Medical students seem to be put off choosing psychiatry as a career by their psychiatric attachment during medical school. Why is this and can anything be done about it? Raj Persaud Consultant Psychiatrist in Private Practice in Harley Street discusses the predicament with young psychiatrists in training.
Raj Persaud and Peter Bruggen
Sir David Nicholson, head of the health authority that oversaw the Mid Staffordshire NHS Trust hospital for 10 months in 2005 and 2006, before becoming the head of the NHS in England, told a committee of MPs a couple of months ago, that he was "absolutely determined" to carry on leading the NHS.
Before his appearance at the committee, he was reported to enjoy the support of Downing Street, but afterwards, it was said, such backing was on the wane. Now he has resigned, he's been quoted as admitting that the health service "can still sometimes fail patients, their families and carers".
It seems that you can oversee the unnecessary deaths and suffering of hundreds of patients yet be promoted in the NHS. However, should you embarrass the Prime Minister's office, before a parliamentary committee, then you're in real trouble.
Charlotte Leslie, the Tory MP for Bristol North West, is quoted in the Daily Telegraph as being "absolutely sickened" that Sir David has been able to retire on his own terms. She is quoted as declaring:
"While whistle-blowers who raised serious concerns about patient safety were sacked, and had their careers ruined, a man who mislead Select Committees, did not intervene as promised in whistle-blowing cases, who implied those raising concerns about mid-staffs were simply 'lobbying' and who presided over the culture of fear and bulling in the NHS, walks away with a large public sector pension."
But scandals can get things going.
Professor Mary Dixon-Woods, Karen Yeung and Charles Bosk recently reviewed examples of scandals around the negligence of doctors from the mid-Nineties onwards, where they appear to have had particular impact: tougher regulation of the medical profession.
In their paper entitled, 'Why is UK medicine no longer a self-regulating profession? The role of scandals involving "bad apple" doctors', the academics from the University of Leicester, King's College London and the University of Pennsylvania list examples of recent outrages which galvanised medical regulation.
Professor Dixon-Woods and colleagues suggest in their study published in the academic journal 'Social Science and Medicine' that in part the power of scandals derives from the intensity around their reporting. Vivid, emotional rhetoric, provokes public alarm. They argue that to some extent the extreme nature of the transgressions, the innocence and dependency of the victims and the chasm between claims of virtue of the offenders and their actions, create momentum for change.
Dangerous doctors appear to be a threat. Antagonistic Chief Executives and NHS bureaucrats do not appear as dangerous, although administrators might be more hazardous than individual clinicians.
Historically faceless bureaucracies have killed many more individuals than even the most dangerous doctor, but it's the 'bad apple' physician who seems most capture the public imagination. But does this distract those who should be paying more attention, allowing a 'Mid-Staffordshire' crisis to occur under their noses?
The Royal Colleges have been mysteriously quiet about NHS scandals, seeming blind to them until they erupt into the press, along with the GMC, Monitor, Care Quality Commission, Health Care Commission and the Nursing and Midwifery Council. The preoccupation on what went wrong at Mid-Staffordshire, as exemplified by the questions Sir David faced in parliament, has side-tracked commentators from asking a more fundamental question, namely where was everyone else? Where were the GMC and the Royal Colleges? They were meant to be upholding standards as well.
Doctors are now surely one of the most regulated professions in the UK?
Bodies like these are often not as independent as they would like to be seen. They all may have become too dependent on government discretion and support. There seem to be many ways in which senior clinicians move over 'to the other side', appearing keen to court the ear of the 'establishment'. They don't rock the boat as much as their primary allegiance to patient and medical science should provoke them to.
If the public cannot rely on the host of regulators all of whom failed, then patients and the population of the UK are going to have to become a key part of future regulation, perhaps just as lay members now play a much greater role at the GMC, following the scandals of the 1990s. This means taking much more interest in their NHS, looking after it, protecting the good doctors and nurses they find there.
The public will have to question their local trusts and other health care organisations, using the Freedom of Information Act if necessary. Lobbying whenever experiencing an example of good care, as well as bad, means trust will be restored in the system because of confidence in regulation by patient.
Doctors are going to have to be much more honest with patients when the care being provided is sub-standard medically, particularly if they are administrative and bureaucratic reasons.
Recent events reveal we can't complacently leave the NHS in the hands of the bureaucrats and the politicians. Our experience is they have created a culture of fear and bullying whereby good clinicians are persecuted for standing up for patients or medical science. We have seen officials who endeavoured to discourage whistle-blowing promoted and, at very worse, paid off handsomely.
There has been little interest shown by regulators in pursuing those in management who colluded with gagging clauses in clinician's leaving agreements - emblematic of the culture of bullying in the NHS - stopping doctors speaking out about poor care. These agreements are now supposed to be illegal - but what is being done about those who implemented them, and who are still in post in senior positions in the NHS?
We therefore need to re-centre the whole organisation around the sacredness of the encounter between clinician and patient.
Because, the failure to root out the true rotten core at the heart of the NHS, means more scandals will inevitably follow, even after this latest resignation.