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As a result of my erasure in 2006 from the register of medical professionals in the UK, I had a lot of time to reflect on the events leading up to it. I have from time to time also reflected on this following my restoration in 2014. In the meantime, I had re-trained in law, paradoxically inspired by my experience of the judicial process. This was not a brief Masters in medical law, but both my Bachelor and Masters of Law, as well as the pre-solicitor training course. To do the last bit, I had to be approved as a fit and proper person by the legal regulator, the Solicitors Regulation Authority. I enjoyed my study of the English legal system, and reflect that if I had never studied law I would never have met the late Prof Gary Slapper – a formidable academic with an interest in conspiracy theories and corporate manslaughter.
This is all rather awkward, not least because Charlie Massey and Jeremy Hunt get on well, despite having divergent views on the implications of the #BawaGarba judgment. In a way, the General Medical Council (GMC) does not actually do ‘personal’, although ensuing events do rather appear like a hate campaign. It has become traditional to issue a sop to the ‘victim’ of misfeasance of a Doctor, and I do genuinely feel that there can be few things worse than the mental anguish of a grieving relative. The GMC and Medical Practitioners Tribunal Service maintain separation of powers, and, whilst I feel that the GMC can move in mysterious ways, I feel that the GMC believe that they are doing their very best to maintain public safety and confidence in the medical profession. This blogpost is therefore not an easy one to write, and inevitably will mean that I could accidentally cause offence. I am reflecting on issues to the best of my ability, and, if I fall short, I do apologise.
#BawaGarba found herself in a perfect storm. There are various systemic factors arguably out of direct control of the GMC. These are the exact funding of the NHS, including whether there is a sufficient number of doctors on rotas in individual hospitals. Notwithstanding, the GMC has a statutory duty in education and training, and, from what I know, will intervene in cases where NHS Trusts offer a suboptimal training experience. But there are important other systemic factors. It is quite common for non-white British trainees, once a GMC alert has been triggered, to be ‘thrown to the wolves’ from the regulatory process, but whether this achieves statistical significance is worth exploring. The trend has been for, once these Doctors have been reported, for all positive references to be withdrawn, and, often, although the source of the leaks are never identified, for the Doctors to receive a barrage of unfavourable press prior to any hearing. A media presence seems to defy any traditional notion of contempt of court, or right to a fair trial, as Doctors are subject to a total monstering and humiliation in the media. But it is not uncommon for papers in the English media, and their class of readers, also to subject groups of Doctors, such as EU Doctors, to an utter monstering as well, allowing xenophobia and outright racism to flourish. The scope for moral panic is enormous. But to lay these problems at the foot of the GMC, I feel personally, is unfair.
The GMC indeed also has an important statutory duty for patient safety under section 1 of the Medical Act 1983. The “There but the grace of God go I” used alarmingly frequently by white, English doctors on Twitter might reflect the observation that some Doctors are safer from attacks from institutional racism than others. This is particularly problematic if the NHS Trusts continue on its trend to trigger an official regulatory complaint effectively to cover their own backs rather than a genuine attempt to improve the performance, health and wellbeing of their Doctors employed under employment contracts. This has indeed been witnessed in the enforcement of the junior doctors’ contracts, arguably. Also, the “There but” observation is also problematic from the point of view that it seems to signal an admission that registers an admission that registered Doctors go to work knowingly taking risks and making mistakes. Most Doctors will admit to having taken risks and having made a mistake, and the number of mistakes reported daily in the NHS, a mere fraction of the real number, must urge a need for an open and transparent culture where people can learn from mistakes. But the GMC and the higher courts will tend not to tolerate any mistakes, or catalogues of error, whatever the mitigating factors. This might include an unblemished record for 30 years. The issue is that if the performance is way below a standard, there can be no excuse for it. If somebody has died, the threshold for mitigation has to be high, most reasonable persons might argue. And if a court of law has found someone guilty of manslaughter, whatever the process involved for doing so or the people involved, it is hard to leave no sanction on the Doctor, it is argued, whatever the need for organisational learning. Both the GMC and higher courts have consistently argued that public trust and confidence in the medical profession are more important than any individual doctor’s career.
