accrediting training placement providers and programmes should be configured to apply the principles set out above."

Francis also mentions that the role of routine visits in terms of patients safety:

"Training visits should make an important contribution to the protection of patients:
- Obtaining information directly from trainees should remain a valuable source of information – but it should not be the only method used.
- Visits to, and observation of, the actual training environment would enable visitors to detect poor practice from which both patients and trainees should be sheltered.
- The opportunity can be taken to share and disseminate good practice with trainers and management.
Visits of this nature will encourage the transparency that is so vital to the preservation of minimum standards."

Francis also adds that LETBS should have a medically qualified postgraduate dean:

"All Local Education and Training Boards should have a post of medically qualified postgraduate dean responsible for all aspects of postgraduate medical education."

Overall Francis' recommendations are good.  Routine regulatory visits have needed reinstating for some time.  It is utterly vital that the Colleges have a prominent role in this new regulatory structure.  The concern I have concerns the role of visits in terms of patients safety.  Of course if trainees mention things relating to concerns for patient safety then there must be mechanisms in place for ensuring that these are dealt with appropriately. However it is important that visits are primarily about training quality and training problems.

It is also vital that those  who are entrusted to take part in these visits are trusted by trainees and are properly independent.  I sorely hope the government act on these recommendations and do not ignore them as they did with John Tooke's excellent report.  It is a little worrying that there is no mention of medical training in the government's initial response to Francis.

Tuesday, 16 April 2013

The Francis report and what it should mean for medical training- part 2

Here is my part 2. The first chunk is extremely significant, it highlights the gross failings of the current regulatory system.  PMETB, the GMC and the Deaneries are all mentioned, it is made abundantly clear that the system was superficial and that it was not properly looking at training experience on the ground. Francis reiterates much of what I have already said in a BMJ Careers article, the system is toothless and ineffective:

" Deanery/universities

1.84 The system of regulation and oversight of medical training and education in place between
2005 and 2009 failed to detect any concerns about the Trust other than matters regarded as
of no exceptional significance. There were a number of factors contributing to this:
-While patient safety was theoretically given primacy in the system, the domain to be monitored was unduly limited to the potential risk posed to patients by the trainee.
-Insufficient consideration was given to the relevance of good quality training of practice in a setting which complied with minimum patient safety and quality standards, and to the professional obligation to protect patients from harm.
- The Postgraduate Medical Education and Training Board (PMETB)/GMC/deanery wide reviews focused on deanery systems of quality management, resulting in only superficial examination of the standards being observed. Such reviews did not consistently consider compliance with patient safety standards.
- When concerns were raised about inappropriate pressure or bullying by staff towards trainees these were not followed up or investigated.
- Systematic communication of indications of serious concern, such as the HCC investigation, was almost completely lacking between the regulators, and between them and the deanery.
- A reluctance to prejudice the provision of a service or the training of trainees has resulted in the implied threat of removal of approval for providing training places being largely theoretical."

The next two  paragraphs make the obvious but necessary point that training cannot be allowed to take place in clinical areas in which patient safety is not adequate:

"1.85 While requirements for remedial action must be proportionate, training should not be allowed to take place in an environment where patient safety is not being adequately protected. Perceived difficult consequences should never be permitted to hinder steps required to protect patients, and the oversight of medical training should not condone or support unacceptable practice. As elsewhere in the system, a sense of urgency may have been lacking, even after the scale of the deficiencies at the Trust had become apparent.

Medical training and education
1.172 Medical education and training systems provide an opportunity for enhancing patient safety. Students and trainees should not be placed in establishments which do not comply with the fundamental standards, and those charged with overseeing and regulating these activities should, like all other participants in the system, make the protection of patients their priority. A number of recommendations for this purpose have been made."

Overall these sections I have highlighted sum up all that is wrong with medical training as things currently stand.  The regulation of quality is poor and as a result it is far too easy for trainees to be put into dangerous clinical environments.  Francis hits the nail on the head in my opinion.  Part 3 is still to come.

