Striking is not a punishment; Mr M

Holding onto this theme of striking and being struck off, I looked on the web-site to see how the HPC define it. I have copied and pasted the item below, and inked the page to the heading here above, but want to highlight three points in particular. First it is a very serious step. Second, it is not intended as a punishment, but as a last resort to protect the public. Third, it appears to last forever - there is no mention of a time scale. Given the first two statements, the hearing of Mr M seems in breach of the HPC remit. If this were a game, I might point out that the HPC are saying one thing and doing another, which in their terms is grounds for prosecution. But it is not a game, it is a serious business to deprive someone of their livlihood, and I recall that Mr M had been doing this work for 25 years. My question now is, what can and should be done to maintain the possibility of belief in the system of ordinary British justice? Something is clearly out of kilter.

Striking off

We recognise that striking off is a very serious step. A striking-off order will only be imposed in cases where the panel feels that there is no other adequate way to protect the public and maintain public confidence. Circumstances in which a striking-off order may be considered include serious convictions involving violence or sexual misconduct, or where there has been dishonesty or a serious abuse of trust.

Any action the panel takes is intended to protect the public and is not intended as a punishment. The panel will always consider the individual circumstances of a case and take account of what has been said by everyone at the hearing before deciding what to do.

In hearings of the health committee or where the allegation relates to lack of competence, the panel will not have the option to strike off a registrant at the first hearing. This is because we recognise that in cases where ill health has impaired fitness to practise, or where competence has fallen below expected standards, it is possible that the registrant’s health may improve or, in competence cases the registrant may receive extra training or supervised practice.

Interpreting the texts: Mr M

The case against Mr M seems to be entirely built on a particular interpretation of words which doesn't seem possible to put into question.

For example, the first allegation was that Mr M 'failed to immediately' act on the patient. I heard that the unfortunate man had suffered a heart attack in his car, and when the ambulance crew arrived Mr M commenced the procedures when the patient was on the trolley. The lawyer interpreted the guideline's word 'immediately' in a very literal way, and did not consider the context or pose questions about Mr M's decision. The printed word was 'immediately', and this was unambiguous according to the lawyer.

Secondly, a point about responsibility. The crew was made up as follows: Mr M plus one other, not qualified as a paramedic but of long service and experience. Ms J arrived a little later and joined them in the ambulance to the hospital. Mr M was the senior member and filled in forms stating that he took responsibility for this call. Much of the physical action (of resuscitation and so forth) was carried out by the two other members of the team. The question of delegation became transformed into 'abdication' as the fact was established that Mr M's hands had not actually performed the tasks.

The question at the heart of the hearing seemed to be more concerned with the fact that he wrote that he took responsibility whereas 'in fact' the other man pumped the heart while the woman pumped the air. What I'm driving at here is this: from my lay-person's perspective, I am not at all shocked to hear that a senior member of staff takes responsibility for the subordinates' actions. This is every day ordinary life. I didn't hear anyone say that the actions of the subordinates were dangerous or ill-conducted - no-one said that the outcome of this team's work resulted in a disaster for the patient. What seems to be of interest to the lawyers at the HPC was that Mr M was lying! This is a very strange interpretation of the text, but I do believe there's a very good chance that this was indeed the level of the allegation.

Mr M seems to have been severely punished (struck off the register, and his details published on the website) because he took responsibility, delegated to his staff, and made decisions according to the actual circumstances rather than mindlessly following the guidelines. I cannot see anywhere how the public was put in peril by his work.

One other thing. I was struck by Ms J's witness statement. She said she had been doing this work for about 20 years, had seen the other two team members around, and had no doubt whatsoever about their ability to manage the situation that day. She also said that she was someone who 'liked to help out'. I think this is probably why she had agreed to be at the hearing. My guess is she will be shocked at the panel's decision. I don't think it occurred to her that the hearing would be anything other than fair and reasonable. I wonder what she will think of the representation of her words in the report. They have her say that 'she recalled that [Mr M] had taken little part in the direct care of the patient'. I didn't hear her say that, and I didn't interpret her words as in any way damaging to Mr M. The summarising of her position in this way makes me very uneasy indeed.

Struck off.

