Sunday, October 1, 2023

‘Lovely Lucy’ and the impotence of consultants

The role of the hospital consultant has changed radically over the last few decades writes Dr Chris Luke, and the recent Lucy Letby case in the UK highlights the dangers of sidelining consultants’ opinions in hospital management

As a boy, I was blessed to be the patient of two particularly inspiring South Dublin GPs, Dr Aiden Meade and Dr John Fleetwood Snr, so I had a very high and warm opinion of family doctors from an early age. And the wonderful Kay Conway, ‘across the road’ from my house, made me believe that all nurses were sweet-natured, and kindly.

It was a different matter, however, when it came to the ‘high priests’ of the medical profession. My earliest (and long-enduring) paragon of a hospital consultant was the bombastic and irascible surgeon, Sir Lancelot Spratt (played by James Robertson Justice), the leading character in the 1954 film, Doctor in the House, which also featured a young Dirk Bogarde as a nervous medical student, Simon Sparrow, newly arrived at St Swithin’s Hospital, in London. Sir Lancelot absolutely dominated life in the hospital and, although his well-hidden heart of gold was revealed at the end of the movie (and in its numerous sequels), his every utterance inspired trepidation in all those around him, whether it was in the lecture theatre, operating theatre, or on the ward round.

All of this reflection on the impression that doctors and nurses make – how they are perceived – was prompted by the unfolding horror story featuring Lucy Letby, the nurse who, from June 2015 to June 2016, killed and maimed so many babies in the neonatal intensive care unit at the Countess of Chester Hospital, an institution with which I was familiar when I was a consultant in nearby Liverpool in the 1990s. I was even better acquainted with the Liverpool Women’s Hospital, where our third daughter was born, and where Letby trained. Alarmingly, investigations have started to see if Letby actually commenced her murderous campaign there, before she moved to Cheshire.

Now, I’m reluctant to mount a bandwagon at the best of times but, seeing how the tide may be turning, it would be remiss of me to ignore how the perception (or misperception) of hospital staff, like consultants and nurses, seems to have been at the very heart of the grotesque tale of a nurse (‘Lovely Lucy’), who cunningly killed seven neonates – and horribly injured at least six others – by means of injected insulin and air, massive amounts of force-fed milk, disconnected tubes and leads, objects rammed into windpipes, or so forcibly pressed against one liver that it partially ruptured.

Unfortunately, I’m long enough in the tooth to have lived through similar terrifying episodes from the world of healthcare.

Dr Harold Shipman, a popular Manchester GP, may have killed as many as 250 elderly patients, starting in 1971 (usually by injecting them with Diamorphine, for the purposes of euthanasia, or to benefit from their altered wills, or ‘in revenge for his mother’s death’, it has been suggested, but we’ll never know, as he killed himself in prison in 2004). And another nurse, Beverley Allitt, killed four infants (and tried to kill another nine) in Grantham Hospital in 1991, also by injecting her victims with insulin and air.

These are just three examples of malignant healthcare professionals who intentionally killed very vulnerable patients, but there are many others around the world who have deliberately or accidentally killed, or permanently injured their patients. During my own time in the NHS, it was said that 170 children died in the Bristol (heart surgery) unit between 1986–1995, who would have survived in other NHS hospitals but succumbed as a result of “staff shortages, a lack of leadership, [a] unit that was ‘simply not up to the task’, ‘an old boy’s culture’ among doctors, a lax approach to safety, secrecy about doctors’ performance, and a lack of monitoring by management”. And of course, infamously, in recent years, there has been the oft-repeated message that in the United States, ‘medical errors are the third-leading cause of death after heart disease and cancer’, and doctors ‘kill’ between 250,000 and 400, 000 people every year.

If you add in the historical animosity between politicians and (especially pin-striped) consultants and the way that so many ‘Sir Lancelots’ treated their patients, students and colleagues (including managers), you can easily see why a process of ‘taking consultants down a peg or two’ might have been deemed both necessary and desirable.

