Sorry Ray it is not easy at all to accurately monitor GP's performance,
even by those who want to do it most the GP's themselves!
As well as the obvious problems that a GP has no control over the
behaviour of the patient out of the surgery, There are such things as
work patterns, social influences, personal genetic and medical history,
for which we have no accurate personal data. These all have a major
influence on mortality. One thing that must not be forgotten is the
degree of self determination available to people for it appears that
those with the ability to control their day i.e. when they turn up to
work leave what they do during the day do better in almost all medical
states, thus those with no such control (i.e. workers in factories and
shops etc.) will do worse, GP's have no influence on that, so whom do
you compare each practitioner with?
The problems really start when you look at the data available. I don't
know any data source that gives that employment status of individuals
let alone the type of employment and the degree of self determination
that employment entails. The clinical data is only available from the
doctors, so how do you check the accuracy of that? The social and
demographic data is only available at an ecological level. I am a
professional person living in a deprived area generally social class 5,
so the census data wrongly classifies me and because of confidentially I
don't even appear in the SAS. (I've looked). On top of that at present
there is no way of linking hospital events to community events in the
same person, though perhaps the new NHS number will solve that.
Another point that seems to have been missed is that only one third of
deaths take place outside hospitals in the UK. Those GP's who work in
Practices, like the one I used to belong to, have a tradition of taking
their dying home; to care for them at the end and to help the family;
would appear to have higher home death rates than others and would
undoubtedly be outliers. Those GP's who have surgeries attached to
Hospitals as happens in parts of Scotland would be in deep trouble as
their deaths on the surgery site would be way up!
What I find so devastating about all this was not that an evil man got
away with evil but that I can't see how any system is going to prevent
evil from flourishing. I noted for example that it is proposed according
to one newspaper that GP will be banned from using controlled drugs in
the terminally ill. I presume that means that all the good work by the
likes of Dame Saunders is going to be banned and a patient requiring
strong analgesia for cancer pain will have to be admitted to an acute
bed. Presumably patients who have heart attacks and so might die soon
will also not be permitted to have diamorphine (the drug of choice for
their pain). Well there goes the Health of the Nation Target of reducing
deaths from Heart attacks! We had better start building a lot of large
hospitals to cope with the terminals.
I suspect the only real solution is to get to know the practitioners in
each areas and monitor them as people. That is a labour intensive, slow
process. From my own experience in a very different case, even when you
are sure something is going on, it is very difficult to prove wrong
doing in the genuinely guilty, all you can do is wait for them to make a
mistake, which in the case of Shipman was when he forged the will of the
mother of a probate solicitor. Having shown he was a crook getting the
evidence to find his other crimes becomes easier as notes computer
records etc. can be obtained under warrants. Prior to that only the
innocent would reveal faults; the truly guilty would, as with Shipman,
cover their tracks. Remember Al Capone was convicted for Tax evasion not
for murder!
The only real solution is to ensure that there is plenty of time for
people to pause and think. I'm afraid in today's "efficient" NHS, time
is one thing that is in very short supply. Patients suffer as a result.
My own personal views of course, but I suspect quick solutions are not
possible rather a piece meal improvement in the data and methods that
may take a century or more to perfect is required.
I beg list members to excuse a rather rambling submission but I do worry
that we will forget that "hard cases make poor law". We may regret
forgetting that just because one evil man killed many people, many more
good people have just quietly gone on helping their neighbours and in
many cases saved their lives by nothing more than simple care and
attention.
--
Dr Mark Temple <[log in to unmask]>
Glannant
7 Glangwrelych
Pontwalby
Glynneath
West Glamorgan
SA11 5LN, Tel 01639 721521
Fax 01639 729010
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