Before beginning to dissect the three and a half pages of text produced by the panel at yesterday's hearing, I want to take time to consider the phrase 'struck off'.

It is a little relic from the old days, which referred to the action of a man with a pen striking the name of another from a written register. It has the grandness of ritual written into it. 'Struck off' includes a gesture, a performance, and an audience. All this was necessary to invest the meaning of the phrase with the importance of the act and the magnitude of the misdemeanour perpetrated by the offender.

For those professions that have their roots in those old days, it is understandable that they keep the nomenclature, repeat the ritual, recite the words. It is a kind of homage paid to the pioneers who worked hard to establish a practice and who tried to set and maintain a standard. Without the work of these people who came before, it says, no-one would enjoy the fruits of this labour today.

Why, tho, is it within the language of the HPC?

The HPC is new, was brought into being by the Privy Council under New Labour, and is set up on the understanding that old professions are a danger to the public and must be transformed. Leaving aside for the moment the small detail that the HPC does not regulate the old professions, it is worth wondering why they would begin to dress themselves in this borrowed garb.

When the HPC first emerged onto the scene it did so with all appropriate marketing. Four posters from an early campaign are pinned to the wall on the way to the rooms of the hearing. Here is the text of their message:

1. A picture of a man dressed up as Dr McCoy from Star Trek on the Bridge of the Star Ship Enterprise. The Headline: "You can trust me... I'm the real McCoy." The small print: "Who can say if a health professional is genuine? The fact is that any genuine health professional must shortly be registered with the Health Professionals Council. The HPC is the statutory UK body appointed to regulate and maintain the standards of 12 health professions. To use one of the professional titles below, pretenders have until July 8th 2005 to meet our criteria. If they prove to be genuine, they can join over 150,000 professionals already on our register. Anything less and they're on a different planet."

Leaving aside the facile tone of this poster, I want simply to point out the argument that is being put to use. Before the 8th July 2005 the health professionals are pretenders, afterwards those accepted onto the register of the HPC are real.

2. A picture of a woman with a very very very long nose and rouged cheeks, looking a little like Pinocchio. The words on a poster behind her: "The Muscle Management Consultancy PH.one.Y." The voice bubble: "professional titles? to tell you the truth they're a thing of the past!" The small print: Who can say if a health professional is genuine? Sometimes letters after a name don't prove anything. Anyone who is a genuine health professional with genuine qualifications must shortly be registered with the Health Professionals Council ... after that telling lies becomes an offence."

3. Picture of a woman in a spot light, wearing something in very large check. The speech bubble: "Tonight, Matthew, I'm going to be ... a Health Professional!". The Small Print: "Who can say if health professional is genuine. You don't become qualified overnight. All genuine health professionals must shortly be registered with the Health Professions Council... after that they are acting beyond the law."

4. Picture of a man in a white coat and a swimming hat standing in front of a wall of certificates. Speech bubble: "Fitness to Practise? I can show you hundreds of certificates." He is holding up a certificate got from school days proclaiming him swimming champion 1978. The Small Print: "Some qualifications aren't worth the paper they're written on. All genuine health professionals must soon be registered with the health Professionals Council to prove their credentials. ... All true professionals have until 8 July 2005 to become registered with us or lose the right to use titles listed below. Those that lie will be in deep water.

In this two-dimensional world there would appear to be only liars or truth tellers, fakers or real things, criminals or innocents, locals or aliens. Invisible in this simple scene is the One in charge of telling the difference, the One whose job it is to hold the scales and to decide. This is the HPC.

Is this a good time to ask: who, exactly, are these people, hidden just off screen?

Mr M, paramedic, ambulance driver.

Mr M, had written to the HPC last year telling them that he had stopped working as a paramedic and asking to be removed from the register. It did not respond. He wrote again this year reminding it, again without success. He wrote to the law firm acting on behalf of the HPC in today’s fitness to practice hearing pointing out that to proceed with the hearing against him was a waste of time and money. In a rather touching move he added ‘I know the ball is rolling now, and that you say it is impossible to stop’, but again stressed the waste of time, and of tax payers’ money.

Nevertheless, the HPC takes its duty seriously. Its public, apparently, deserves its pound of flesh.

