<< and in 
addition have clinical governance imposed by a mixture of management, the 
post-Bristol GMC and the MDU? >>
No I don't.  My point about clinical governance---and I have actually gone
and sat with 140 managers on a seminar on it----is that it is utter shite
and not worth one hundredth of the amount of paper which will be consumed
in the process.  I listened to a medical director from some Oxford trust
giving us supposedly the facts.  Maybe I missed his definition of it but I
did not miss his detailed account of the reporting from this committee to
that board, of the paper processes involved.  Absolute and utter shite.  
Reminded me at once of the story I heard from one of N Ireland's top
entrepreneurs on concrete lifejackets and the BS5750/ISO 9000 industry. 
What he said was that you could gain those accreditations for making
concrete lifejackets (non-sailors might like to note that it is *not* a
good idea to put out from land wearing a concrete lifejacket)  so long as
you had it nicely written down, processes documented, QC etc etc. 
What is clinical governance?  The only hard fact I got out of his talk was
that the Chief Exec of the trust will be personally accountable and
possibly liable for clinical  wrongdoing.  And remember,  skipping a few
steps in the arguments, that no-one works unless they want to. NO Chief
Exec can actually make a clinician do something which is against his will. 
Clinician might decide to take the money for now,  to go for a quiet life
etc but the point is that no Chief Exec can walk in on a Monday morning and
start telling clinicians what to do to keep *his* ass out of the fire.   
Most places I know, the reply will likely be, where's that coal bucket?
The GMC is an emasculated bogey man even with current powers---what has it
done about PRHO education for example over all the years we have all known
that PRHO education was terrible?    If things go ahead as predicted then
the GMC will have even less power.
Power over the profession will then reside in some weird amalgam of
management,  lawyers, GMC perhaps and local politicians.  
Have you ever got involved in a NHS attempt to get rid of a totally
incompetent staff member?  I have been there and believe me, even under the
present system which is pretty loaded in general terms *against* those low
down the food chain,  legislation *still* provides for considerable
protection for the accused.     The inevitable accompaniment of spreading
power over several agencies is increased bureaucracy;  the inevitable
accompaniment of bureaucracy is legislation, legal action and prolonged
court cases.   Laws are rarely written simply and there is usually plenty
of space in the cracks between the words for lawyers to make hay and
sometimes do good for their clients. 
So it will (if it ever gets going which I doubt it will properly because it
will take a lot of money and time to do it properly)  be a mess.  Such a
mess that no-one will take it seriously and I certainly cannot see it doing
the profession much harm. 
"Well you see,  your honour, I did not know the latest on smear
interpretation because the trust Chief Exec refused me study leave last
year so I could not go to that international conference where I would have
learned all about it,  did the best I could of course but you know, not
really my fault...." 
"Of course I accept that my management of this kid's  big ears was
incorrect and that the expert advice was available on the net back then but
my health board refused me computer reimbursement so I couldn't afford a
computer.  I would happily have spent five grand of my own money on giving
my patients a better service but I simply could not afford ten."
ETc Etc Etc.

<< Clinical freedom is the cry at the moment - but you raised the 
subject of mirages, clinical freedom is the classical example. Are you for 
instance free to treat tonsillitis by amputation of the great toe? No.
Should 
you be able to ignore guidance on best practice. No.>>
But I don't think I mentioned clinical freedom, did I?   But I do mention *
judgment* which was well defined by James McCormick in the college rag a
few years back and there is precious little room for judgment in the
guidelines etc.  There is also   the importance of using hard-won knowledge
of that patient and the patient's circumstances to modify standard
management in order to do most good for that patient.  Let's face it,  all
the hypertension guidelines in the world can't do anything to save patients
from the increased sick leave which follows the diagnosis of hypertension
or the anxiety of being told they have an illness when they feel fine.  But
you know all this stuff.
We must not confuse negligent practice ( as practiced frequently by doctors
who need at least some help and maybe even suspension for re-training) 
with the ability to match the patient with the treatment practiced by most
good GPs. 

<< We accept the BTS guidelines etc why not others? Is the mirage of 
clinical freedom more important than the standard of treatment we
provide?>>
Speaking for myself, the BTS guidelines make sense and fitted in what I was
doing already and what I had gleaned from about ten years of reading and
practice on asthma. But you cannot just assume that because one set is good
then all are good. Can you?
Take for example, the old RA guidelines which recommended at least two
months on NSAIDs before any more aggressive treatment.  I had several
people in GP who would have been dead, committed or crippled with wrecked
joints if I had left them two months before treating more aggressively.  
I don't think that the present way of doing things lacked the power to sort
out those who were failing----what it lacked most conspicuously was the
professional will to do anything about the failures.  And the NHS, with its
culture of blame and scapegoating, notably lacked any form of decent
support for those in trouble.   I am sure that those two were connected. 
Declan


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