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Article 50 and Labour

A reply to my Labour MP, who kindly emailed me (and many others) explaining his intentions in the vote to implement Article 50, and commence Brexit.

Many thanks for taking the trouble to explain your intentions. I’m aware how difficult this is for Labour, and I’m familiar with the arguments you put forward. However, I think we all know that this government is not going to accept any meaningful amendments, and even if they did, the right course of action would still be to vote against the implementation of Article 50.

The first responsibility of MPs is to safeguard the welfare of the country, and the only way to do that is to stop Brexit in its tracks. It was depressing to hear people like Margaret Beckett saying that although she knew it would be a disaster for the country, she would be voting for implementation. That statement alone should disqualify her from sitting as an MP. We repeatedly hear that ‘the people have spoken’, but they spoke in an ill-conceived and unnecessary referendum following a campaign characterised by deliberate lying and obfuscation. Many of those voting leave have since, sensibly, changed their minds now that they realise what they were voting for. Many Leave voters are members of Labour’s core demographic, and will suffer the most from leaving the EU.

There is absolutely no requirement on Parliament to implement the result of an advisory referendum – particularly one which results in major damaging constitutional changes based on the votes of a minority of the population, indeed, it is Parliament’s duty to refuse to do so.

Labour’s stance, led by Jeremy Corbyn, has been pitiful, and his insistence on loyalty to his leadership, given his past voting record, strays beyond irony into hypocrisy. What the country needs from its politicians is a clear statement that Brexit will be so debilitating for the country that they can no longer recommend leaving the EU, and will continue to argue for reform from within.

I’m pleased to know that you will vote against the third reading if there are no suitable amendments, but I believe the most likely outcome will be that Corbyn, weasel that he is, will accept any crumbs tossed to him by May et al, in the mistaken belief that it will get himself, and the party, off the hook.

Like many of your natural supporters, I will never vote Labour again. If Corbyn thinks his actions are the best bet for staving off catastrophe in 2020, he has been badly advised (but then, he has made rather a thing of surrounding himself with malicious or just plain incompetent advisers). If Article 50 is invoked with Labour’s connivance, you will have lost the support of at least two generations of voters, and will have ceased to be a meaningful force in UK politics, thanks to your actions in aligning yourselves with UKIP and (effectively) Trump.

Never did we have a greater need for an effective opposition. Never did we have such a pathetic excuse for one.

All of which saddens me – you are a very effective and conscientious MP, who would normally command my support.

Regards

Just think for once, commentators!

OK – if you’re expecting a serious piece on the current state of the NHS or anything else, don’t bother reading on –  one of the best things about starting a blog like this is that it gives you the chance to get stuff off your chest, and today I want to do just that.

Mostly, the inanities of sports commentators make amusing reading, and those of us of a certain age think fondly of Colemanballs in Private Eye. But there’s one thing they do repeatedly which really gets on my nerves and which has me screaming in frustration at the TV set, and that’s why, still frothing at the mouth, I intend to unload on you all now.

I don’t know if you’ve noticed, but nearly all commentators have a tendency to simply tot up the missed chances in a game, add them to the actual final score, and say ‘If only they’d not missed those three clear chances, they’d have won 3-2’ Spot the fallacy? Of course you did, but they never do, and no-one seems to pick them up on it.

One of the worst serial offenders is Mike Stephenson, who is a regular commentator on Sky’s rugby league coverage (RL – a rough northern game that most of you won’t have heard of). Known by everyone as ‘Stevo’, he is an ex-international RL player, and his commentating style tends to be fairly dogmatic, which leads to him taking quite a bit of good-natured stick from his fellow commentators.

Stevo regularly adopts this simplistic view of missed opportunities, and their possible effect on the final score. There was a good example in the commentary on the first game of this year’s Super League programme, in which ‘my’ team, Leeds Rhinos, were beaten 10-12 at home by Warrington Wolves. As if that wasn’t bad enough, I was reduced to incoherent gibbering by Stevo’s assertion that if Leeds had kicked their three first-half penalty goals, they would have been six points better off, and would have won.

YOU CAN’T KNOW THAT YOU NUMPTY!

Look – if they had indeed kicked the first of those goals rather than kicking for touch and getting no return for it, the entire subsequent course of the game would have been different, because the match would have been restarted from the centre spot. Those second two penalty opportunities would therefore never have arisen, and depending on what did happen, Leeds might have lost even more heavily. Alternatively, they might have scored three brilliant tries and/or had half a dozen other penalties awarded and gone on to win handsomely, but THERE IS NO WAY OF KNOWING.

Sorry to keep shouting, but as you may have realised, this is one of those unimportant little things that can take over a chap’s waking hours. And Stevo – just in case you’re still struggling with this, let me explain more fully. Our lives (and sporting contests) are made up of a sequence of events, each one of which leads on from, and is a direct consequence of, what went before. Change one of those events by, say, missing an open goal or converting rather than missing a penalty, and you also change what comes after. So, you can’t simply look at a series of missed chances after they have occurred, add the points/goals/runs they would have generated to the actual total and produce a number that means anything.