In the little bit of time that emerged as the system waited for the actors to show up, the HPC solicitor bantered with the legal adviser. She read out: " It says "Mr M has been working for 25 years without a single incident" she smirked as she added the word ‘reported’. It seemed pretty clear that she interpreted his absence and his letter as an admission of his guilt and an attempt to worm his way out of the humiliation. From the public benches it seemed at least equally likely that he had no faith in the fairness of the system and wanted not to become grist to this mill.

The complaint about Mr P’s work was made by Mr D: an instructor and sectional training manager and 'responsible', as he pointed out, ‘for Mr P being up to date’. He happened to be at the scene when the ambulance arrived, and he saw that Mr P was driving it.

Of course, it is not a crime for an ambulance driver to drive an ambulance. The crime this time was in delegating responsibility to the two other workers who remained in the back of the ambulance during the 6 minute journey to the hospital. One of these workers was a witness at this morning’s hearing.

She has worked for the service for 20 years, and is an emergency medicine technician. She had no doubts whatsoever about her team’s competence to work safely with the patient that day. But it was also her opinion that a paramedic on the team should stay with the patient and delegate the driving to a non-paramedic. This was her opinion, she repeated, though she knew that everyone had their own ideas.

It was her opinion and not that of the man in charge at the scene. Nevertheless her opinion is matched by that also written in some rule-books. It is written in a liaison committee’s guidelines, and appears in the European Resuscitation Council’s guidelines. These ‘guidelines’, however, are not open for discussion. Which is surprising, for guidelines.

The process appears to proceed like a giant unstoppable machine, yet the machinery is made up of people and bits of paper. Many of the people concerned would call themselves ‘professionals’, which implies that they are trusted to exercise their personal judgement. Their judgement and their actions can surely be subject to debate.

The real nature of the scene in question again seemed un-interesting to the HPC. The nitty gritty business of driving an ambulance, intervening in real life traumas and crises, and of making decisions about another man’s life is reduced to what is written in a few pre-printed books. What is at stake is whether the man’s character can be read from the way he relates to the administration. From this distance, it looks very much as if the HPC is a very heavy sledge hammer used to force a centralised rule book into the bodies and minds of local ambulance drivers.

It was Karl Popper who remarked that ‘you can centralise all power, but you cannot centralise all knowledge’. He knew, however, that sometimes, and especially in bad times, some people like to try.

Perhaps Mr P was a dangerous man, perhaps it is right that after 20 years of unblemished service, he should no longer be paid to save people’s lives. Perhaps. But the way that the case is being pursued is running roughshod over important questions and values and leaves a lot of useful knowledge and insight stumbling around in the dark.

My question, as before, is what kind of public is being imagined in order to justify this work of the HPC? It is not one that I am familiar with. And what kind of peril is it being saved from. From an ordinary, yet educated point of view available in the public benches, what can be seen as taking shape is quite a different danger. It is this that needs to be brought to light if we are serious about protecting a real public from the real danger - of creating something pernicious.

I await the publication of the panel’s conclusion, and will report on it tomorrow

The Professional Liaison Group for Counselling & Psychotherapy

The call for applications for members of the Professional Liaison Group for psychotherapy and counselling at the HPC went out in the summer 2008. It was announced in the autumn. There were 38 applications. There are 17 members of the PLG, 6 of whom are already serving the HPC in some other capacity. The selection of the PLG was made by Diane Waller and Anna van der Gaag, President of HPC. Diane Waller is an Art Therapist member of the HPC and was appointed as Chair of the HPC. I'm not yet sure how this happens, but I shall try to find out - perhaps it is already written on the web site.

I would like to know more about each of the people on the PLG, and indeed how they come to be there. I would like to ask Diane Waller how she went about selecting her panel.

Today I rang up the BACP and the CPCAB (Counselling and Psychotherapy Central Awarding Body) to start the process. Each of these organisations has a member on the new panel, Sally Aldridge for BACP and and Fiona Ballantine Dykes for CPCAB. Both work for the administration of their professional organisations. I have been invited to submit my questions to each. In brief what I would like to know at this stage is how each organisation selects a representative, how each representative made their application, and what manifesto, if you will, each will be persuing.