The argument that ‘We go to work and are caught between a rock and a hard place’ merits scrutiny too. This comes down to the nature of how a crime is satisfied in English law – there can be intention to do the crime, and, although there is some finesse about the jurisprudence, there might be recklessness. The law in this is fairly well settled since R v Adomako. It might seem unfair to blame a Doctor having to cover seven bleeps one morning, but the point in law is that the Doctor by carrying those bleeps has assumed a duty of care to his or her patients, and any breach therefore of this duty of care, given the issues of causation and remoteness, is negligence. It might be argued that in tort the Doctor has assumed this responsibility under duress, but in reality most Doctors pick up the bleep from an office in the Hospital without any altercation. And Doctors are entitled to resign if they feel that there has been a fundamental breach of a contract, including a bilateral feeling of trust and confidence, between employer and employee. In reality, Doctors never do, despite the potential risks for patient safety.
Whilst there might be outrage about the lack of due emphasis on organisational learning, this organisational learning nor indeed any individual duty of candour are operational at any meaningful statutory level, meaning they exist in an Act of parliament or statutory instruments. And nobody is above the law. If there had been no sanction on #GawaBarba, a possible interpretation might have been that mistakes, whatever the reason, are excusable because of the ‘state of the NHS’. It might then be argued that the correct course of action might be for corporate manslaughter against the Secretary of State for health and social care, for ‘avoidable deaths’, but this has to be proven beyond reasonable doubt – an incredibly difficult offence to fulfil, as the late Prof Gary Slapper I am certain would testify.
I doubt, if #BawaGarba finds herself back on the GMC Register, she will find it easy to find employment again, especially with at least a five year gap in training. The GMC, even with its statutory duty for education and training, as well as patient safety, seems pretty indifferent to the professional rehabilitation and retraining of Doctors put back onto their Register. But the observation that no Doctor can ever be professional rehabilitated does concern me, even with the strong emotions that the ‘punishment should fit the crime’, and the need for a scalp can be overwhelming. For example, #BawaGarba has found that her subsequent good performance had become somewhat irrelevant as far as the regulator and higher courts were concerned.
As the old trope provides, there are no winners. There are only losers. It’s said that the GMC ‘doesn’t do personal’ in the same way a sanction is delivered in the same way a parking ticket is issued, and the GMC’s purpose isn’t, it is argued, to do ‘show trials’. The GMC’s position is that they are not in the business of ‘punishing Doctors’, but, I feel, it is of concern that unintended consequences, including a culture of fear, could continue to be dominant in the medical profession. The GMC doesn’t likewise, perhaps reflecting their perceived concerns from the general public, want to allow free rein on Doctors ‘free to make mistakes’, and good doctors will argue that they are all trying to do the job to ‘the best of their abiility’. The problem facing the GMC is whether ‘the best of someone’s ability’ is simply good enough. The general approach is that there is no shortage of doctors, and it is a honour to be a registered doctor. Whether there is a sufficient number of doctors for the demand is a concern the GMC can decide to involve itself with, or not. There is a clause in the code of conduct – Good Medical Practice, 2013 – stating that it is the responsibility of doctors to identify any shortfall of resources. I doubt all the senior Consultants or even STs in training taking to Twitter outraged about the #BawaGarba judgment are writing this morning to the GMC to warn about shortage of resources in their own hospitals, despite concerns about patient safety. It is noteworthy that the GMC in their statement on the case mentioned this only yesterday even. But individual Doctors have also been rather effective at protecting their own backs?
An innovative programme to encourage extensive knowledge sharing: the HE KSS/BSMS Primary Care Dementia Fellowship Programme
The HE KSS/BSMS (Health Education Kent Surrey and Sussex / Brighton and Sussex Medical School) have launched the “Primary Care Dementia Fellowship Programme”.
This is a programme for GPs, practice nurses and staff, and community nurses in Kent, Surrey and Sussex.
(Health Education Kent Surrey and Sussex will provide the funding to release Fellows to attend a regional skills development programme that will run from March to September 2014.
The Fellows will join with doctors and nurses from Kent, Surrey and Sussex (KSS) to build the knowledge and skills needed for them to create better dementia services in KSS.
Prof Sube Banerjee and Breda Flaherty of Brighton and Sussex Medical School (BSMS) are leading this initiative based on their successful experience in the NHS London Deanery.
It appears that the main aim is to build a network of Fellows who can act as ‘change catalysts’ (my words not theirs), to spread best contemporaneous practice in dementia care.
