This man is now 70 years old. He was born into a
family of peasant farmers in South India. He did well at school as well as
helping on the farm, so he went to secondary school where he loved
history. His teacher told him that
science was a better choice in terms of bettering his lot in life and that of
his family, and with the help of a charitable foundation he was supported to go
to university and study to be a doctor. There he met his wife to be, from a
slightly more privileged background. After qualification, like most of his
fellow students he emigrated. He was going to go to Australia but could not
since he, like most of his village, had not had his birth registered, and had
no birth certificate. The UK was not so fussy then, and there was a shortage of
junior doctors in the 1970's so he found work as a junior hospital doctor in
the Manchester area. In those days even in A&E, the working week was Monday
to Friday, and then on top of that there was overtime. The on call rota would
be usually every second or third evening and night on, and ditto weekends. This
overtime was paid in so called UMT's or units of medical time. The assumption
was that only a third or a quarter of hours on duty were actually worked so the
pay was set at about a quarter of the standard hourly pay rate. Not
surprisingly busy jobs such as A&E were shunned by anyone who could get
anything less arduous. However, he had been brought up on a peasant farm, and working
all the hours there were was not unusual. So he accepted the conditions,
thinking that he was after all getting good experience. In the apprenticeship
like system that existed in those days he learned some valuable lessons.
Eventually he and his wife got the chance to try
General Practice. Initially he was exploited
as a salaried assistant, but it did not take long before the opportunity arose of
taking over a practice in a central and somewhat deprived area of a northern
industrial town.
They started of course with no appointment
system and a very small staff, but they worked very hard and he augmented his
income with work as a police surgeon. Gradually, they developed the practice
and after the GP reforms of the 1980's they built a purpose designed surgery.
His life was his work, and his work became his life. He gradually recruited a
team of helpers to whom he was devoted and they became devoted to him. He
continued to work a seven day week, and his wife brought up their 2 children
mostly unaided.
The practice went well. He resented the cost of
employing locums for his holidays so he seldom took any. His patients
appreciated the way that the surgery was always available in a way that is
almost inconceivable nowadays, and continuity of care was excellent. He loved
working as a GP in the NHS because he made an adequate income doing what he was
most interested in, with none of the commercial pressure, conflicts of interest,
and outright corruption that he was all too aware was endemic in Indian
medicine. He earned enough to help his family in India build houses and to
support a school, thus giving back to the society that had helped him and to
which he felt a debt of gratitude. He spent a large part of his spare time
going to educational medical meetings, generally on proper clinical bedside
doctoring rather than practice organisation.
He did have some problems of course. Being so
accessible meant that he was not well protected against patients who wished to
manipulate him, and some patients interpreted his wish to help them as
weakness. He prescribed diazepam and similar drugs as GPs did in those days,
and then when he refused to continue the prescriptions because of possible abuse
and the danger of addiction, patients sometimes complained. When his police
surgeon job was reorganised away from his town he started to replace that work
by doing a lot of weekend shifts for what was then an out of hours GP
cooperative. He often did 20 hours at a weekend, and he received the
appropriate share of patient complaints. Asian doctors get many more complaints
than English doctors. The reasons are not totally clear but there is no doubt
that communication difficulties and racist attitudes in some patients play a
significant role.
The first big problem however, started with the
2004 GP contract. It brought in Quality payments for GPs (QOF), which made
computerised records essential, at least for those aspects like recording Blood
Pressures and smoking status. Computers were provided free by the NHS but there
was little in the way of training and no funding for the huge task of inputting
handwritten data. For a doctor in his
late 50's this was a challenge. For several years he continued to use hand
written records from which his staff extracted the information to ‘feed the QOF beast’. This gradually became less workable after the
lab stopped sending paper reports, and he then used a dual system with major
illness, prescriptions, lab data on the computer, and consultation notes and
hospital letters still filed on paper. Many doctors went through the same
process of gradual transition, but he was one of the hindmost.