As may be expected more than one person from the BACP applied for a place on the PLG (it is a very large organisation, and 2 of the Board also wished to participate). Perhaps more than one applied from the CPCAB, I don't know. But as only one representative per institution is allowed to sit on the PLG, I asked the BACP to pass my requests for information on to those who had applied but who were declined. I am interested to know how they will maintain their interest even tho excluded from the group.

The fact that only one person per institution is allowed to sit on the board raises questions about representation. Viz: What is it to represent an institution? In what way are these people representatives? Are they representing scientific interest, practitioner interest, or institutional interest?

A second question arises. One of the members of the group is attributed to the Skills for Health organisation. I asked myself the question "why would a government department have a representative on the HPC PLG?" I telephoned John Stephenson, Director of Corporate Affairs at S4H to find out.

He wasn't able to answer me directly, but invited me to send him an email with my request. He also revealed that the S4H was not a government department but a part of the National Health Service Trust at University Hospital Bristol.

How come I didn't know that?

He suggested I read their web-site.

Struck Off in order to protect the public

The paramedic, Mr C, whose FTP hearing I attended last week, has been 'struck off' the HPC register in order to protect the public. The report of the panel is published on the HPC website. Had the case been not proven, the HPC would not publish the details. This has the strange consequence of making it appear that all the allegations pursued by the HPC are successful, which is not the case. But that is an issue for another time. What I am interested in here is discovering what it is that the public is being protected from, and what kind of public it is, that is being imagined into existence.

As I mentioned in a previous blog entry, the hearing at the HPC does not appear to be interested in the actual facts of the specific case. They are more concerned with a generalised idea (or ideal) and must rely in great part on what has already been written not in great texts by eminent thinkers in the proper scientific application of their work, but by the Professional Liaison Group set up by the HPC at the start of the process of regulation. This begs lots of questions about science knowledge and management, and calls up the spectre of Galileo.

The case was questioning the actions of Mr C in relation to one patient who he 'paced' due to low heart rate and then gave diazemul (10mg). The case against Mr C was that there was insufficient consent from the patient to 'pace', and that the justification for the diazemul was incorrectly justified (the justification should have been linked to the patient's fitting, not to the patient's stress). Mr C disputes both these allegations, so the case turns around what was said at the moment of the emergency call, and what was said three days later in a management meeting. First Mr C had framed his decision in terms of calming the patient, reducing stress, only later did he articulate it to the patient's history of fitting. It is because of this that the HPC panel were persuaded that Mr C was not of good character and so would undermine the public's confidence should it be discovered that such an inconstant man was included on the register of the HPC.

It is certainly worth considering for a moment the nature of the medication. I, a member of the public, would like to know the nature of the risk that Mr C put his patient to by administering 10mg of Diazemul.

An internet search reveals that Diazemul is a benzodiazepine and that these are used for their sedative and anxiety-relieving effects.

What I happen to know from a few years work in adult acute psychiatry a few years ago, is that this range of medication was contentious because many patients really liked them. The underlying sort of 'common sense' assumption was that people would prefer to be ill in order to enjoy the effects of the drug. A limit to their prescription was therefore encouraged on the ward where I worked as a kind of 'moral' approach to the cure. Is this why Mr C should not have administered the drug to his patient? Has this moral fear made its way into the rules of practice currently consulted by the HPC? Is the fear that the patient would have developed an immoral preference for the medication? I don't know - the knowledge behind the decision was not on show. But it does begin reveal one kind of idea that is taken for granted about 'the public'.

This exclusion of relevant knowledge is something this case shares with the case of Mr U, which I attended the week before and wrote about on this blog. In that case Mr U was accused of verbally and physically assaulting a member of the public, and the impression was that he had done this unprovoked (which was not at all the case). Nevertheless, it was not these facts that led the panel to find the case unproven against him, but that he had been contrite. It was his confession of guilt that allowed the panel to leave that man alone.

In the case of Mr C, however, there was no contrition. In fact, as I mentioned before, there was something approaching its opposite. His representative let it be known that the case was a waste of time, founded on pernicious motives, and which distorted the evidence in its favour.