It’s important as dementia is one of the top five strategic priorities in the KSS Skills Development Strategy.
Modules will be led by Banerjee and Flaherty, with contributions from clinical experts in dementia; colleagues in social care; people in the care home sector; NGOs; persons living with dementia and carers; specialists in service development; commissioners and researchers.
I believe that such a course will have considerable competitive advantage in being totally disruptive in how traditional training for juniors in dementia is conducted.
The value is clearly in the collaborative ties between members of the network. By lowering the cultural barriers in this way, the team at Sussex have something very special here.
The set-up is perfect for boundary-less knowledge sharing, and this is enormously value as we all get to grips with what the priorities in local and national policy in dementia might be.
There are three modules running from March to June: good practice in dementia assessment and care, good practice in dementia, and changing practice.
These are followed by a ‘Next Steps’ conference and a period of evaluation and research.
Such an approach might become paradigmatic for future learning in the NHS in dementia.
‘Reasons to be cheerful’ part 4. Prof Sube Banerjee’s inaugural lecture in Brighton on living well with dementia.
For me the talk was like a badly needed holiday. I joked with Kay there, a colleague of Lisa, that it felt like a (happy) wedding reception.
@charbhardy hello Chars – not at all the same without you. Thinking of you and G. Very windy on seafront here at Brighton x
— shibley (@legalaware) February 27, 2014
Unknown to me, the title of Prof Banerjee’s talk is an allusion to this famous track from 1979 (when I was five). It’s “Reasons to be cheerful (part 3)” by Ian Drury and the Blockheads.
The Inaugural Lecture – Professor Sube Banerjee (“Professor of Dementia”), ‘Dementia: Reasons to be cheerful’ was held on 26 February, 2014, 6:30 pm – 8:30 pm, at Chowen Lecture Theatre, Brighton and Sussex Medical School, Sussex Campus. BN1 9PX. Details are here on the BSMS website.
I found Prof Banerjee to be a very engaging, ‘natural’ speaker.
I arrived with hours to spare, like how the late Baroness Thatcher was alleged to have done in turning up for funerals.
Brighton are very lucky to have him.
But his lecture was stellar – very humble, yet given with huge gravitas. Banerjee is one of the best lecturers of any academic rank in dementia I have ever seen in person.
Banerjee started off with a suitable ‘icebreaker’ joke – but the audience wasn’t at all nervous, as they all immediately warmed to him very much.
He is ‘quite a catch’. He is able to explain the complicated issues about English dementia policy in a way that is both accurate and engaging. Also, I have every confidence in his ability to attract further research funding for his various teaching and clinical initiatives in dementia for the future.
Most of all, I was particularly pleased as the narrative which he gave of English dementia policy, with regards to wellbeing, was not only accurate, but also achievable yet ambitious.
1979 was of course a big year.
Prof Banerjee felt there were in fact many ‘reasons to be cheerful’, since Ian Drury’s remarkable track of 1979 (above), apparently issued on 20 July of that year.
Banerjee argued that the 1970s which had only given fruit to 209 papers, but things had improved ever since then.
It was the year of course Margaret Thatcher came to power on behalf of the Conservative Party.
In contrast, there have already been thousands of papers in the 2000s so far.
Banerjee also argued that “what we know is more likely to be true” which is possibly also true. However, I immediately reminisced of the famous paper in Science in 1982, “The cholinergic hypothesis of geriatric memory dysfunction”. This paper, many feel, lay the groundwork for the development of cholinesterase inhibitors such as donepezil (“Aricept”, fewer than twenty years later.
It is definitely true that ‘we are better at delineating the different forms of dementia’.
I prefer to talk of the value of people with dementia, but Banerjee presented the usual patter about the economic costs of dementia. Such stats almost invariably make it onto formal grant applications to do with dementia, to set the scene of this particular societal challenge.
I am of course a strong believer in this as my own PhD was in a new way to diagnose the behavioural variant of frontotemporal dementia. In this dementia, affecting mainly people in their 50s at onset, the behavioural and personality change noticed by friends and carers is quite marked. This is in contrast to a relative lack of memory of problems.
Not all dementias present with memory problems, and not all memory problems have a dementia as a root cause. I do happen to believe that this is still a major faultline in English dementia policy, which has repercussions of course for campaigns about ‘dementia awareness’.