However, with the considerable help from his
staff, they managed quite well. Patient surveys were good, which was a huge
achievement in a poor area, prescription statistics were good, and the QOF points
were at least up to average. He had yearly appraisals, during which hints would
be dropped about rather the old fashioned record system and prescribing out of
fashion drugs like antihistamines to kids with colds, but no serious problems
emerged.
Then around 2008, Blair appointed Arai Darzi, a
highly specialised London Surgeon, to sort out the problems of general
practice!, which in London were largely about inadequate buildings without other
services, and lack of GPs in deprived areas. As a result, all the local areas
in the NHS were told they had to build a new multipurpose medical centre, and
the career prospects of NHS administrators depended on the success of the
scheme. Unfortunately, many towns had plenty of doctors and pretty good
premises already often with other services like district nurses on site, so
filling a new building with patients was a challenge. The obvious answer was to
persuade existing practices to move to the new building.
As a result, an NHS administrator (a former car salesman)
visited the practice. When the doctor learned that his patients would have to
travel 2 miles without a good bus route or free parking, he refused to move.
The manager told him that he would not take no for an answer, and that if he
did not comply he would eventually get the practice closed down.
Things settled for a while as the 15 million
pound surgery building took a long time to build, and then it didn't work as
they had failed to build an adequate sewage system. Then matters took a turn
for the worse when the NHS implemented the new Conservative Health Bill, which
no one had either read or understood. Many NHS managers took redundancy, and
were then re-employed in the new NHS administration. The manager who had made
the threat to close our man down ended up moving sites and sharing an office
with the "Performance Review Department".
So it happened that in May 2014, the doctor was
notified that he was to be visited by a Doctor and assistant as part of a
Performance review. The inspecting team came and inspected 4 sets of case notes
and asked a few questions in an aggressive manner, and concluded by saying that
they would be back for a further visit. He had by now got the wind up a bit,
and asked if he could have representation at a future visit. It was agreed that
a doctor from the local medical committee (which represents local doctors)
would be present for the next visit, scheduled for early July.
Despite several requests and the passage of over
6 weeks, no report from the first visit was sent to the doctor until the day
before the second visit, giving the doctor no time to respond.
During the second inspection visit, done by the same
doctor as the first visit, 3 more patient records were examined. The LMC doctor was only able to be present
for the first hour.
After the records were examined, the doctor was
told that they had found severe deficiencies, which would be reported to the
performance review panel meeting that was scheduled for within the next 10
days. At this stage no other evidence of performance had been examined
(although a lot of statistics are collected routinely by the NHS ), no one else
had been interviewed, and no consultations had been observed.
It was thought to be adequate that the opinion
of one doctor, who only examined 7 patient records was sufficient to end the
career of a man who everyone agrees is dedicated to his patients. Given that
judgements of this sort are well known to be highly subjective, and prone to a
host of biases, and that racist bias was an obvious possibility, this is
astonishing.
After the inspecting doctor had left, the other
member of the team spoke to the practice manager and suggested that it would be
better for the doctor to hand in his license to practice in order to avoid
publicity and shame. As he relied heavily on her advice he did as suggested,
surrendering his licence to practise to the GMC, and resigning from the local
performers list. Within 2
working days the authorities wrote letters to all the patients
informing them that the practice was closing, and informing them of nearby
practices that they could register with. On the front side of this list were 2
practices which were both located in the new building, while all the other
practices were listed over the page. The obvious conclusion was that the
inspection and its results were pre-planned by the manager who shared the
office with the Performance review team.
In the following days and weeks the doctor
discussed the situation with colleagues, who examined the report of the first
visit and found it to be both ill informed and unfair. They were horrified at
the way that the procedure contravened natural justice. Several weeks after the
second visit no report of that visit was supplied. When it did come it was seen
to be even less fit for purpose than the first. He and his colleagues
complained to the performance review authorities who promised to look into it.
However, the review procedure turned out to be
no more than a rubber stamp and a delaying tactic. They admitted that the delay
in writing and sending the reports was a serious flaw, but insisted that the
process and the 'decision' was valid.
So, can we trust British ' Justice' ? Maybe, but Not in the health service at any
rate.
