Bill passed away on 5 February 2015 after a brief illness.
Dr Bill Pickering was a huge influence on my thinking over 15 years, and along with the Bristol whistleblower Steve Bolsin and Bristol parent Maria Shortis (now Maria Von Hilldebrand), he was the most lucid thinker about patient safety that I was privileged to meet. Steve demonstrated the urgent need for NHS staff to be able to speak up about NHS failings without fear of persecution, and the duty of managers and regulators to act on this. Maria lost her baby at Bristol and yet started a wonderful charity called Constructive Dialogue for Clinical Accountability, whose focus was on culture change in the NHS towards an honest, open and trusting relationship between users and staff that was truly accountable. But it was Bill who had the best idea on how to achieve this.
I supported his vision for an independent medical Inspectorate as far back as 1999 in Private Eye. Having a local and independent body in every region, free from the NHS brotherhood yet staffed by clinicians, who would swiftly investigate all serious clinical concerns arising from patients, carers and staff – and could go in and access the notes – was a brilliant idea. It was strongly resisted by the medical establishment, although elements of it appear in the CCQ hospital inspectors and the new whistleblowing guardians. Bill’s idea was much simpler, leaner and quicker – and in my view would’ve been more effective. Instead of sending 80 inspectors to hospital at huge expense to invade a hospital periodically, have a lean team locally placed and charged with continuously monitoring the concerns and experiences of patients, carers and staff. This would use the frontline of the NHS as a smoke alarm to nip problems in the bad and prevent them becoming disasters. It would also dismiss vexatious complaints quickly.
Below is just a selection of the mentions of Bill’s work in Private Eye and some of my private correspondence with him. He was great company, funny, driven and absolutely committed to clinical accountability and a safer NHS. His ideas and passion will stay with me for life. We should all read his chapter in Regulating Doctors.
See Pickering W. in Regulating Doctors, ISBN 1-903 386-0
WHO PICKS UP DOCTORS’ MISTAKES?
Private Eye 18 November 1999
Can you make the NHS safer from the top down? We now have a National Institute for Clinical Excellence (NICE) to sift through the evidence and decide on what the NHS should (and shouldn’t) provide, and the Commission for Health Improvement, to ensure that NICE’s diktats are observed. The commission’s first job has been to change its acronym from CHIMP (the ape-association was deemed too flippant) to CHI (half a celebrity panda).
Whether either of these quangos will change behaviour on the ground is debatable. For over ten years Dr William Pickering, a GP with wide experience of medico-legal work, has campaigned for an independent medical inspectorate by asking ‘who picks up doctors’ mistakes?’ Pickering has concentrated on the very basic and rudimentary clinical errors that any reasonably competent doctor should avoid. These generally involve the unnecessarily late diagnosis of treatable disease and the improper supervision of ongoing medical treatment.
In his medico-legal work, Pickering has seen repeated examples of doctors of all ages and ranks failing to follow basic medical rules. For example, failing to investigate blood in the urine resulting in death from undiagnosed bladder cancer or failure to put a patient with a heart attack or a stroke on medication to prevent a further attack. Errors such as these happen every day in the NHS but even when they result in patient harm, they are rarely picked up or commented on. Even at the simplest of levels, there is no systematic way of identifying and acting on doctors’ individual mistakes.
Pickering believes that an independent medical inspectorate, headed by doctors with a presence in every region, would be a huge step forward. Only doctors have the easy access to patient records necessary to make an informed judgement, and they have a much clearer idea of what is acceptable practice. The inspectors would not, however, be employed by the NHS and would therefore be less likely to let misguided loyalty get in the way of rational thought. Just an idea.
TRUST ME, I’M STILL A DOCTOR
Private Eye 3 February 2000
Harold Shipman is free to doctor his fellow prisoners, despite his fifteen murder convictions, since the GMC is prohibited from taking action while a criminal investigation proceeds, and will be further delayed if Shipman appeals. Once criminal proceedings are completed, the GMC is then required to give 28 days’ notice of the intention to suspend a doctor from the register. So Shipman can call himself a doctor for some while yet.
Many doctors now have little faith in the GMC’s ability to regulate the profession. As Dr Bill Pickering writes: ‘One important reason that Shipman got away with it for so long was because he knew that in the NHS, and in general practice in particular, doctors can do more or less what they like. They call it “clinical freedom” and cherish it. No one (except the law) can meaningfully challenge their actions, and then only if they are found out. Medical ethics do not include commenting on another doctor’s practice, nor do they insist upon an open mentality. The “self-regulation” of doctors is, therefore, equivalent to no regulation.’