A major drive in the national campaigns for England is targeted at destigmating persons with dementia, so that they are not subject to discrimination or prejudice.
The dementia friendship programmes have been particularly successful, and Banerjee correctly explained the global nature of the history of this initiative drive (from its “befriending” routes in Japan). Banerjee also gave an excellent example to do with language of dementia friendship in the elderly, which I had completely missed.
Raising awareness of memory problems in dementia is though phenomenally important, as Alzheimer’s disease is currently thought to be the most prevalent form of dementia worldwide.
The prevalence of dementia may even have been falling in England in the last few decades to the success prevention of cardiovascular disease in primary care.
The interesting epidemiological question is whether this should have happened anyway. Anyway, it is certainly good news for the vascular dementias potentially.
That dementia is more than simply a global public health matter is self-evident.
I’m extremely happy Banerjee made reference to a document WHO/Alzheimers Disease International have given me permission to quote in my own book.
Banerjee presented a slide on the phenomenally successful public awareness campaign about memory.
Nonetheless, Banerjee did speak later passionately about the development of the Croydon memory services model for improving quality of life for persons with mild to moderate dementia.
In developing his narrative about ‘living well with dementia’, Banerjee acknowledged at the outset that the person is what matters at dementia. He specifically said it’s about what a person can do rather than what he cannot do, which is in keeping to my entire philosophy about living well with dementia.
And how do we know if what we’re doing is of any help? Banerjee has been instrumental in producing, with his research teams, acceptable and validated methods for measuring quality of life in dementia.
The DEMQOL work has been extremely helpful here, and I’m happy Banerjee made a point of signposting this interesting area of ongoing practice-oriented research work.
Banerjee of course did refer to “the usual suspects” – i.e. things you would have expected him to have spoken about, such as the National Dementia Strategy (2009) which he was instrumental in designing at the time: this strategy was called “Living well with dementia”.
“I’m showing you this slide BECAUSE I want YOU to realise it IS complicated”, mused Banerjee at the objectives of the current English dementia policy.
I asked Banerjee what he felt the appropriate ‘ingredients’ of the new strategy for dementia might be – how he would reconcile the balance between ‘cure’ and ‘care’ – “and of course, the answer is both”, he said to me wryly.
Banerjee acknowledged, which I was massively pleased about, the current ‘barriers to care’ in this jurisdiction (including the known issues about the “timely diagnosis of dementia”.
Clearly the provision at the acute end of dementia care is going to have to come under greater scrutiny.
I increasingly have felt distinctly underwhelmed by the “medical model”, and in particular the repercussions of this medicalisation of dementia as to how grassroots supporters attempt to raise monies for dementia.
That certain antidepressants can have a lack of effect in dementia – Banerjee’s work – worries me.
That antipsychotics can have a dangerous and destructive effect for persons with dementia – also Banerjee’s work – also clearly worries me.
I am of course very proud that Prof Alistair Burns is currently reading my book focused on the interaction between the person and the environment in dementia.
And of course I’m ecstatic that Lisa Rodrigues and Prof Sube Banerjee signed my book : a real honour for me.
I signed Lisa’s book which was most likely not as exciting for her! X
— Lisa Rodrigues (@LisaSaysThis) February 26, 2014
There was a great atmosphere afterwards: the little chocolate brownies were outstanding!
Being an antisocial bastard, I didn’t mingle.
BUT I had a brilliant chat with Lucy Jane Marsters (@lucyjmarsters) who gave me a little bag of ‘Dementia is my business’ badges, very thoughtfully.
We both spoke about Charmaine Hardy. Charmaine was missed (and was at home, devoted to G.)
I’ve always felt that Charmaine is a top member of our community.
@legalaware oh Shibley how did you enjoy it? I wish I could have been there but it’s not possible to leave G anymore. Good being by the sea.
— Charmaine Hardy (@charbhardy) February 27, 2014
A reason not to be cheerful was leaving Brighton, for many personal reasons for me.
Not even the Shard was a ‘reason to be cheerful’, particularly.
— Lisa Rodrigues (@LisaSaysThis) February 27, 2014
But when I came back, I found out that ‘Living well with dementia’ is to be a core part of the new English dementia policy.
— Living Well Dementia (@dementia_2014) February 27, 2014
I have, of course, just published a whole book about it.