I’m not sure about the changes in general practice but, having been a clinically active consultant in the NHS and the Irish health system for about 30 years, I suspect that the curbing of ‘consultants’ power’ has always been an attractive political proposition.

Recent initiatives to limit senior medics’ influence have included the introduction of ‘modern management’ processes in the NHS, as prescribed in the 1983 Griffiths Report, with the appointment of general managers in all hospitals, the creation of the ‘internal market’ (with NHS Trusts ‘competing’ against each other), a blizzard of often-conflicting governance and clinical regulations, the calamitous Modernising Medical Careers training reforms, the new consultant contracts foisted on doctors (trying to ‘stuff their mouths with gold’, it seems, with predictable drops in medical morale and performance).

In practice, for consultants, the consequences included the loss of their coffee room, ‘consensus’ on hospital policy (traditionally hammered out in consultants’ committee meetings) and even control over their working environments, resources, and the quality or safety of their service. And, in due course, came the perennial anxiety, the sleepless nights and the constant fear of litigation or vexatious complaint to the GMC or Medical Council of Ireland.

Few accounts of the dwindling importance, and growing impotence, of consultants have been as succinct, vivid and powerful as that of Dr Stephen Brearey, the lead consultant paediatrician in the neonatal unit in Chester in 2015, who tried repeatedly to tell the senior management team there (the CEO, Director of Nursing and Medical Director) about his concerns that the soaring rate of deaths in his unit was statistically shocking and medically inexplicable. “You go to see senior colleagues about a problem”, he said on BBC Radio 4 in late August 2023, describing his experience, “and you come away feeling confused and anxious, realising that they see you as the problem”. (I know how you feel, Stephen, I really do)

And it got worse (as it always does when there’s a cover-up). In spite of months of repeated warnings by other consultants, the Countess of Chester Hospital managers effectively enabled Letby to murder, or permanently damage, five more babies before she was moved from the unit. At one point, the hospital management compelled Dr Brearey and his colleagues to write a ‘grovelling’ apology to Letby, and ordered them to attend ‘mediation’ with her, despite their growing conviction that she was a killer. There was even a suggestion that the consultants should be reported to the GMC (a tactic which has reportedly been used by numerous NHS Trusts to silence medical ‘whistle-blowers’, along with baseless performance management processes or other negative consequences).

I am old enough to remember why some hospital consultants were feared and loathed. There were quite a few such despots around in the hospitals I worked in throughout the 1980s and 1990s. And I was around when many of the political, legal and organisational initiatives were introduced, to directly or indirectly constrain (some might say ‘emasculate’) difficult or under-performing consultants. And with the suggested mortality and mishap rates associated with unregulated doctors, one can see why strict sanctions for ‘not listening’ or ignoring the facts were warranted.

Still, it seems to me that the ‘God-like’ consultants of yore are on the endangered list, and pin-striped Sir Lancelots are vanishingly rare. One obvious reason is that most medics are now female, but I genuinely believe that we now have a far more approachable, courteous and humble cohort of consultants, the likes of Dr Brearey in Chester (or – on this side of the sea – that exemplar of modesty and good humour, the President of the Royal College of Physicians of Ireland, Professor Mary Horgan).

So back to the bandwagon: doctors are rightly fearful of being referred to the GMC or Medical Council of Ireland. A public inquiry into their fitness to practise can be nightmarish (I gather) and to be ‘struck off’ means professional catastrophe. It also nullifies years of exceedingly difficult training, exhausting exams and CME, not to mention the profound dedication to patients and medical science often found in even the most egregious of medical ‘sinners’.

In short, the sanctions for serious medical misconduct are severe, and I would contend that they are a real deterrent to the aberrant. But, in a 21st century remake of Doctor in the House, the person with the real power of life and death would now be a hospital CEO. It really does seem strange – outrageous even – that this new Sir Lancelot (or Queen Guinevere, if you recall the legend) might still get away with murder.

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