Of course, quantum mechanics raises the possibility that there is a parallel universe in which Leeds did kick the first of those penalties, but if we had a way of seeing into that universe, we would find that we were watching a completely different game, from that point on, to the one that unfolded at Headingley last week.

I can’t surely be the only person to have picked up on this, and Stevo is certainly not the only offender. But I wish they’d stop it.

And……………..relax.

 

Old dogs and new tricks

When I finally retired from my career as a consultant radiologist in Leeds, I didn’t imagine for a moment that three years later, I’d be going back in to the hospital as a volunteer, and especially not as the Trust’s first humanist chaplain.  I didn’t even realise that I was a humanist until I was in my early forties – I won’t bore you with the details of my reverse Damascus road experience now, but if you’re interested, you’ll find an account here. Discovering humanism made a big difference to my life, but not much to anyone else’s, so when I retired and had more time, I looked around for ways to give practical expression to my beliefs.

I suppose before I go any further, I should define humanism, because until I saw the light, I knew very little about it, except that it was a non-theistic view of the world and our place in it. There are two basic beliefs inherent in the humanist world view. The first is that we can explain the world around us using scientific method, evidence, and reason to discover truths about the universe without invoking the existence of a supreme being. Secondly, we believe that we only have the one life to live, and that we should make that life a worthwhile and fulfilling one by placing human welfare and happiness at the centre of our ethical decision making.

So anyway, when I retired, the first thing I did was to enrol on the British Humanist Association’s (BHA) training course to be come a funeral celebrant, accredited to officiate at non-religious humanist funerals. I had naively assumed that I would find it fairly undemanding, because I’d done a lot of public speaking in the course of my career – not just conference presentations and lecturing, but after-dinner speaking as well – and I didn’t think that the actual presentation of the ceremony would be a problem. So when, during the first training session, the speaker emphasised the importance of careful preparation of your script, ensuring it was printed double-spaced in large font to ensure that you could keep your place and maintain regular eye contact with the mourners, I thought ‘what do I need with scripts? – if I can wing it in front of three hundred drunk doctors at a conference dinner, I can manage without a script at a funeral service’.

I  was quite wrong, of course and, you might think, even a bit arrogant. A funeral is much more important than any of the other public speaking I had done – after all, if you mess up a conference presentation, another one will be along in a couple of months, and there’s a good chance no-one’s listening anyway. A funeral, on the other hand, is the family’s only chance to get it right, and it matters. With only a couple of days to meet with them, write the service, including a eulogy which says everything the family and friends want to say while keeping within the strict time limits applying at crematoria, you can’t leave anything to chance. In fact, from being over-confident, I rapidly began to think that I’d bitten off more than I could chew, and came close to baling out of the training. I’m glad I didn’t, because working with bereaved families over the past few years has been one of the most challenging and rewarding experiences of my life so far.

Then, having gained that experience, my thoughts turned to hospital chaplaincy services. I’d had very little contact with chaplains during my long career in medicine, largely because I was a radiologist by trade, and radiologists are not involved in the long-term care of patients; we do the interesting bit – making the diagnosis – and then let the referring clinician worry about prognosis and treatment. So my ideas about chaplains were the same as those of most patients: I assumed that anyone styled ‘chaplain’ was a vicar (or priest, or imam or rabbi etc. in these multi-faith times), and I would have been right. Which means that the 40% or so of patients who tick the ‘no religion’ box on their admission form are effectively disenfranchised when it comes to accessing pastoral care in hospital

It occurred to me that there was a parallel here with my funeral work: twenty or thirty years ago, you would have been hard-pushed to find anyone offering non-religious funerals. In fact, I suspect that many funeral directors would have told you that there was no demand for them, and yet now that they are widely available, around one third of services fall into the non-religious category, and fewer than half of all funerals are conducted by the Church of England, Catholic and Methodist churches combined. Pastoral care is ripe for a similar revolution, because while it is true that many chaplains practise what is called ‘generic chaplaincy’ – meaning that they make themselves available to patients of all religions and none – the patients themselves are not necessarily aware of that.

Consequently, if a patient with no religious belief is troubled, anxious or scared and wants to talk to someone who is neither a member of the family or one of the medical and nursing team caring for them, they may well hesitate to ask for the chaplain, fearing that he or she would approach things from a religious point of view which had no meaning for them. This didn’t seem right, and I had been considering a direct approach to my old hospital to see if they felt that there was a place for a humanist in their pastoral care team, but wasn’t sure what sort of reception I’d get.

