Second Opinion: The dangers of deference
Now that Harold Shipman, the Manchester GP convicted of murdering 15 of his patients and suspected of causing many more deaths, is securely behind bars, numerous commentators have pointed out the absurdity of making this bizarre case the basis for restructuring the medical profession.
Yet within hours of Shipman's conviction one member of the council of the British Medical Association, east London GP Sam Everington, appeared on Newsnight to proclaim his agenda for reform. He denounced the General Medical Council (GMC) for not striking Shipman off the register for a drug offence 25 years earlier, and called for a lay majority on the council, thus effectively ending the principle of professional self-regulation that has prevailed since 1858. A closer look at Dr Everington's agenda reveals some ideas that could pose a greater threat to the integrity of the medical profession, and to the relationship between doctors and patients, than Shipman ever could.
Dr Everington first came to prominence in the campaign for shorter hours for junior hospital doctors in the 1980s. A long-standing Labour Party activist, he became an adviser to Robin Cook when he was shadow health secretary before the 1992 general election. However, Everington's main contribution to the campaign was what became known as 'the war of Jennifer's ear', which followed a party political broadcast featuring a five-year-old girl whose grommet operation had - allegedly - been delayed because of Tory health cuts. Unfortunately the broadcast provoked a public row between Jennifer's father, a Labour supporter who approved of it, and her mother, a lifelong Tory voter who denounced it. Exit Everington.
Rumours up to the 1997 election that Everington would become an MP, and after the election that he would join other New Labour toadies in the House of Lords, all came to nought. Instead he teamed up with a minister of the United Reformed Church to set up the Bromley by Bow Healthy Living Centre, which he modestly describes (on the website of the New Health Network, a virtual think-tank committed to modernising the NHS) as a 'focus of national and international attention for policymakers'. According to Everington, 'the centre has been named as a flagship project by the government, offering an example in practice of what the Third Way is about'.
Indeed, the Bromley by Bow centre figured prominently in the public health green paper Our Healthier Nation, published in 1998, which explains that the object of such centres is to provide 'opportunities for local community action to improve health and for individuals to take responsibility for improving their own health'. They are also 'an important means of raising local awareness' about matters such as diet, smoking, drinking, drugs and exercise. In other words, the Third Way means a doctor and a vicar preaching the same old 'look after yourself' sermon that Virginia Bottomley wrote when she was minister of health back in the days of Jennifer's ear. The only difference is that this victim-blaming message can be much more effectively communicated in the 'healthy setting' of 'an attractive urban village community' financed by the lottery and private sector funding.
Now we risk having Everington's 'vision of primary care' - an insufferably patronising, intrusive and implicitly authoritarian vision - imposed upon us in the guise of the 'modernisation' of the health service. This process is being driven by a powerful elite in the world of medicine in alliance with the New Labour government, which brings us back to Everington's Newsnight performance.
Though Everington was critical of the past record of the GMC, there is less a real conflict than a division of labour between himself and Sir Donald Irvine, who became its president in 1995. Under his direction, the GMC has taken a much more proactive role in regulating the profession and has substantially increased lay involvement. Like Everington, Irvine has been impatient at the slowness of the GMC, a notoriously conservative body, to accept reform. In 1998, he seized on the case of the Bristol children's heart surgeons - which he chaired personally - as an opportunity to promote the reform agenda. Last year the GMC finally agreed to introduce a system of regular revalidation of all doctors, which is currently under discussion.
Given all the recent horror stories, it is worth noting that there have always been medical rogues - and the GMC has long been criticised as an ineffectual watchdog. What is new in recent years is a declining trust in doctors, which is part of a wider breakdown of trust in society. The most striking recent development is the medical profession's loss of confidence in itself, which is expressed in the quest for reassurance through some form of audit or assessment. One irony of recent trends towards professional self-abasement is that they are taking place after a period of general improvement in medical standards (particularly in general practice) and after the GMC has become more dynamic than at any time in its history.
The tradition of self-regulation reflects the medical profession's confidence in its capacity to maintain its own standards. Doctors have long asserted their independence of both market forces and the state. Whereas the market ideal is that the consumer rules, the professional answers to a higher standard - that of the authoritative judgement of fellow professionals. A traditional definition of a quack was a practitioner who tries to please his customers rather than satisfy his colleagues.
Everington's notion that lay people should sit in judgement over doctors is a New Labour populist gesture which merely expresses a lack of professional self-respect. That some doctors have fallen below an acceptable standard, and that the GMC has been dilatory in maintaining this standard, is a poor justification for abandoning a tradition of autonomy which remains an important protection for patients and doctors, and a crucial guard of the integrity of the relationship between them.
Dr Michael Fitzpatrick
Reproduced from LM issue 128, March 2000