See Pickering W. in Regulating Doctors, ISBN 1-903 386-0
LETTER FROM BILL
Now is as good a time as any for you to re-ventilate the Independent Medical Inspectorate, and probably an excellent time, as change is in the air.
Whilst the idea of clinical accountability is obvious to me, to Janet Smith, and to just about every patient or taxpayer I have ever spoken to, others find it uncomfortable – ie. doctors, medico-politicos. Politicians like the idea but are lay persons and guided by the very doctors who don’t want it. Accountability is not popular. ‘Doctors are professionals and above that’ – they are not of course, anything but.
Whilst you are (very reasonably) driven by Bristol (hospital, high profile, children) I too am interested in hospitals (incl. paediatrics). But I’m every bit and perhaps more struck by what happens in the maw of general practice.
Without even having to trawl for elementary errors, I hear from people I know (lay) of what has been missed, and their terribly remiss consultations, (and adverse outcomes): week by week.
Medico-legal cases I have seen defy belief (and never make it to the GMC).
It is important to realise how many basic clinical errors there are every day, nationwide. The ‘Professional’ and statutory bodies alleged to deal with them, including the Law, see but a pinprick.
In the torrent of ‘innovations’ currently mooted by the government ± profession, there seems nothing which smacks of clinical accountability or IMI.
I am glad you propose to bring it up.
Were meaningful clinical accountability to be in situ, the NHS would save a hatful of money overnight (and render expensive ‘ways around it’ redundant).
To answer your questions:
- Nobody listens to whistle blowers (you write) in the NHS (or private).
They may be ‘silenced’, but the real point is they are not listened to when they are not silenced. Hence IMI.
- Complaints and responses (my idea, JRCGP Nov ‘88, p517; and also: ‘An Independent Medical Inspectorate, in CIVITAS booklet June 2000 ‘Regulating Doctors’.)
Sent to a named GP you say? In consortia. Who is responsible?
Well …… better than nothing. But in my view, impartiality is only the domain of a separate body. Separately paid. No nepotism, partisanship. Cold impartiality.
- Send to GMC/CQC (don’t really fully understand the latter by the way!)
Phil, the GMC would groan under the weight of work. They wouldn’t know what had hit them.
Yes, send GMC the papers if you want (they may then get their act together), but the matter must be dealt with immediately in the region by the IMI. If the GMC want to deal with it in their own way, fine. But sort the matter in the district/region asap. Eg. “Why did you ignore this man’s haematuria!? 3 points on your licence.”
Once this is done, one can expect to see bad medicine plummet in the region. All reports published. The message will soon get around.
- The purchasing arm of the consortium would have a duty to ensure safety concerns were adequately addressed before using public money to purchase unsafe care.
Yes. But it is the IDENTIFICATION of errors which is the real issue going unaddressed, AND them being remarked upon so that they stop.
- And the regulating GP arm would ensure all practices responded appropriately to complaints and concerns.
The IMI, separate body, deals with actual clinical errors.
At the same time GPs must see that complaints and concerns are addressed – but they never have, not impartially, and in my view won’t. The IMI could, by example, force their hand in being attentive to complaints and errors however.
- GPs have to have the balls to ensure what they commission is safe and high quality and this seems to be a good way of gathering information?
Information gathering has been going on for centuries. We are up to our necks in information. It is action that is the issue; identification of sub-optimal practice, on a basis of one doctor to one patient (basic error, why?, stop it! 3 points), not generic overview – this is exactly the lamentable pitfall of the alleged revalidation etc. It is all overview, mood music – it is NOT accountability and will not raise clinical standards by one jot.
I can’t rewrite here all my BMJ articles (most of which are on Rapid Responses), or other letters elsewhere from 1988 onwards, or the Civitas dissertation.
In essence you are RIGHT to bring the matter up; do it loudly. Such is the defensiveness of doctors that they will do anything to avoid their own clinical accountability with real patients.
I wish you well with it. Use the right words (by no means all of which are above here) to force people to think. After all you are writing to mainly lay taxpayers and not doctors, and the former will agree wholeheartedly with you. The doctors are the problem. It is all unassimilable to them For politicians one has to be fluent, brief and obvious (so they respond with: ‘well is all this not already in place then?’ No. (You are probably good at that!) The GMC and the rest see a pinprick of simple medical errors) And make it sound, as it will, that it will save money and force efficiency.