On the clinical question at the heart of this case - the administration of 10mg of Diazemul - the Panel declared itself uninterested. I quote from their concluding remarks: "The Panel does not consider it necessary to dwell on the issue raised at the hearing as to the proper dose of Diazemuls. This is because the clear finding of the Panel is that no quantity of that drug should have been administered to that patient at that time. However, the Panel should record the fact that it did not find the evidence adduced by the HPC in relation to an acceptable dose to be helpful."

This statement is odd. First it says that it is not relevant to discuss the dosage of the drug, as the use of the drug was prohibited in these circumstances. Second, although the Panel finds the dosage irrelevant, it takes the time to say that the evidence the HPC furnished on the dosing of the drug was not helpful. Third the 'clear evidence' on which the HPC panel makes its decision seems mainly to be the fact that Mr C said something on one occasion, and another three day's later. These utteranes are taken as the bedrock of the case rather than the clinical facts pertaining.

I happened to hear a little of this discussion, so from my position in the public gallery, and on the balance of probabilities, I would guess that quite a bit of time had been taken up on the previous day to the question of how much diazemul was fit for the purpose that day. In fact, the HPC had gone to the trouble of bringing a witness to speak about it. This opens up a can of worms. There is, at the very least, ambiguity about this drug.

There is also some ambiguity about the nature of the public. In this case, the public is a phantom figure who seems likely to drop his trust and run screaming for this hills at the thought that Mr C said one thing on one day (I administered the drug to calm the patient) and another a few days later (not directly reported but that relates to the patient's medical history of fitting).

The other figure of the public in this scenario is that of the patient. The complaint against Mr C did not emanate from this man, nor any member of his family. He remains wholly outside the field of reference of this hearing. Only by implication can anything be deduced about him. Is it that he, a 70 year old man, could not be trusted to receive the medication Diazemul in case he developed a liking for it that Mr C's name must be struck from the register of the HPC?

Or was it that the case reveals a wobbly basis for the rule about the use of this medication - an ambiguity that is not resolved on the level of science, truth, or real life practice, but by reference to the pre-determined rules of a centralised State sanctioned committee?

Another day at the HPC FTP hearings.

Today I attended, as a member of public, the second day of Mr C’s hearing. This was chosen at random.

Most of the hearing had happened yesterday, and this morning’s sitting was restricted to a slow and carefully spoken rehearsal of the argument by the lawyer on behalf of the HPC. The timing of her precisely enunciated speech seemed set by the speed at which the panel could write down what she said – she seemed to be dictating them a narrative. This was followed by a rebuttal by the representative of Mr C spoken in real time, if you will, and in a real regional accent. The gist of this rebuttal was that the case was a waste of time and probably pernicious. The legal adviser present then gave the panel a lot of careful guidance on how to structure the conclusion according to a well laid out formula: going through points a, b, and c, and using special forms of phrasing. They then retired for a very long time indeed to consider their conclusion.

Whilst the panel retired to consider their decision, I took the chance to stroll around the park with Mr C. He is a paramedic working in the ambulance service for more that 20 years, and was dismissed by his NHS Trust last year following a complaint made by another member of staff – I won’t say ‘colleague’ as they had never met before. He has been working for a private company ever since. They had written a very warm reference for the HPC to consider and promised him continued employment no matter what the outcome today. Mr C didn’t know how the HPC got hold of his case - the notice came out of the blue – but he speculates that someone at his old place of work found out he had been re-employed and wanted to cause him more trouble. The truth has yet to emerge. I asked him how the original case arose.

“In essence, I was told that I had saved the patient’s life, but that the Trust wanted it saved like this (indicating one hand), not like that (indicating the other)”. In the process of saving the patient’s life, another paramedic arrived and asked Mr C why he had administered the drug in question. Mr C didn’t want to explain right then and asked him to wait till they arrived at the hospital. When they got to the hospital, different circumstances took over and the moment was gone. After trying to pass on the information 4 times (which was no longer interesting to anyone) Mr C went home without writing a full set of notes. The patient lived, the system worked, but the cover story was not constructed. The other member of staff was more aware of the consequence of this: he had been through a hearing before and did not want to leave himself open to the possibility of it happening again. So, in order to protect himself, conjectures Mr C, ‘he put in a complaint against me’.