Then serendipity (or fate or the hand of God, depending on your point of view) stepped in. I clearly hadn’t been the only one thinking about this issue, and out of the blue I received an email from the BHA offering training in pastoral care to humanists wishing to work as volunteers in the hospital and prison services. To cut a long story short, I did the training, and was able to approach the chaplains in Leeds with a bit more credibility than would otherwise have been the case. It turned out that I was pushing at an open door, and Chris Swift, the Head Chaplain and a C of E vicar, welcomed the opportunity to include me on their team. I’m based on the teenage cancer unit, but make myself available to any patient in the Trust who specifically requests pastoral care from a non-religious chaplain.

It’s still early days, and of course, and as I said earlier, patients won’t ask for a non-religious chaplain unless they know that such an exotic creature exists. Still, I’m managing to publicise my presence using internal bulletins and social media, and I’m slowly becoming recognised in my new role, and receiving referrals from other chaplains and chaplaincy volunteers. Incidentally, should you be unfortunate enough to find yourself, or a family member, in hospital and in need of a bit of support, and if you are not religious, you might want to ask if there are any non-religious chaplains available. There probably won’t be, in which case you could ask why not, and just remind them of the equality agenda, because not all of those seeking to do this work have been as lucky as me, and are often rebuffed when they approach chaplaincy departments offering to get involved.

Why am I telling you all this – is it just to make myself sound like a really good person? Well, when I retired, my daughter, who has inherited my rather dry sense of humour, asked me ‘what will you do with yourself, now that you no longer serve any useful purpose’. OK, she was joking (I think), but there’s an underlying kernel of truth in her question, and while I’d like to think that altruism is the chief motivation for my voluntary work, I guess that whenever we undertake something that makes us feel good, there’s invariably an element of selfishness involved as well.  I don’t miss going to work every day, but after a busy career, and particularly in a profession like medicine, I do miss the feeling that, no matter how frustrating the job might have been, I did occasionally make myself useful to someone. The chaplaincy work has given me that feeling again, and I’m unashamed to admit that I enjoy it.

But no, that’s not the reason I’m telling you all this. I’m telling you because you might imagine that spending a significant chunk of my retirement (but not enough to interfere with the fishing) officiating at funerals and working with young victims of cancer would be fairly depressing. In fact, nothing could be further from the truth – my funeral and pastoral care work has shown me, more vividly even than forty years of medical practice did, that human beings are pretty bloody amazing, if you’ll pardon the expression.

When I meet families to arrange a funeral, I’m repeatedly struck by the extraordinary lives that have been lived by outwardly very unexceptional people. There was, for example, the elderly gentleman who had lived in Bradford for seventy years despite an eastern european name, and whose life had seemingly been a pretty mundane one, working in a factory, enjoying a weekend pint in the working men’s club and not doing anything remarkable. It turned out that at the age of seven, he had, with his parents, walked pretty much the length of Europe, fleeing first the Russians, then the Germans. Then there was the elderly lady who had been living a quiet life in her neat little house since her husband died a few years previously.  While talking to her family to get material for her eulogy, I discovered that she had been a stalwart of the early trade union movement, and a friend and colleague of the Labour Party leaders of the fifties and sixties. Singing The Red Flag at her funeral was a first for this ageing small ‘c’ conservative. I could give many other examples.

More importantly perhaps, I’ve been impressed by the amazing resilience that people demonstrate in dealing with the most distressing events, and here I think of the young couple, barely out of childhood themselves, who had just suffered the loss of their first baby at fourteen weeks gestation and wanted me to conduct a funeral service. They were just the most together and composed pair you could imagine; tears had been, and continued to be shed of course, but they were determined to provide a service that would mark their child’s all too brief life and establish her place in their family unit, and had very clear ideas on how to go about it. When I met their relatives and friends at the service, I realised where some of that strength came from. I’ve seen the same thing again in my early dealings with the patients and families on the teenage oncology unit. Their lives have been turned upside down by a disease which highlights the random unfairness of life, but they are just getting on with it and coping.

So here’s the take away message, and I’m sorry I’ve rambled on so long in getting to it, but I thought you needed a bit of background.  I have belatedly realised what humanism is all about:  my experience over the past few years has convinced me that when it comes to human behaviour, belief in a supreme being is an irrelevance. If you feel inspired by the example of Jesus (or any other prophet or teacher) to live your life in a certain way, that’s fine, but we can take responsibility for our own lives and the lives of those around us without ascribing any good we do to God, and blaming all the bad stuff on estrangement from Him, or, worse, to the Devil’s promptings. We are gradually chipping away at the apparently mysterious workings of the universe, using rational processes of enquiry without resorting to the cop-out that ‘God did it’ every time we get to the difficult stuff like dark matter or quantum entanglement (sorry, showing off a bit there – I don’t actually know what they are either, but I’m delighted that someone, somewhere is getting to the bottom of it all).

