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BMJ 2008;336:1438 (21 June),=20 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=20 prevented from seeing their patients. I had attended a woman = with a=20 massive postpartum haemorrhage who nearly died. After = resuscitation=20 and various medical and surgical procedures, she needed a=20 hysterectomy. She recovered well and went home after a week = with her=20 baby. She did not attend her postnatal follow-up, but no = further=20 appointment or letter was generated.
Eventually, she went to her general practitioner with various=20 questions as she was unhappy. After a saga involving lost = letters,=20 an appointment was finally made with her consultant = obstetrician=20 and me, the operating surgeon.
Two weeks before the scheduled appointment an exploratory legal=20 letter arrived at the trust. Without sight of the GP=92s = letter,=20 the head of legal services decided that the patient was on "a = fishing=20 trip" as "the solicitors were well known to be aggressive." = It was=20 said that the issue was not clinical, and there was a fear = that two=20 consultants might jeopardise the hospital by admitting = liability. I=20 was asked to cancel the appointment, on my colleague=92s = behalf, as he=20 was on leave. I refused, and made vigorous representations = that this=20 was the wrong course of action; I was supported by the = clinical=20 director and the medical director.
Women whose fertility is unexpectedly and dramatically ended = are=20 often upset. Patient care justifies my existence, and consultants=20 make themselves available if GPs refer for opinions. Even = though=20 the woman=92s life was saved, she might have been traumatised = and=20 was entitled to ask questions about her care.
I wrote a detailed report and was pleasantly surprised to find=20 good notes and documentation, exemplary management from the=20 whole team, and no areas of medicolegal risk. I gave the = trust=20 the Medical Defence Union=92s advice, which was to meet = the=20 patient, especially as cancelling would likely be inflammatory. = I=20 offered to have a tape recorder or others in attendance; all = to no=20 avail. The appointment must be cancelled. The MDU also warned = me that=20 employees have to obey instructions. My calls to the legal = department=20 were not returned. The chief executive was dragged in. The = legal=20 department advised that cancelling was the advice of the NHS=20 Litigation Authority (NHSLA), and with less than 48 hours=92 = notice,=20 the chief executive authorised the cancellation by recorded=20 delivery.
When things go wrong, the General Medical Council advises that=20 patients "have a right to expect prompt, open and = constructive=20 response . . . You must not allow a patient=92s complaint = to=20 prejudice the care or treatment you provide or arrange for = that=20 patient." It seemed odd that the NHSLA would give conflicting = advice,=20 particularly when its website recommends resolution, so I = inquired=20 whether it was happy that the decision to cancel had been = made in its=20 name. The NHSLA chief executive replied diplomatically: the = NHSLA=20 hadn=92t been asked for advice and would have recommended = continuing=20 with the appointment, but the matter was one between employer = and=20 employee, in which, of course, the authority wouldn=92t wish = to=20 interfere.
I went back to the head of legal services and medical director. = I=20 obtained permission from them to clarify the medical issues, = and rang=20 the GP, who expressed bafflement at the interference in a = normal=20 referral process. They may have been moved by the revelation = that the=20 chief executive=92s action had exposed two senior consultants = to a=20 direct complaint to the General Medical Council. After many = battles=20 (via emails, phone calls, letters, responses, and entreaties) = and=20 four months after the original appointment was cancelled, we = were=20 "allowed" to see the patient. She had a discussion about the = events=20 and consequences and was examined. She was offered a copy of = the=20 notes, a specialist referral, and a letter with further plans = for=20 care, and support was sent to her GP. She went away happier, = though=20 she did subsequently obtain an independent report from a = plaintiff=92s=20 expert, who reassured her we had not been negligent. =
Did simple medical care need to be so difficult? My small = skirmish=20 was, of course, a pyrrhic victory. By neglect of the = "clinical"=20 in "clinical manager," the patient and her needs were lost in = bureaucratic exchanges. Basic professional values were = compromised,=20 and consistent medical advice from four advocates (the GP, = two=20 consultants, and medical director) was over-ridden. The = decision=20 is explicable only if protection of an institution takes = precedence=20 over good care of its patients. The trust=92s behaviour = was=20 disappointing. One should not be fooled by rhetoric about = "putting=20 patients first" or catchphrases such as "Delivering = Excellence."=20 Watch the behaviour, and judge if it=92s really about = patients.=20
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