Many questions arise:
1. The medication in question is contentious – why? At what level? A little of this was discussed in yesterday’s part of the hearing, but without making much impact. This raises questions about science, practice, and what constitutes a ‘professional’. That is, who is entitled to argue about it? Better, whose duty is it to argue about it? It appears that this level of discussion is effectively out of bounds, which immediately throws into question the meaning of the word ‘professional'. It leaves a black hole in place of science.

Instead of practical knowledge it appears that the HPC restricts itself to the question of whether or not Mr C followed a set of pre-written rules (administrative knowledge). So, the legal advice to the panel followed two lines: had Mr C administered the drug because he didn’t know he shouldn’t, in which case he was incompetent; or did he give it knowing that he shouldn’t, in which case it is misconduct. A third possibility was not mentioned: did he administer the drug having weighed up the situation and deployed his professional judgement? However, the decision was framed entirely in terms of pre-written codes of practice and ethics and took for granted that the medication was mis-used. It was up to his representative to remind the panel that there was no evidence whatsoever that the medication should not have been given! The whole thing was turning on a perception of attitude and behaviour rather than the medical facts of the case.

2. How and why does the HPC select a case to pursue? What were the grounds for pursuing this one? Who is the complainant? If these facts are made clear, it might be possible to make a judgement about the nature of the complaint. As it stands we are forced to take it on face value and swallow an awful lot of questions. In their place come a lot of other questions. Why does the HPC act in this way? Is it pursuing the case for its own gain: to give it something to do? to accumulate a set of statistics? For the pleasure of depriving a man of his livlihood? This is where that vacuous statement comes in handy – it is done to ‘protect the public’. But unless it makes plain who is in danger, and what is the nature of that peril, then no-one can make a sound judgement.

3. Why is the context excluded? In his summing up Mr C’s representative posed the question “was the situation as bad as some of the HPC witnesses made out?” he wanted to know why the case had been embellished. It may be that this is sour grapes, but there may be a reason for their sourness. From my point of view in the public benches, the grapes could easily be sour because the climate is not correct. To push the allusion a little, one might want to talk about the sun not being at the centre of this universe. Instead of grounding the evidence in a Copernican paradigm of truth, it is grounded on a committee’s pre-written prescriptions. As it stands, Mr C was being judged on whether or not he could obey previously written administrative rules where the real event was unimportant. Unfortunately, where this becomes the norm it is not unusual to find people willing to dump each other in the pit in order themselves to avoid a ducking. This is not news. It may be an unintended consequence of this new and emerging system, but our rich and brilliant culture bears silent witness to the fact that it cannot be unexpected.

Prof Michael Rawlins comes out against hierarchies of knowledge

An article from the Independent, 16 Oct 08 (click heading to go to the original page) quotes Michael Rawlins, head of NICE clearly, acknowledges the place of professional judgement. Apparently this counts as news in 21st Century Britain.

Michael Rawlins: Statistics can help, but doctors must also use their judgement

Nowhere is the longstanding argument over the choice between inductive and deductive approaches more hotly argued than in the nature of the evidence that should support the use of therapeutic interventions.


The dispute about the evidential basis of modern medicine has become particularly apparent with the emergence of "hierarchies" of evidence. Such hierarchies place randomised controlled trials (RCTs) at their summit with observational studies nestling in the foothills. They are used to provide some intimation of the "strength" of the underlying evidence, and to then "grade" therapeutic recommendations.

But the notion that evidence can be reliably placed in hierarchies is illusory: judgements are an essential part of the decision-making process. As Bradford Hill, the architect of the RCT, stated so cogently: "Any belief that the controlled trial is the only way would mean not that the pendulum had swung too far but that it had come right off the hook."

At root, the problem with hierarchies is that they attempt to replace judgement with an over-simplistic assessment of the quality of the available evidence. But as William Blake observed: "God forbid that truth should be confined to mathematical demonstration."