The NHS (to save money) needs to get back onto a clinical track and away from the pastoral proligate bandwagon.
Get back any time Phil. I can go to London or elsewhere easily if anyone wants to discuss it. God knows, I’ve been thinking about this long enough.
Good luck and all the best. Bill P.
PRIVATE EYE – SHOOT THE MESSENGER
June 27, 2011
The GMC obliges doctors to raise concerns about patient harm or risk being struck off, but it then fails to support them and will even spend years investigating vexatious complaints against whistleblowers. Many surveys have found doctors and nurses are still too frightened of repercussions to report concerns about patient safety. The BMA claims to support whistleblowers but the largest portion of compromise agreements with gag clauses are negotiated by the BMA. Professor David Hands knows why: “Professional bodies frequently collude with managers to define the problem as an employment issue because the sacrifice of one employee (who will shortly no longer be paying subscriptions) is better than losing a cosy relationship with an employer.”
NHS whistleblowers are not always right, but are usually genuine in their concerns. They often end up leaving employment while those who suppress their concerns are promoted. Their dedication and altruism is lost forever, and the harm they’ve tried to expose is buried. Lessons are not learned, dangerous care is repeated and thousands of patients die from avoidable harm.
America has its own National Whistleblower Centre and offers huge support to whistleblowers. Why? There is good evidence that whistleblowing is more effective than regulatory authorities, saves vast sums of public money and many lives. The UK should follow suit. What’s needed is not just better statutory protection for NHS employees who raise concerns, but statutory enforcement of sanctions for any professional – managerial or clinical – who fails in their duty to investigate the concerns. And the investigation needs to be truly independent.
The NHS needs its own crash investigation team, free from the NHS brotherhood, that goes in fast and dirty in response to poor outcomes, an unexpected death or injury, serious patient complaint or whistleblowing concern, do a thorough analysis and publish it. This was proposed by Dr William Pickering in 1998 and endorsed by the Eye. The CQC cannot be both regulator and inspector. The key Bristol Inquiry reforms must now be enforced to enshrine safety, humanity and transparency at the heart of the NHS
Medicine Balls , Eye 1345 July 26 2013
Sir Bruce Keogh’s review into the quality of care and treatment provided by 14 NHS trusts with high death rates was shrewd and thorough, but his proposals for proper NHS inspections lead by doctors are nothing new. In 2000, MD endorsed the idea of an independent medical inspectorate in his evidence to the Bristol Inquiry and the Eye in November 1999, based on the work of Dr William Pickering.
“Shipman got away with it for so long was because he knew that in the NHS, and in general practice in particular, doctors can do more or less what they like. They call it ‘clinical freedom’ and cherish it. No one (except the law) can meaningfully challenge their actions, and then only if they are found out. Medical ethics do not include commenting on another doctor’s practice, nor do they insist upon an open mentality. The ‘self-regulation’ of doctors is, therefore, equivalent to no regulation.”
‘Most medical disasters start with single errors or near misses, and yet they only come to light much further down the line when many more mistakes have been allowed to occur. Even then, it needs the strident clamour of patients or the press to get near the truth. So-called regulators have been of singular irrelevance; had it been left to them, many recent disasters would be continuing yet.”
“The only way to exact such basic clinical standards is to have a person in each district of the country undisguisedly looking for sub-optimal clinical practice, working within an Independent Medical Inspectorate. Each Inspector should be informed (a doctor) and impartial (paid from outside the NHS). The Inspectorate will glean its information for any source, including whistle blowers and patient complaints. All clinical complaints, plus a copy of the written response and explanation to the patient from the doctor, will pass across the Inspectorate’s desk. This will press medical personnel into prompt, open and accurate explanations. If indicated, the Inspectorate would examine the medical records and if sub-standard clinical practice is evident, it will swiftly inform the doctor and the regulatory bodies. It’s very presence will force all clinical staff to examine their practice. Clinical standards may be expected to quickly rise. Expensive legal defence costs and awards are likely to drop. Above all, patients can be sure that their doctors are, at last, meaningfully clinically accountable.”
13 years and many disasters later, Keogh and Mike Richards, the new chief inspector of hospitals, have reached the same conclusions, adding in patient assessors too. It remains to be seen how many clinical staff and patients volunteer to be inspectors (MD will), and whether they will be completely independent, properly funded and able to speak the truth to power without getting bullied, ostracised and silenced as has happened to those who raise concerns in the past (Eyes passim ad nauseum). By calling Mike Richards the whistleblower in chief, Jeremy Hunt has at least given the appearance of getting the importance of whistleblowing. Whether he remains so enthusiastic as failures in NHS care under his watch emerge near election time remains to be seen.