Everywhere, I see ‘ordinary’ people living as if this was their only life, getting on with things under the most adverse circumstances, and enriching the lives of those around them in the process. They do this because they think they should, and because it makes life better for everyone, not because they are told to do it by supposedly sacred texts written at a time when the sun was still thought to be hauled into the eastern sky behind Helios’s chariot every morning.

Meeting people like this at critical stages in their lives has been a privilege, and is the polar opposite of depressing, so I just wanted to say this. If anyone ever tells you (and they probably will) that a sense of awe and wonder, feelings of joy, and hope for the future can only be experienced in the context of religious faith and a belief in the world to come, politely tell them they are wrong. Tell them Bob said so.

 

The strange case of FGM and the CPS

You will have seen the reports of the case brought against Dr Dhanuson Dharmasena for alleged female genital mutilation (FGM). The accusation was that, in suturing the perineum post delivery in a patient who had previously undergone FGM in Somalia as a child, Dr Dharmasena had restored the previous status quo, thus effectively performing FGM himself. The employing hospital had found that he had no case to answer, but someone reported him to the Crown Prosecution Service (CPS) and the General Medical Council (GMC), and he was suspended from practice almost a year ago.

The High Court jury took less than half an hour to find Dr Dharmasena not guilty, and we can see why they found it so easy to come to that decision if we look at the following points made  by the Royal College of Obstetricians and Gynaecologists (with some explanatory additions by me):

  • Dr Dharmasena did not perform deinfibulation (repair the results of previous FGM) or reinfibulation (re-perform FGM) on his patient, known as AB.
  • In fact, AB had already been deinfibulated at Kingston Hospital before the pregnancy.
  • As a result of her repair at Kingston, there were no difficulties with vaginal examination in labour.
  • The urethra was obscured by a band of scar tissue which Dr Dharmasena incised in order to insert a catheter as there were signs that the baby was in distress
  • After delivery, Dr Dharmasena repaired the bleeding edge of the scar tissue with a single figure of eight suture. The vagina was not closed by the single stitch.
  • AB had a further baby within the year without need for further deinfibulation (in other words, Dr Dharmasena’s repair had not produced any obstruction, confirming the assertion that it did not represent a re-establishment of the patient’s previous FGM).

So, while there may be some argument about the technical details of the repair Dr Dharmasena performed, this would, at most, be a case for some re-education by his consultant, which is what the hospital recommended, and which subsequently took place.

FGM has been illegal for a number of years, but shamefully,  no cases had previously been brought against those performing this mutilation. So why on earth would Alison Saunders, the Director of Public Prosecutions, choose to break her duck with this very atypical case, one which would seem to be doomed to failure? There have been suggestions that the fact that she went public with the decision to prosecute just three days before she was due to be interrogated by the Home Affairs Select Committee over her previous abject failure to act might be of some relevance in determining her motivation. While that may be an unworthy suggestion, how else else to explain the failure to go after one of the many back-street practitioners who butcher women in insanitary premises, rather than an obstetric registrar who was simply doing his best to stop the bleeding after a difficult delivery?

I don’t pretend to understand the reasoning, if any, of the CPS in this case, but it would be good to think that Ms Saunders will face her own disciplinary inquiry following such a senseless decision. I won’t be holding my breath, though – when interviewed about the verdict on the Today programme, she seemed to imply that Dr Dharmasena had received the benefit of the doubt due to the fact that the criminal court requires a high level of proof (beyond reasonable doubt) before convicting. But presumably she knew of this requirement before she brought the case?

And of course, it isn’t all over for Dr Dharmasena. He still faces the GMC disciplinary hearing. Now you might think that they would simply abandon the case in the light of the High Court finding? Not a bit of it. Experience tells us that they will probably bumble on in their inefficient way, taking months to actually convene a hearing, then as long again to produce a verdict. And, worryingly in view of Alison Saunders’s comments on Today, the level of proof required by the GMC before they take away a doctors self-respect, reputation and career is the lesser one of  ‘on the balance of probabilities’. Derek Keilloh’s case linked to earlier in this paragraph tells us that their disciplinary panels can be quite cavalier in the way they interpret this, sometimes reaching their apparently capricious decisions on the basis of evidence which boils down to ‘he said; she said’.

So in a case which no-one other than the CPS wanted to see brought, the only people to suffer have been Dr Dharmasena and the patient. The patient (who had no complaint about her treatment) at least enjoyed the anonymity provided by the requirement for medical confidentiality. Dr Dharmasena has been publicly vilified, lost a year of training, and now faces the trauma of an unnecessary GMC hearing, with no assurance that he will not be struck off despite the High Court declaration of innocence.

Clearly the CPS need to be free to prosecute cases where they believe a crime has been committed, without the fear that they will be taken to task every time a defendant is found not guilty. In this case, though, their insistence on proceeding despite professional advice has set back the fight against FGM and potentially destroyed the career of a good doctor.