Decision-makers have to incorporate judgements in reaching their conclusions. Experiment, observation and mathematics have a crucial role to play in providing the evidential basis for modern therapeutics. Arguments about the relative importance of each are an unnecessary distraction. Hierarchies of evidence should be replaced by embracing a diversity of approaches.

This is not a plea to abandon RCTs and replace them with observational studies. Rather, it is a plea to investigators to continue to develop and improve their methodologies; to decision-makers to avoid adopting entrenched positions about the nature of evidence; and for both to accept that the interpretation of evidence requires judgement. It is scientific judgement – conditioned by the totality of the evidence – that lies at the heart of making decisions about the benefits and harms of therapeutic interventions.

Professor Sir Michael Rawlins chairs the National Institute for Health and Clinical Excellence. ...

Report of a public FTP hearing at HPC, 5 Nov 2008

Report from a public hearing of the fitness to practice panel at the HPC 5 November 2008

Mr U has been on the HPC register since it opened. He has been in the ambulance service for 16 years, and for 12 of those he has been qualified and employed as a paramedic. He is at the HPC today because in June 2007 he argued with and pushed a ‘younger and more aggressive’ man who had let rip when the ambulance driven by Mr U got in his way while he was parking his car. Mr S chose not to report this to the police, but instead made a complaint to the hospital. As a result of this a full and proper inquiry was conducted by the senior manager which eventually concluded that Mr U was fit and competent for work, but should attend a ‘de-escalation’ training course as soon as he could. Mr U returned to work about 5 weeks after the incident and has been working well and reliably (according to his manager) ever since.

An HPC administrator was present at the hearing in order to recite the case against Mr U: she said “Your fitness to practise as a registered health professional is impaired by reason of your misconduct in that during the course of your employment as a Paramedic with North West Ambulance Service: 1. On June 28 2007 you verbally and physically assaulted a member of the public outside Lx Women’s Hospital.

The lawyer acting on behalf of the HPC put it to the panel that ‘this must be misconduct given the high standards we expect for the profession, therefore you must accept our case and find Mr U unfit for practice’.

A Trade Union rep spoke on Mr U’s behalf. He told the panel that Mr U admitted to verbally and physically abusing Mr S, and this was not in question. He asked the panel to focus solely on the question: does this mean that Mr U’s fitness to practice is impaired? He put it to them that it did not.

Mr S was not at all interesting to the HPC – he was simply someone who had given them reason to take up the cudgels, so to speak. By refusing to put Mr S into question, the context of the dispute completely vanished and it was only by chance that any of the details found their way into the proceedings at the hearing. Until that point, from the perspective of an observer in the public gallery, without access to the ‘bundle’ of documents related to the case, it was as if Mr U had suddenly turned on an innocent by-passer and launched a surprise attack.

At one nervy moment in the proceedings, Mr U volunteered to go into the witness box. This rendered him open to questions from all the parties to the hearing and it was through this avenue that he found his way to say something about the context of the case. The panel asked him whether his action had caused a delay in getting his patient (a woman in labour with a breech baby, I believe) into the ward. Mr U seemed to hear this as an accusation, and gave a lengthy answer into which seeped details of the encounter he had with Mr S. Until this point the hearing had not gone into any details about this but did watch several silent minutes of cctv footage. Mr U said that the camera missed Mr S aggressively shouting right into his face accusing him of cutting him up in the car park. He went on to say (repeatedly) that it was an error of judgement on his part to have responded to the attack in this way, and ventured that perhaps it was because he was confronted by a younger and more aggressive man. He had never done it before nor since, in spite of the fact that he had experienced worse offenses from the public on many occasions. He stressed that he was full of remorse and that he certainly would act differently next time – he would stay in the cabin, lock the doors and call for help from security or the police. No-one asked how much time this alternative course of action would have taken.

Shame played a large part in the proceedings. Mr U was a very quietly spoken man, and very humble. He repeatedly said he had made an error of judgement, showed remorse, made frequent reference to the reflection done and insight got, and declared that he now knew that he should have remained passive and called the police for help. Much of this was repeated by the panel in its concluding remarks.

