Chairwoman of Shipman inquiry protests at lack of action

The government, the General Medical Council, and the medical profession were criticised last week for failing to respond to the recommendations of the inquiry into the case of Harold Shipman, the GP who murdered more than 200 patients.

At a meeting convened at the Royal Society of Medicine in London to discuss trust between doctors and patients after the Shipman case, Janet Smith, chairwoman of the Shipman inquiry, said that the case had “disclosed a raft of flaws in professional governance” and that “inaction cannot be defended.”

The GMC's plan for revalidation was “stopped in its tracks,” she said, which was “good because as proposed it was merely a rubber stamping exercise, but 18 months on we are still waiting to learn what is to be done.”

Aneez Esmail, professor of general practice at Manchester University and an adviser to the inquiry, said that the “continued silence” of the chief medical officer indicates that an “unholy compromise is being worked out.”

“And when it does appear I predict it will be a fudge,” he said.

The inquiry's recommendation to revise death and cremation certification (BMJ 2002;325: 919) should already have been implemented, speakers underlined. It was the most effective way of “preventing another Shipman” and—unlike revalidation (which could not identify a serial killer)—was simple to implement.

When questioned this week about progress on certification, a spokesman for the Department of Constituional Affairs told the BMJ that the department was expected to announce a draft bill in parliament next month setting out its changes to the coroners' service.

A recent MORI poll, referred to at the meeting, showed that the trust patients had in doctors remained high. At a political level, however, trust in the profession had fallen to a “150 year all time low,” said John Lilleyman, president of the Royal Society of Medicine.

Dame Janet said that the Shipman debacle, and other events in the 1990s such as the retention of children's organs at Alder Hey Hospital, Liverpool, and the poor quality of children's heart surgery at Bristol Royal Infirmary, had opened patients' eyes “to things that go wrong.”

Dame Janet Smith: “Trust should not be blind”

Credit: JOHN NOBLE/PA/EMPICS

She added: “And good riddance to blind faith. Trust should not be blind. It should be based on confidence in doctors' competence and honesty.” Anne Alexander, the lawyer who represented 200 families whose relatives were murdered by Shipman, agreed. “Patients should know if their doctor's copy book is blotted,” she said, “and near misses should be recorded too.”

“When things go wrong patients must have access to (and be encouraged to use) effective and robust complaint systems,” Lady Justice Swift told the conference.

The message that reform of the GMC is overdue came from several speakers. The demise of community health councils and patients' forums had weakened the patient's voice, they said. Patients' representation on the GMC needed to be strengthened, and patients' interests needed to be protected to the same extent as those of the medical profession.

The case for introducing a bill of rights for patients was raised by Jonathan Montgomery, professor of healthcare law at Southampton University, but he warned that “such a bill would be confrontational and undermine the trust between patient and doctor.”

The GMC was also attacked for “being in receipt of a lot of information, but failing to do anything with it.” John Spencer, an orthopaedic surgeon, said that the National Patient Safety Agency needed to take on the role of coordinating information about poorly performing doctors and should adopt an early warning role.

Lawyers and doctors at the meeting expressed frustration at the medical profession's lack of leadership and failure to initiate change as a result of the Ship-man inquiry. Presentations did, however, provide clear evidence that in some places, at least, changes had been made.

“Locally we have made a lot of changes, including revising our cremation form procedures,” said Raj Patel, whose surgery is opposite to the one that was owned by Shipman. “But change needs to be coordinated, not done on a post-code basis.”

Several speakers discussed the potential of measuring and monitoring mortality in general practices to identify professional “outliers” (BMJ 2003;326: 274-6) (Quality and Safety in Health Care 2003;12: 337-42). Paul Alyin, an epidemiologist at Imperial College London, warned that in the future patients may expect all their doctors to provide personal morbidity and mortality data prior to giving informed consent.

Brian Hurwitz, professor of medicine and the arts at King's College London, said that Ship-man would have been identified earlier if the misgivings of the local pharmacist, receptionist, taxi drivers, funeral director, and district nurse had been collated and passed to the GMC. Concerns about doctors operating outside professional norms need to be documented and followed up.

A new system analogous to the yellow card scheme for reporting adverse drug reactions could be adopted to report concerns about doctors' performance and behaviour. Information from negligence actions was not enough, he said. The former Tory health minister Julia Cumberlege had a clear response to the question of why more had not been done since Shipman. She referred to the “maelstrom” of organisational, social, and scientific change and to the NHS as “unstable, chaotic, and pressurised.” The medical workforce was “cross, angry, and miserable,” she said. Nevertheless, she warned, the profession urgently needed to agree on and enforce high standards of professionalism.

Iona Heath, a GP in north London and chair of the BMJ's ethics committee, expressed fears that the response to Ship-man would be excessive. Doctors are already over-regulated, she said. “The content of consultations with patients is now dictated by factors outside the encounter. Patients should not be used to achieve political ends.” (See Personal View, p 1161.)