Alison Saunders should be considering her position this morning.

Suicidal doctors lack resilience

One of the recommendations of the report into the fact that 28 doctors have committed suicide while under investigation by the GMC is the institution of an ’emotional resilience’ training scheme for those subjected to its disciplinary processes. While this has been welcomed by the Chairs of the BMA and RCGP – and it is clearly a good thing that the GMC is at least recognising that a problem exists – there does seem to be a suggestion that the fault lies with the doctors (not ‘resilient’ enough) rather than with the GMC’s own procedures.

To be fair, there are other recommendations too, including the fairly startling statement that doctors should be made to feel that they are innocent until proven guilty – startling because the author of the report clearly felt that it needed to be said, thus confirming the impression of many doctors that the regulator tends to assume the opposite when complaints are made against them.

Of course, some doctors do come before the GMC’s disciplinary panels (or, more accurately, the Medical Practitioner Tribunal Service panels, which are supposed to operate at arm’s length from the GMC) as a result of mental illness. This may predispose them to thoughts of suicide, and it must be right to ensure that they have the appropriate support not only to get them through the disciplinary process, but to address their mental health issues and enable them to return to their careers. However, mentally ill or not (and most are not) any doctor subjected to disciplinary procedures will find themselves experiencing dark moments of the soul – especially when they are innocent of the charges brought against them, and even more so when panel hearings are beset by unnecessary delays, dithering and incompetence.

At the risk of boring those who have already seen my previous blog on the issue, I’ll use the case of Derek Keilloh as an example, because the timeline is instructive.

1. September 2003. The date of the alleged offence: failing to recognise signs of ill treatment of a detainee in the heat of battle in Iraq.

2. July 2007. A complaint is made about Dr Keilloh to the GMC. They wish to wait for the outcome of the public inquiry into the Baha Mousa case before deciding whether to investigate, and in the meantime he carries on working with the threat of proceedings hanging over him.

3. October 2008. Baha Mousa Enquiry opens.

4. September 2011. Enquiry report issued. Over four years since the initial complaint, and despite the fact that the report does not accuse Dr Keilloh of lying, the GMC decide to instigate proceedings.

5. June 2012. After another nine month delay, the MPTS hearing begins. After six weeks, in mid-July, the panel decides that they have run out of time, and postpone the hearing.

6. December 17, 2012 after another three months of agonised waiting for the Keilloh family, the hearing resumes, and lasts for a week.

7. December 21, 2012. Four days before Christmas, and with his excited young family looking forward to the festivities, the MPTS inform Dr Keilloh that he is being struck off the register, and no longer has a career. He has 28 days to decide whether to appeal, with many of those days blighted by the official inactivity which accompanies Christmas and New Year holidays.

8. In January 2013, a depressed and exhausted Dr Keilloh decides that he can’t subject himself and his family to the trauma of an appeal. In any case, he has no job and no support from his medical insurers to cover the considerable costs of such an appeal.

I’ve talked about the injustice of the GMC’s verdict and sentencing of Dr Keilloh elsewhere, and won’t go over it again now, but I think the outline of his case, involving five years of constant and increasing anxiety, may explain why so many doctors appearing before the GMC have been reduced to taking their own lives. It is to his credit that, after selling the family house and accepting the loss of the career which he loved and for which the country had trained him at great expense, he has managed to rebuild his life. It wouldn’t have been surprising, though, if at some point in the sorry course of events outlined above he had begun to wonder if it was worth going on. He was fortunate in having the support of a strong and loving family and of his patients, who continue to lobby for his reinstatement. It is easy to imagine how much worse it would be for a doctor going through the process without that support structure.

And Dr Keilloh’s case is not an isolated one. Colleagues called to give evidence before one of these panels have told me of the capricious way in which hearings are cancelled or rearranged at the last minute – in one case, when all those attending were already on their respective trains to London. A hearing was also held up when it transpired that one of the panel members had not read the papers relating to the case.

There is little doubt in the minds of most doctors of my acquaintance that the GMC is a dysfunctional organisation which fails either to protect patients or to ensure fair treatment for doctors appearing before its disciplinary panels. Paying a compulsory annual subscription of £400 for the sort of treatment received by Derek Keilloh and others does not seem like a good deal, and I for one would far rather take my chances before a properly constituted and publicly-funded quasi-judicial body than face the lottery of an MPTS hearing.

In his response to the report on suicides, Niall Dickson, Chief Executive of the GMC said:

we want to handle complaints as effectively as possible and ensure our processes are as quick, simple and as low stress as we can make them. We have made some progress on this but we have more to do.’

You do indeed, Mr Dickson, you do indeed.

 

 

 

 

 

 

An easy death – whose job is it?

The vexed issue of ‘assisted suicide’ has surfaced again in recent weeks, thanks to the media reports of the elderly lady who starved herself to death, in the absence of any state-sponsored mechanism for achieving her desired end.