The photograph of the poppy was of course taken by Charmaine Hardy: I have such great feedback on that one poppy in particular!
And what does the future hold?
Over to Prof Banerjee…
The definition of ‘dementia’ in neurology has experienced a number of different iterations in recent years. This has been a direct result of physicians developing a growing awareness that Alzheimer’s Disease, although the most common form of dementia in the senile age group, is not the only form of dementia. In fact, there are about 200 different types of dementia at least. This means that dementia is not always typified by loss of memory, the so-called amnestic syndrome. However, in Alzheimer’s Disease, the most pervasive cognitive deficit is inability to learn new memories, whilst memory for previous events or people can be relatively well preserved consistent with that outstanding French physician from the Paris School, Ribot, in his famous 1881 treatise on memory. Frontal lobe dementia has been speculated to be the most common form of dementia in the pre-senile age-group, characterised instead by a profound change in behaviour and personality, rather a cognitive deficit of a strong amnestic flavour. The NHS is undergoing now, against the will of the medical Royal Colleges and the British Medical Association, a fundamental strategic change, and this tweet yesterday evening caught me eye. It seems to me that the term ‘organisational dementia‘ could be applied to this organisational change at a number of levels.
In organisational development, learning is a characteristic of an adaptive organization, i.e., an organisation that is able to sense changes in signals from its environment (both internal and external) and adapt accordingly. A central issue is how adaptable the culture of the NHS is in general – many would like to see the NHS to adopt a stronger innovation culture, and in fact the NHS Innovation and Change provides extremely useful guidance on how innovative change in the NHS can be implemented successfully. Helen Bevan from that unit points to Harold Sirkin and colleagues who have published a model in the Harvard Business Review. The reason Bevan likes this model is that it is based on evidence from more than 1,000 change initiatives globally. I view a failure to implement change in the NHS, for example as will be necessary following the implementation of the Health and Social Act, will be in part be due to a failure in organisational learning, what you could call an ‘organisational dementia’. Bevan, in her brief article, points to two critical factors where organisational change will be impossible to achieve, and this should very much be borne in mind as the Government, with the help of McKinseys, try to effect their change without stakeholder cooperation.
“There must be active, visible backing for the change from the most influential senior leaders. They say that if, as a senior leader, you feel you are talking up the change initiative at least three times as much as you need to, your organisation will feel you are backing the transformation. In addition, the change is unlikely to succeed if it is not enthusiastically supported by the people who will have to operate within the new structures and systems that it creates. Staff need to understand the reasons for the change and believe it is worthwhile. The final factor is effort. There is an NHS tendency to launch major improvement initiatives without taking account of the extra responsibilities for change projects on top of busy operational jobs. The authors assert that if anyone’s workload increases by more than ten per cent as a result of the initiative, it is likely to run into problems. Organisations need to calculate upfront how much extra time and effort will be required to execute the change and create the space for it to happen.”
A further interesting contribution to the ‘organisational learning’ research comes from Common (2004) who discusses the concept of organisational learning in a political environment to improve public policy-making. The author details the initial uncontroversial reception of organisational learning in the public sector and the development of the concept with the learning organisation. According to Common (2004), research in UK local government has centred around four powerful obstacles for organizational learning in the public sector: (1) overemphasis of the individual, (2) resistance to change and politics, (3) social learning is self-limiting, i.e. individualism, and (4) political “blame culture.” This could be responsible also for a type of organisational dementia in the NHS; resistance to change and ‘blame cultures’ are two particular potentially serious issues for the NHS.
So far, I have considered an ‘organisational dementia’ in the NHS where the dementia has an amnestic flavour. There could of course be relatively change in its capacity for learning or memory, but there could be a profound change in its behaviour and personality. As the NHS becomes increasingly privatised, where patient care is reconciled more-and-more with an obligation in law to maximise shareholder dividend, it may be that the personality of the NHS becomes unrecognisable in a few years’ time. This to me, and I suspect many others, would be very sad.
So, in conclusion, I have outlined how a label of ‘organisational dementia’ might be applied to the NHS using organisational learning defects as a basis of an argument, using Alzheimer’s disease as a corollary. I have also applied the term in the way akin to frontal dementia. Organisational learning is a very powerful notion in business management, and its critical application to the strategic change in the NHS has not gone unnoticed by me.