Hunt’s Commons response to Keogh was a dangerous game of trying to hole Andy Burnham below the waterline and damage Labour’s credibility as saviours of the NHS. Where Keogh had wisely avoided blame and sensationalism, and focused on the complexities of providing safe NHS care in a cash-strapped service in parts of the country that find staff recruitment tough, Hunt and Cameron went straight for the Labour jugular. MD repeatedly exposed Labour’s missed opportunity of using all the extra funding to rebuild the NHS around quality and safety, the woeful variations in standards of care, toothless regulators fearful of government and appalling treatment of staff, patients and relatives who try to raise concerns. But this has continued under the government’s watch and divisive, political point scoring is ludicrous, particularly given that all political parties have endorsed Sir David Nicholson as NHS leader, despite overseeing such an unsafe and bullying culture. Hunt started off not blaming Labour, but in changing horses while keeping the same jockey, he is setting himself up for a fall. Politicians need to unite around what’s best for the NHS, and the best way to encourage clinical leadership is to have a wise clinical leader. Keogh must step up.
LETTER FROM BILL TO THE GMC
Dr William G Pickering
MB.BS. MRCP. MRCGP. DCH. DRCOG. AFOM. MSc.
Registration and Revalidation Directorate
General Medical Council.
Re: • Your email 12.3.14. • The disparity between GMC claims about revalidation and the daily occurrence of rudimentary clinical errors throughout the UK.
Dear Ms Barton,
Thank you for your further email 12.3.14. I appreciate your efforts.
You admit that the GMC’s revalidation is “not primarily a mechanism for identifying poor practice”. Yet you somewhat irrationally boast that revalidation gives patients “ongoing assurance that doctors meet professional standards.”
Unless the GMC is for its own ends empowered to corrupt the accepted use of English, I am not sure “assurance” is the correct word. ‘Pretence’ would seem more apt.
Taxpayers with bitter experience of the UK’s clinical lottery would be justified in feeling that in its assertion of “assuring professional standards” the GMC is kidding itself and hoodwinking the public.
Dame Janet Smith (Shipman Inquiry Chair’s Report: e.g., V, vol. 3) was neither ‘assured’ nor convinced by revalidation either, and she was in pole position to authoritatively assess the GMC’s rhetoric.
You write of the “high risk nature of medical practice”. It is certainly “high risk” for patients whose doctors who are clinically unaccountable for simple and avoidable errors (e.g., taking an incomplete history, ignoring abnormal laboratory results). The driving of vehicles by licenced drivers is also high risk, but potent traffic police make it less so by instantly punishing transgressors, thereby deterring others. By contrast, there is currently no such impartial accountability to stop or deter UK doctors from driving through clinical red lights by the day, the week or for a working lifetime. They can (and do) break elementary clinical rules with perfect impunity – to themselves.
One wonders why the lofty medical bodies (of which the GMC is but one) are selectively blind to this central issue? No doubt they are politically fearful of incurring the wrath of their members at any mention of clinical scrutiny at the sharp end. So they back off and back off, and instead concoct a remote, modern ‘regulation‘ which permits the most basic medical errors (which are the most dangerous) to continue in quantity, daily and nationwide, just as they have for decades.
Patients’ clinical complaints, assessed by a devoted medical independent body, separately remunerated, with power to promptly punish culprits breaching clinical ground rules with points, fines etc., is one pivotal area to rapidly exact ‘ongoing assurance‘ of clinical quality for patients.
That is very different from crisp GMC revalidation papers whose only certain effect is to licence doctors to earn a salary and pension (both paid by the taxpayer). As you disclose and daily events underline, possession of these documents is supremely irrelevant to rectifying the continuing patchy UK clinical medicine to which taxpayers are subjected.
There is no mention by the GMC of the taxpayer-borne financial costs of revalidation. What are they please? What is the overall annual bill (to the nearest £250,000) for the time lost during the paid working medical year, plus other associated public costs, for 150,000 UK doctors to accumulate the paperwork necessary for them to be accredited and revalidated?
Please pass this letter to anyone you wish at the GMC, Royal Colleges, BMA, House of Commons or to any of the Patients’ Associations.
- Dame Janet Smith.