Some of these reports once again bemoan the fact that doctors are not allowed to assist people to commit suicide (I say ‘people’ advisedly, because they won’t all be ‘patients’ –  we actually need a name for those who wish to take advantage of any relaxation of the regulations around euthanasia, perhaps ‘departees’ would fit the bill?). Why is it always doctors who are put forward as the appropriate profession to pull the plug on those who have decided they have had enough? It’s no longer necessary to give lethal drugs by injection – and even if it was, you don’t need to be medically qualified to get a needle into a vein. ‘Ah’ you say, ‘even with orally-administered drugs, you still need a doctor to provide the prescription’. Well no, you don’t actually – nurses and other paramedical professionals are already authorised to prescribe and administer drugs under controlled conditions (see below).

Of course, it’s true that doctors will be involved in the treatment of many of the departees, because they will be suffering from terminal illnesses. They will therefore be responsible for their treatment, and for advising them on prognosis and on the options available for terminal care, but that doesn’t mean that they should be the ones to pull the metaphorical trigger should their patient opt for early release.

Then there are all the applicants who are either not suffering from any identifiable illness, or who have conditions which are non-terminal. It’s worth noting that the lady identified in the recent reports was complaining of back pain and fainting attacks, both of which are eminently treatable conditions, and which would not have qualified her for assisted suicide under the terms proposed by the supporters of a change in the law. To involve doctors in the killing of these people gives them the status  of state-sanctioned executioners.

Why does any of this matter? It matters because medical practice is based on trust between patient and doctor. Patients who are suffering need to know that their doctor’s one concern is to ease that suffering, something which is nearly always possible, but which occasionally requires doses of drugs that may hasten death. This is an accepted part of medical practice, and is qualitatively of a completely different order to the termination of those who have simply decided that they have had enough, regardless of the presence or absence of treatable disease. Patients need to know that their doctor will not be involved in any abuse of the assisted suicide legislation aimed at achieving their premature departure.

Because, however carefully any new law is drafted, it will be abused. If you don’t believe me, look no further than the 1967 abortion legislation. It was never the intention of David Steele and his colleagues to make abortion available on demand*, but that is what we now effectively have. The same will happen with changes to the law on assisted suicide, and the medical profession should refuse to be involved.

And they don’t need to be involved. If, after they have received any relevant medical treatment and advice, a person wishes to take advantage of relaxed regulations concerning  assisted suicide, their care would pass from the medical into the social sector. After receiving the appropriate counselling (which would hopefully be part of any new legislation) and filling in the necessary forms, they would then qualify for state-assisted suicide. This could be carried out in purpose-built (or converted) premises – I have always thought that ‘thanatorium’ would be a good name for these, although I suppose it might result in a premature end for the patients of short-tongued doctors who really intended to refer them to a convalescent facility.

For those wishing to die at home, there would be flying squads who could bring the necessary drugs and expertise to the departee’s bedside – I wonder how long it would be before someone (probably the Daily Mail) christened them the ‘angels of death’? And one of the consequences of qualification for the service would be that those drugs could be prescribed under an appropriate Patient Group Direction,  the legislation having added employees of the new service to the list of those authorised to administer drugs covered by a PGD. Then all that remains is for someone to hand the tumbler of poison to the departee, assisting them to drink it if necessary.

So there – job done! If society wants  assisted suicide, then society, through its politicians, must devise the necessary legislation and infrastructure. The proponents of a relaxation in the law must not be allowed to get their way and then wash their hands of any responsibility for or involvement in the killing  by offloading it on to the medical profession.

* I use abortion as an example of the ‘mission creep’ which can subvert even the best-intentioned legislation, I’m not expressing an opinion as to the desirability or otherwise of abortion on demand.

 

More political healthcare madness

Over the past couple of weeks we have been blessed with two political ‘initiatives’ on healthcare which would tend to confirm my long-held belief that politicians are not only completely ignorant concerning the science which underpins medical practice, but also incapable of logical reasoning. In the interest of political balance, one of these gems comes from the government (well, NHS England, but it’s the same thing), and one from the hapless Ed Milliband.

First, Ed’s stated intention to ensure that investigations on patients believed to have cancer will be completed in seven days. This compares with the current government’s two week waiting target for these patients. It’s not clear which patients he is talking about: if he’s saying that any patient who might have cancer will be dealt with in seven days, then the NHS will grind to a halt, because just about every symptom known to man could be due to cancer, but usually isn’t. The two week waiting target has already skewed priorities, with the result that some clinics have been swamped with patients whose problems are not really urgent, thus increasing the delay for those with genuinely alarming symptoms.

