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Home > Comment > BMJ
2008;336(7658):1438 (21 June), doi:10.1136/bmj.39602.460498.3A

BMJ  2008;336:1438 (21 June),
doi:10.1136/bmj.39602.460498.3A

Views & Reviews

Personal View

Is it about the patients?

In the strange new world of the modern NHS doctors must now be
prevented from seeing their patients. I had attended a woman with a
massive postpartum haemorrhage who nearly died. After resuscitation
and various medical and surgical procedures, she needed a
hysterectomy. She recovered well and went home after a week with her
baby. She did not attend her postnatal follow-up, but no further
appointment or letter was generated.

Eventually, she went to her general practitioner with various
questions as she was unhappy. After a saga involving lost letters,
an appointment was finally made with her consultant obstetrician
and me, the operating surgeon.

Two weeks before the scheduled appointment an exploratory legal
letter arrived at the trust. Without sight of the GP’s letter,
the head of legal services decided that the patient was on "a fishing
trip" as "the solicitors were well known to be aggressive." It was
said that the issue was not clinical, and there was a fear that two
consultants might jeopardise the hospital by admitting liability. I
was asked to cancel the appointment, on my colleague’s behalf, as he
was on leave. I refused, and made vigorous representations that this
was the wrong course of action; I was supported by the clinical
director and the medical director.

Women whose fertility is unexpectedly and dramatically ended are
often upset. Patient care justifies my existence, and consultants
make themselves available if GPs refer for opinions. Even though
the woman’s life was saved, she might have been traumatised and
was entitled to ask questions about her care.

I wrote a detailed report and was pleasantly surprised to find
good notes and documentation, exemplary management from the
whole team, and no areas of medicolegal risk. I gave the trust
the Medical Defence Union’s advice, which was to meet the
patient, especially as cancelling would likely be inflammatory. I
offered to have a tape recorder or others in attendance; all to no
avail. The appointment must be cancelled. The MDU also warned me that
employees have to obey instructions. My calls to the legal department
were not returned. The chief executive was dragged in. The legal
department advised that cancelling was the advice of the NHS
Litigation Authority (NHSLA), and with less than 48 hours’ notice,
the chief executive authorised the cancellation by recorded
delivery.

When things go wrong, the General Medical Council advises that
patients "have a right to expect prompt, open and constructive
response . . . You must not allow a patient’s complaint to
prejudice the care or treatment you provide or arrange for that
patient." It seemed odd that the NHSLA would give conflicting advice,
particularly when its website recommends resolution, so I inquired
whether it was happy that the decision to cancel had been made in its
name. The NHSLA chief executive replied diplomatically: the NHSLA
hadn’t been asked for advice and would have recommended continuing
with the appointment, but the matter was one between employer and
employee, in which, of course, the authority wouldn’t wish to
interfere.

I went back to the head of legal services and medical director. I
obtained permission from them to clarify the medical issues, and rang
the GP, who expressed bafflement at the interference in a normal
referral process. They may have been moved by the revelation that the
chief executive’s action had exposed two senior consultants to a
direct complaint to the General Medical Council. After many battles
(via emails, phone calls, letters, responses, and entreaties) and
four months after the original appointment was cancelled, we were
"allowed" to see the patient. She had a discussion about the events
and consequences and was examined. She was offered a copy of the
notes, a specialist referral, and a letter with further plans for
care, and support was sent to her GP. She went away happier, though
she did subsequently obtain an independent report from a plaintiff’s
expert, who reassured her we had not been negligent.

Did simple medical care need to be so difficult? My small skirmish
was, of course, a pyrrhic victory. By neglect of the "clinical"
in "clinical manager," the patient and her needs were lost in
bureaucratic exchanges. Basic professional values were compromised,
and consistent medical advice from four advocates (the GP, two
consultants, and medical director) was over-ridden. The decision
is explicable only if protection of an institution takes precedence
over good care of its patients. The trust’s behaviour was
disappointing. One should not be fooled by rhetoric about "putting
patients first" or catchphrases such as "Delivering Excellence."
Watch the behaviour, and judge if it’s really about patients.

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