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
"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
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
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
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
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
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
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
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.