Second Opinion: Naming and shaming
The continuing proceedings against Dr Harold Shipman, the Manchester GP now charged with murdering 15 of his patients, could not have come at a better time for the medical establishment. Following the scandals of the Bristol heart surgeons, the Kent gynaecologist and numerous less grievous cases of incompetence or corruption, any case exposing the dark side of medical practise provides further impetus to the official drive to tighten administrative control over the profession.
The General Medical Council (GMC) recently declared that all specialists and GPs should be regularly 'revalidated' through a detailed scrutiny of their 'knowledge, skills, attitudes and performance'. To everybody who has ever wondered whether their doctor has opened a book since leaving medical school, this seems a reasonable measure. Unfortunately, the measures being taken in an attempt to restore public confidence in doctors are likely to compound the underlying problem: the medical profession's loss of confidence in itself.
The GMC's plans are one aspect of a wider drive to impose 'clinical governance' on doctors. This phrase was coined in 1996 to name the bastard offspring of 'corporate governance' (designed to regulate the financial sector) and 'clinical audit' (the quantitative measurement of medical performance). It is indicative of the fragile state of medical authority in Britain that this concept has risen from obscurity to the brink of total domination in less than three years.
According to its promoters, clinical governance is a 'big idea' that can inspire and enthuse (Gabriel Scally and Liam Donaldson, 'Clinical governance and the drive for quality improvement in the new NHS in England', British Medical Journal, 4 July 1998). In a polemical response, anaesthetist Neville Goodman declared: 'I know people who think clinical governance is a small idea, a rehash of all sorts of "management speak" and poorly thought-out generalisations that can depress or dishearten.' (BMJ, 19 December 1998)
Though I have never met Dr Goodman, I am one of those people. The problems start when you ask what clinical governance means. As he writes, instead of a clear definition, you get (in Scally and Donaldson's account) a 'mission statement': 'a rolling unpunctuated tangle of prepositional and adverbial phrases similar to many that have appeared in the past few years on the walls of our hospitals and clinics.' Indeed, we know them well. In the end, clinical governance emerges as 'a mixture of the blindingly obvious...and the unproved', complete with a hexagonal diagram, a meaningless graph and bullet points.
Clinical governance means the extension to medicine from the business world of new mechanisms of regulation, based on quantitative performance indicators. It marks, according to Michael Power, one of its few critics, 'the spread of a distinct mentality of administrative control, a pervasive logic which has a life of its own over and above specific practices' (The Audit Explosion, 1994). The immediate result of the obviously limited scope for quantification in medical practise is the elevation of what can be measured over what is important (a trend already well established). The process of audit is not only time-consuming but demoralising, as the presence of a shadowy third party in doctor/patient relations has a subtly corrosive effect on professional authority.
While the GMC outlined its plans for revalidation, the government announced its offer of awards to 'beacon' services, including 'Nye Bevan prizes' to the top performers. As the Labour minister of health who introduced the NHS in 1948, Bevan once admitted that in his negotiations with the top consultants he had 'stuffed their mouth with gold' to silence their opposition to the new scheme. The old consultants may have been venal, but they had a substantial estimate of their own worth. Today's doctors have such fragile egos that the crass flattery of Frank Dobson's 'NHS Oscars' is enough to secure their acquiescence to a new NHS in which their professional expertise is firmly subordinated to managerial control.
Trust Me (I'm a Doctor) is the self-mocking title of a new book by teledoc Phil Hammond, in which he purports to expose the shocking scale of medical incompetence and negligence in support of the drive for tougher regulation. 'I'm a doctor, but I don't trust myself' might be a more appropriate title, with a subtitle continuing, 'but I've got guidelines and protocols, a checklist showing specific areas of knowledge, skills and attitudes ticked by a GMC revalidator, and league tables showing various performance indicators as well as overall ranking'. The scale of the professional crisis of confidence, reaching almost self-loathing, that is revealed here should cause serious alarm among doctors and the public alike.
More than 20 years ago the famous epidemiologist Archie Cochrane reflected rather sombrely on the zest for clinical audit he had helped to stimulate with his 1971 lecture, 'Effectiveness and efficiency', subsequently published as a monograph. Questioning whether audit had the effects it sought to achieve, he called for a more critical attitude, 'lest we drift into monitoring for the sake of monitoring' (see Gordon MacLachlan (ed), A Question of Quality?: roads to assurance in medical care, 1976). He emphasised that 'although we all recognise quality when we see it and particularly when we receive it', in healthcare 'outcome' was 'not the whole story' - 'kindliness' and the 'ability to communicate' were also important factors. He concluded that what was required was a 'test for aspirant medical students that would predict whether they would remain kindly in middle age'. Such a test has proved elusive - it does not seem to figure in any current approaches to clinical governance.
In 1994 Michael Power asked 'can we no longer think of accountability without elaborately detailed policing mechanisms?'. The answer is that, in New Labour's new NHS, it appears that we cannot. The defect of this, as of all policing mechanisms, is that the only real beneficiary is the police.
Dr Michael Fitzpatrick
Reproduced from LM issue 119, April 1999