E MAILS FROM BILL re GMC COMPETENCE AND ACCOUNTABILITY
To: Phil Hammond
|Sent:||07 October 2014 00:16:00|
Have you any idea where I can get info. about nos. of GPs taking early retirement. There’ll be a strong correlation with inception of revalidation (which will be being hushed up by the GMC et al). Both GPs and Consultants are going early, can’t be hacked to be revalidated by some squirt on a salary for doing nothing.
I made mention of this to the GMC in my letters (you may or may not have all of them) to them about ‘shortage of doctors, revalidation driving experienced, competent doctors out of the NHS’.
It is scandalous that there are now huge nos. of experienced doctors now not working who could, and would, even part time. And now ……. there are nasty shortages. Brilliant GMC. Well done.
If you get any figures, or know where I can get some (honest figures) some, please let me know.
What the GMC will be doing is collecting the figures of early retirement but NOT correlating prerequisite of revalidation with them. BMA too, no doubt, and Colleges.
Bill P. Dr Bill Pickering
Date: Sun, 31 Aug 2014 10:26:57 +0000
Where were the paediatricians and GPs?
It occurs to me (from ghastly past experience elsewhere) the local paediatricians will have known all about this, but not a peep from them. They’ve clearly also been cowed by pc and turned a blind eye, like the social workers, council, politicians and police. Have you any informative moles to let this fly?
You are possessed of documents in which the doublespeaking GMC say, I quote:
- a) Revalidation assures patients, and
- b) Revalidation is not aimed at uncovering poor practice.
Do let that out of bag. Such imbecilic claims are damning, and, you have the proof, factually accurate.
Dr Bill Pickering
Date: Tue, 6 May 2014 17:44:52 +0000
Lot of mind-changing going on at the GMC.
- My letter 26.3.14 to GMC – I requested in that letter they pass a copy to lay members. GMC refused.
- Further email to GMC – I requested the GMC to send me their work emails so I could send it. GMC refused.
- Email to GMC 27.4.14 (copy below) I request GMC to send me their work postal addresses.
- Today, GMC emailed me to refuse.
But ‘after considering the matter further’ they have allegedly notified the lay council of its existence who can, if they want, see it on request.
The ‘openness and transparency’ I mentioned in email below may have touched a spot. GMC-think: Let’s make it difficult, but not be accused of shutting it down. Anyway a volte-face of sorts from the GMC. They steadfastly refused at the beginning.
Every single tactic has been used to stop them reading it – to isolate them from GMC members’ views. Heaven help the public who might want to contact them.
The original letter of course was about: The disparity between GMC claims about revalidation and the daily occurrence of rudimentary clinical errors throughout the UK.
The lay members, (whose ‘responsibilities’ I am told today by the GMC pertain ‘not to GMC operations’ but ‘to governance of the organisation’), are the very people who should read it.
Note comparison here between this episode, and the difficulties patients have in making clinical complaints and getting anything other than a defensive response.
Dr Bill Pickering
From: William P Sent: 27 April 2014 11:51 To: Complaints & Correspondence Subject: FAO: Ms C Barton, GMC Reg & Revalidation Directorate.
Dear Ms Barton,
Your email to me (para 2) 14.4.14: ‘You have asked if I will now pass your letter of 26 March to lay members of the Council. However, Council members do not have any operational role in the GMC. It would not therefore be appropriate, and nor is it our practice, to provide recourse to them as part of our processes for dealing with correspondence’.
The GMC has perverted my request. I did not ask that the lay GMC Council ‘deal‘ with my letter. Neither did I ask you to ‘provide recourse to them‘. I asked that each lay member be possessed of a copy so they can read it.
The GMC has refused.
Your email (para 3) 14.4.14.
‘you are free to raise your concerns in any other quarter. And this may include contacting any of members of the Council (sic). But that is essentially a matter for you.’
Fine. But as the GMC has also refused to provide me with the email addresses of the lay members, and as their email addresses are not to be found on the www., could you please now send me the 6 postal work-addresses of your Council lay members.
Presuming that the 6 lay members are not used by the GMC as window dressing to dupe the public (and politicians) into thinking their presence confirms openness and transparency at the GMC; and presuming that it is not in-house GMC policy to deliberately isolate these lay members from grassroots views about patchy UK clinical medicine and the ongoing lack of clinical accountability at the sharp end, lest it taint GMC ideology, I look forward to receipt of the above addresses at which they can be sure to be found.
In passing, in striking contrast to the GMC lay members, I was able to easily send a copy of my letter to Dame Janet Smith via her accessible email work-address (and who confirmed safe receipt by thanking me).
Dr William G. Pickering