First and last, it is to the patients and families who suffered at the hands of the abominable Harold Shipman to whom we all — professionals and policy-makers, individually and corporately — owe a duty of care. That said, there is a sense in which we doctors too are Shipman's victims. We too are experiencing the normal sequence of feelings after profound trauma: shock, denial, despair, grief, anger, guilt, blame, and (eventually) being able to move on. As with a personal bereavement, the greatest loyalty we can show the departed is to enrich our own continuing lives with their legacy.
At College Council on 12 February, every shade of this emotional palette was in evidence. We were profoundly touched to hear a GP from Hyde describe the distress felt by Shipman's professional neighbours on learning that, while conducting themselves in no way differently from the vast majority of other GPs with no reason to suspect a colleague of the most egregious crimes, they found themselves, in hindsight and by implication, accused of sins of omission. We were equally moved by Brian Keighley's evident anguish, having devoted a working lifetime to the pursuit of personal and compassionate care, at having his motives and competence as a member of the GMC impugned by Dame Janet's Inquiry. And while the RCGP has emerged from the Inquiry relatively honourably, we in turn find there is a danger that the College's measured and systematic advocacy of ever-higher standards of practice might be highjacked to serve the pressing agenda of detecting the rottenest of rotten apples.
But detecting rotten apples has to be a priority for a profession that wishes to make a credible case for self-regulation. A system of revalidation that, while spotting an apple just on the turn, risks missing one so rotten as to cause damage on Shipman's scale, is simply untenable. And not just damage on Shipman's scale. The GMC's proposals pre-Dame Janet, much as we might wish them to have been adequate, were more appropriate to a golf club's membership committee than to a profession where — granted that most of its members are honest and competent — an unacceptable rump is nonetheless letting us all down. We need to remember that the thrust of Dame Janet's criticism was not that we failed to spot the once-in-a-millennium villain, but rather that the early warning systems that might have spotted rogues as well as villains, outliers as well as psychopaths, were, frankly, not fit for purpose. We have to concede that a small minority of GPs are less than acceptably competent, less than acceptably up to date, less than acceptably professional. A system of revalidation that assumes we all take pride in self-reflective improvement through appraisal, and that the absence of clinical governance evidence of incompetence is positive evidence of competence, will, sooner or later, fail. It may not fail on a Shipmanesque scale, but fail it will; and those failures will do avoidable damage to patients.
So what is to be done? The GMC's proposals were, as Brian reminds us, a world-leading innovation. But we can do even better. Sir Liam Donaldson has, as Brian observes, a heavy responsibility. And we must help him discharge it. Wisdom and humility are needed. We must neither over-react nor under-react. We must all try to rise above personal hurt and parochial ambition. We need to be rational and unemotional. We need to be proud of our professional traditions, yet humble in the face of our shortcomings. Where there is evidence of what will lead to improvement, we must be persuaded by it.
The ghosts of Shipman's victims are entitled to no less.
- © British Journal of General Practice, 2005.