Friday, 12 April 2013

The Francis Report and what it should mean for medical training -part 1

Obviously the problems at Stafford are complex and I have no hope of summarising everything in one.  For my first stab I go back to the first report by Francis in 2009, it is interesting to go back this far as some of the key messages and themes recurred in 2013's report.  Here is recommendation 4 from 2009:

"Recommendation 4: The Trust, in conjunction with the Royal Colleges, the Deanery and the nursing school at Staffordshire University, should review its training programmes for all staff to ensure that high-quality professional training and development is provided at all levels and that high-quality service is 
recognised and valued. "

Then one sifts through the lengthy document and finds some rather key comments concerning the regulation of training:

"72. I received a set of comments about the lack of any system requiring regular monitoring or approval visits by the various clinical Royal Colleges or the general medical and nursing councils.
73. In a letter to the Inquiry the Royal College of Obstetricians and Gynaecologists said that it had had no involvement in the Trust since its visit in 2002. Responsibility for visiting and approving hospitals for training passed in 2006 to the Postgraduate Medical Education Training Board.
74. In another letter, the Royal College of Physicians referred to representations it had made to the Health Select Committee about the loss of regular visits to trusts in the early 2000s.  These were linked to medical training but “were a valuable source of intelligence about clinical issues locally”. The letter also said that “[the] Royal Colleges’ professional networks are invaluable” in cases falling between those resolved locally and those that are reported to regulators.
75. Royal Colleges do continue to operate an invited review system. The Royal College of Surgeons conducted reviews at the Trust in 2007 and 2009. "

I don't want to force opinions into your heads, just read through the above and consider things for a moment.  I shall be back with Part 2.

Thursday, 4 April 2013

Calling all BMA members on GMC social media guidance

The BMA are keen for all members to email them with any concerns they may have over the GMC's social media guidance.  I have written an email summarising my concerns and it is below. Feel free to use the letter yourself, or do email me at if you are a BMA member and you want me to add your name to the letter, obviously email me your BMA membership number with your name!

"Dear BMA

I am writing to you regarding several concerns I have about the GMC's social media guidance:

1. "If you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name. Any material written by authors who represent themselves as doctors is likely to be taken on trust and may reasonably be taken to represent the views of the profession more widely."

This piece of guidance appears to contravene the Human Rights Act, article 8, which entitles doctors with the right to a private life.  'Any material written' could refer to political opinion, sporting opinion or even gardening.  Surely every doctor should have the right to anonymity in the social media unless they are giving out clinical advice to individual patients.  This needs further clarification and if the GMC state that this applies to all material written, then legal advice must be sought and the guidance challenged, as it appears in breach of the Human Rights Act.

2. "You must make sure that your conduct justifies your patients’ trust in you and the public’s trust in the profession."

This piece of guidance is incredibly vague.  It is again arguable that doctors, when discussing non-clinical matters in their private time on the social media, have every right to behave in any way that they choose, providing that this is within the law.  It is arguable that this contravenes the Human Rights Act, article 8, again.

3. "Good medical practice says that doctors must treat colleagues fairly and with respect.  This covers all situations and all forms of interaction and communication.You must not bully, harass or make gratuitous, unsubstantiated or unsustainable comments about individuals online"

This piece of guidance is extremely vague and needs further clarification.  What is a 'colleague'? Most people would define a colleague as someone they have had direct contact with at work (face to face or by telephone for example).  If 'colleague' refers to any doctor on the GMC register then this piece of guidance has truly bizarre implications.  It may mean that criticising a politician who is a doctor may be something that the GMC could investigate and punish.  Again, surely doctors should be able to behave as they see fit in their private time when discussing non-clinical matters in the social media.  There is again an argument that this contravenes the Human Rights Act by interfering with the right of doctors to a private life. 

Yours Sincerely"

Wednesday, 3 April 2013

Stop Cameron selling of the NHS!

Unfortunately our political system is bent and this means that all our major political parties are very happy to ignore the well being of the public in order to keep a few rich elite party donors happy.  The endless privatisation of our public services is a great example of this, there is no evidence that it will be of any benefit to the public, rather the opposite in fact.  However the major parties have all been complicit in the privatisation of several of our key public services.