So let’s give Ed the benefit of the doubt, and assume that he’s talking about patients who have been seen and assessed by a GP and referred to the appropriate specialist, and where there’s a genuine concern that they may be suffering from a malignant condition. If he’s saying that their investigations (imaging, biopsy if indicated, blood tests and so on) must be completed in seven days, that’s a more realistic target. But still completely unachievable. Let me concentrate on the imaging aspects (x-rays, scans, ultrasound), because I’m a retired radiologist and know a bit about it. Even if we had enough equipment to push patients through this quickly, the scans still need to be reported by a radiologist. Giles Maskell, the President of the Royal College of Radiologists issued this press release in response to the initiative. He makes the point that the UK has 48 trained radiologists per million population; Germany has 78, and Sweden and France have well over a hundred. Add to that the fact that demand for imaging services has been increasing at 10% per year for as long as most of us can remember, and it’s clear that any attempt to set new targets will need top address the issue of consultant staffing as well as infrastructure, and this cannot happen overnight – and certainly not within the five year time horizon of politicians.

And of course, it would probably be a waste of time anyway. Despite the public impression that cancers rampage through the body, spreading their tentacles deeper into the normal surrounding tissues like a forest fire, the fact is that most tumours develop over a timescale measured in years rather than hours, so chopping a few days off the investigation schedule is unlikely to make any difference to outcome. There are much better ways to spend £750 million in the NHS.

Which brings us to NHS England’s asinine plan to give GPs £55 for every case of dementia they diagnose. I mean, what exactly are they supposed to do with the money that will make diagnosis more likely? Is the suggestion that GPs currently just can’t be arsed to do their job properly, and that a couple of quid in their back pocket will induce them to behave professionally? This is where I begin to despair of the ability of NHS chiefs and their political masters to construct a logical argument. I cannot conceive of any way in which this piddling payment will have any effect on the diagnosis of dementia. Yes, late diagnosis is a problem, but that’s because patients present late, not because GPs are too stupid or lazy to recognise the condition when they see it. The money would be far better spent on public education to increase awareness of the early symptoms and signs of dementia, and improving the support service available to sufferers and their carers. But of course, that wouldn’t be eye-catching enough, and wouldn’t attract any headlines.

Ebola is scary, but much more scary is the intellectual poverty of the political class which produces this sort of crowd-pleasing nonsense.

GMC vindictiveness

Imagine the scene. You are a doctor in the Royal Army Medical Corps. You have been posted at short notice to Basra, and you are working alone, in temperatures around 40C in a hostile active service environment, with no readily available advice or supervision from more senior army medics. Your requests for training for your new role were refused, because the remainder of the detachment (from a regiment you had never worked with before) had already received theirs before you were suddenly drafted in.

This was the situation that faced Derek Keilloh on 15 September 2003, at the height of the Second Gulf War. He was a young doctor who had joined the Royal Army Medical Corps as a medical student, and was still 6 months short of completing his training as an army GP – in the UK, he would not have been working unsupervised. When he arrived, he found that, in addition to the troops in his unit, the base housed a detention centre. He was given no clear instructions concerning his role and responsibility, if any, in relation to detainees, or how to deal with them.

This latter omission became relevant on that September evening, when Dr Keilloh was called urgently to see a prisoner who had collapsed. There was no electricity in the stifling detention block, and he had to examine the patient, Mr Baha Mousa, by moonlight. Realizing that he had suffered a cardiac arrest, Dr Keilloh commenced resuscitation procedures, then moved him to the adjacent medical centre, where there was at least some illumination from a single flickering fluorescent tube. Resuscitation attempts by Dr Keilloh and his hastily-assembled team continued for some time, but were ultimately unsuccessful.

Like all doctors following a failed resuscitation attempt, I’m sure he went over the events of the night in his mind, wondering what more he could have done, but to this day, no-one has suggested that he has any cause to reproach himself. There is universal agreement that the treatment given by Dr Keilloh was exemplary, and that Baha Mousa’s death was not due to any shortcomings in the medical care he received.

Dr Keilloh left the army in 2005 at the end of his fixed-term commission, going on to become a successful and highly-regarded GP in Northallerton. When evidence emerged that some detainees at Basra, including Baha Mousa, had been mistreated, a court martial tried four soldiers, one of whom was found guilty and sentenced to one year’s imprisonment. Dr Keilloh was called as a witness at that time, but no charges were made against him. He subsequently appeared before the Baha Mousa public enquiry in 2008, and again there was no suggestion that he had lied about events in Iraq.

Subsequently, a delayed complaint concerning Dr Keilloh was made to the General Medical Council (GMC). They are strangely coy about the source of the referral, but there is general acceptance that the complainant was Phil Shiner, whose Public Interest Lawyers (PIL) specialize in bringing cases against British soldiers for alleged war crimes in Iraq. This is the same PIL which was recently forced to admit that there was no evidence to substantiate their claims that troops in Iraq had illegally killed up to 20 civilians. The al-Sweady enquiry initiated by PIL collapsed earlier this year, by which time it had been sitting for 167 days, consuming £22 million of public money. To some observers familiar with Dr Keilloh’s case, much of the evidence in that enquiry sounded familiar, despite the fact that it related to different events and was delivered by different witnesses.