One other point that I believe needs to be raised relates to the use of the cctv footage. The security guard who had been on duty on the day, and who had been present during much of the altercation, had given a statement which had been submitted as part of the bundle of papers. He was not present for the hearing and three rather contradictory reasons were given for this: first Mr U was not disputing the fact that he had verbally and physically assaulted Mr S, and therefore his testimony was not required. Secondly the man was currently on night shift and so would have been greatly inconvenienced by a trip to London. Third, his statement was already included in the bundle. I was puzzled, then: what reasons there could have been for playing the footage?

A second anomaly relates to the cctv film. I was surprised that the HPC lawyer remarked to the operational manager in the witness box: ‘you were able to seize the footage’. The manager quietly corrected him – “I asked for it, and they gave it to me.”

If Mr U had not gone onto the witness stand, and had he not rambled on, the inappropriate action of Mr S would never have come up. I suppose that it might have been written in the documents that lay in the bundle that the panel had read before coming in. However, there was no mention of it whatsoever during the hearing and it seems this was something the HPC find unnecessary to question. This suggests that The Public is unquestionable. Is there not a good reason to expect the public to act in a way that gives them the right to make a complaint? From what seeped into this case, and judging from the conclusion of the Manager at the Hospital, it seems rather likely that Mr S has a little case to answer on the question of insight, appropriateness, or even fitness to practice as a bone fide member of the public! Tho I don't propose we erect a bureaucratic edifice to bring him to face this fate.

One last point, when the Panel returned to give their decision they kept us all on tenterhooks. It was a highly ritualised occasion, and the chair of the panel read out a written document that was preprepared. It repeated statements about the assault that was never in question before coming to the rather un-contentious point – the case was not well founded.

Upon leaving the HPC after the event, I had the chance to bump into Mr U and his representative. I took the chance to explain to them who I was and why I happened to be there. They were grateful as they had thought I may have been a journalist who might suddenly whip out a camera and take their photos to publish in the press. In fact it was chance that took me to this hearing. I was there to begin to try to understand exactly how the HPC acted. In this respect I was simply a member of the public. However, as I explained, I was also very interested in the sociological implications of the HPC for our society, and as a psychoanalytic practitioner I had a more pressing reason to discover the reality of this work.

At this point Mr U snapped out of his quiet fatigue and in a very alive and focussed way instructed me to work very hard right now to avoid ever being taken into the HPC.

Fonagy's faith in the chemicals of the brain

The recently published list of people selected to sit on the professional liaison group for the HPC as it approaches the question of regulating counselling and psychotherapy includes the Freud Memorial Professor of Psychoanalysis at University College London, Professor Peter Fonagy. However, on the plg, he is neither credited with his academic title, nor his professional one, but appears as a representative of a Government Ministry: Skills for Health.

Peter Fonagy is a prolific writer and a busy manager - but it is difficult to square his current work with the aims of psychoanalysis. For example, he has abandoned the idea of the patient as a human subject in favour of the fashion for Gold Standard's of Objectivity. Under his directorship an era of randomised controlled trials was been ushered into the work at the Anna Freud Centre. Another quite alarming report appeared in the Times Newspaper about a year ago. It also appeared as a little news item reported in Therapy Today - the BACP monthly magazine:

"Toddler brains scanned for neglect" (From The Times, May 12, 2007, by Jo Carlowe - click heading for link)

"Psychologist Peter Fonagy, chief executive of the Anna Freud Centre, wants the Government to routinely scan toddler brains to discover signs of neglect - in order to find which children may grow up to be a nervous wreck, a criminal or a psychopath if early intervention is not made. 'The idea would be for parents to check if their kid's socio-emotional development is as expected. There would be no stigma attached,' he says. 'If a child needed a little developmental help, they could be put into a remedial programme, such as psychotherapy.' Fonagy has already started to scan infants to track differences between 'normal' brains and those of children who are neglected and unloved. The aim is to ensure that a child grows up mentally healthy."

quoted from BACP magazine Therapy Today, June 2007, vol 18, No 5 p26

This is quite a backward version of psychotherapy, and quite a contentious view of child development. It is also quite a cynical use of brain scan technology. Rather than appealing to argument and reason to put the case for the link between a child's love relations and his or her destiny, Fonagy appears to be playing the 'government funding game'.