The NHS is just one of many chunks of the public sector that our corrupt government is intent on selling off.  They want to drive the NHS into the ground in order to catalyse its takeover by numerous huge multinational health care corporations.  Billions have been wasted doing this and the new system will be far less efficient due to a burgeoning bureaucracy that is needed to enforce the corrupt privatisation process.  International trade agreements are a key part of this antidemocratic process that works against the best interests of the general public.

The sad fact is that the political parties are largely funded by rich elite businessmen in whose interests it is to sell of vital public services such as the NHS.  The corporations owned by this rich elite will destroy the NHS and cut services in order to increase their profits, as soon as they have got their foot hold in the system.  The only hope we have of stopping this process is by putting pressure on David Cameron to exempt the NHS from the US/EU free trade agreement that is to be discussed later this year.  So please click on this E-Petition and sign on, every little helps!  The politicians should be the pawns of the public and not the evil weapons of elite billionaire businessmen.

Monday, 1 April 2013

The GMC on doctors and the social media

The GMC's guidance on doctors' use of the social media has attracted much comment and for very good reason. I would firstly urge anyone to actually read the GMC's full guidance before commenting, I have done and here is my two pence worth.

Firstly I think guidance has to be clear to be interpretable or meaningful, and this is one area in which the GMC's guidance badly falls down.  There are numerous elements to their guidance which are poorly defined and consequently extremely vague in terms of meaning.  When treating 'colleagues' fairly and with respect, what is a 'colleague'?  Most people would see a ‘colleague’ as someone one has come into direct face to face or telephone contact with in the workplace about a clinical matter, not a random person encountered on the web about a non clinical matter.  Also 'fairly and with respect', what does this mean?  The social media sees numerous very different people interact, people are routinely offended, often unintentionally, and this is a huge can of worms in itself.  Here is another massive vaguery:

"You must make sure that your conduct justifies your patients’ trust in you and the public’s trust in the profession."

This is so vague and so incredibly subject to the interpretation.  Why on earth should a doctor's conduct in their private life, as long as it is within the law, have to be any different to that of a general member of the public?  Personally I think the GMC's guidance in this regard rides roughshod over the Human Rights Act, which clearly states that all of us have a right to a private life.  Conduct in the workplace is different, but this is contact in the private lives of doctors that the GMC is referring to, and do they have any right to offer this guidance?  I think not.  It is akin to regulating how we behave on the sports field, with our children or at a social event.  Arguably the most contentious piece of guidance refers to 'confidentiality':

"If you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name. Any material written by authors who represent themselves as doctors is likely to be taken on trust and may reasonably be taken to represent the views of the profession more widely."

This piece of guidance is based on foundations of sand.  For one thing it is rather insulting that the GMC assumes that the general public are so stupid that they take everything said by a doctor as being the complete truth, this borders on the nonsensical for me.  It is also ludicrous to assume that the views of one individual doctor will be taken to represent the views of the profession.  Also how does being named help with these stated problems?  It doesn’t and it shows that the GMC may well be hiding the real, potentially more sinister, motives for clamping down on our anonymous use of the social media.

Overall I am deeply unimpressed with the GMC's guidance.  I took the choice a long time ago that I would not be anonymous in the social media, however I can appreciate that for many people this is not possible, for example it is impossible for psychiatrists given their job, it is also impossible for those who are effectively whistle blowing online, there are many other good examples of where doctors must keep their anonymity online or risk serious physical harm to them or their families.  The GMC's logic for doctors having to name themselves in the social media is weak and arguably incoherent.  Most seriously the GMC appears to be paying scant regard for the rights of doctors to have a private life that is free from the interference of government or regulatory bodies, as laid out in the Human Rights Act, and this kind of disdain for the rights of doctors shows the GMC up in a very bad light indeed.  I am very deeply unimpressed. 

ps I would also urge everyone to sign this petition which urges the Department of Health to rethink this invasion into the private lives of health care staff