Shiner alleged that Derek Keilloh must have seen evidence of Baha Mousa’s mistreatment and should have reported it to his superior officers. This assertion was largely based on the fact that photographs of Baha Mousa’s body appear to show evidence of physical abuse. The photographs concerned had been taken six days post-mortem, after his corpse had been driven 20 miles in a body bag to the nearest morgue. Dr Keilloh has repeatedly and consistently denied seeing any such evidence of mistreatment as he struggled to revive his patient in the gloom and heat of Basra, and it is widely accepted that bruising can evolve post-mortem even in the best of conditions. These were not the best of conditions.

Nevertheless, the GMC decided there was a case to answer, and their Medical Practitioners Tribunal Service (MPTS) hearing commenced in June 2012. After unacceptable, stress-inducing dithering, they finally reached a verdict just before Christmas 2012. Let’s hear some of the things the panel said about Derek Keilloh: he was ‘a man of good character; a highly respected and dedicated doctor with excellent clinical skills who is trusted and respected by colleagues and patients alike; an honest, decent man of integrity’. They concluded: ‘The Panel is satisfied that you do not pose a risk to patients. It has a large amount of information before it that you are an excellent doctor’.

So – not guilty, then? Back to work with you? Not a bit of it. They decided that, ‘on the balance of probabilities’ (the standard of proof required by the GMC to deprive a doctor of his profession and his or her patients of their doctor), he had lied about his awareness of the mistreatment of prisoners, and that they had ‘no alternative’ to erasing his name from the medical register. When the GMC was criticized recently by the High Court in relation to another unsafe verdict against a GP, their lawyer defended the organization by re-iterating its overriding responsibility to protect the public. But just who were they protecting from Derek Keilloh – this ‘honest, decent man of integrity’, this ‘excellent doctor’?

I worked in a military field hospital in the Middle East, and can imagine the conditions that faced the young, unprepared Dr Keilloh. The MTPS panel claimed to recognize and allow for this, but then proceeded to judge him as if he were a civilian GP working in a pleasant, UK surgery with ready access to advice and support from his seniors. Reading the transcript of the hearing it is difficult to avoid the conclusion that their verdict was based on a desire to punish, rather than on a proportionate response to the facts of the case, or concern for the welfare of patients.

Compare this to the case of Mohammed Kassim Al-Byati, a doctor who appeared before the MPTS in 2013, again on the basis of events in Iraq many years earlier. It found that he had known that his patients had been tortured, and that they would be tortured again when they left his care. Did the MPTS erase his name from the Register? No, they merely suspended him from practising for ‘up to 12 months’. So, despite the panel’s assertion, there were alternatives available, even if they thought Dr Keilloh was guilty.

Judith Nicholls, Derek Keilloh’s mother-in-law, says ‘my family have suffered a great wrong and I won’t rest until I’ve done all I can to clear his name and help to change the system that caused the damage’. His patients in Northallerton offered spontaneous support, and have campaigned vigorously for his return to work. A petition asking that his case be reconsidered has attracted almost 2000 signatures, and can be found at: https://you.38degrees.org.uk/p/support-Derek-Keilloh.

Later this year, Parliament are due to review the legislation relating to the GMC’s disciplinary role, and not before time. Although the Professional Standards Authority can investigate GMC verdicts which are thought to be too lenient, there is no mechanism of appeal for doctors who feel that they have been too severely treated. At the suggestion of William Hague (her MP) Judith Nicholls sent her ideas for the new legislation to the Department of Health, but they refused to look at them, and suggested she send them to the GMC. Not surprisingly, she sees little I hope of a favourable reception in that quarter.

The GMC runs the risk of alienating both the doctors it is supposed to be regulating, and the public it should be protecting. Its disciplinary decisions often seem to be inconsistent and conflicting: on the one hand, they deprive Derek Keilloh’s patients of the services of a GP who they themselves declare to pose no risk; on the other, they have, for example, been criticised for allowing doctors convicted of sex offences to remain on the register.

But for now, Derek Keilloh’s career is effectively over, and his patients have been deprived of the care of a GP recognized as ‘excellent’ by the GMC, at a time when GP services are under greater pressure than ever. All this because the disciplinary panel decided he might have fallen short in his duties as a whistle-blower in the heat of war 11 years ago. If anyone thinks that is fair or sensible, they will need to explain it to me. Carefully.

Baha Mousa undoubtedly suffered a great injustice, which cost him his life. Derek Keilloh, the man who tried to save him, is still alive, but he has been deprived of his career. He is the second victim of the Baha Mousa affair.