Redefining 'Professional' & Frightening the Public: more on Mr R

From the transcript of the case of Mr R. [I have used the name Freddy in place of his real name, to reflect the familiar diminutive that was used at the hearing.]

Ms B, the witness said: "A family member, the father, said that this was the work that Freddy had given his son to do privately. When I questioned him and said "was it the case that Freddy also saw your son privately?" the answer was "Yes". The family felt very anxious and asked me whether I was in touch with Freddy. I explained that I had never met Mr R and that it was not good practice or approved practice to work with somebody privately whilst on their NHS case load. The family were anxious. They really liked Freddy and they had built up a very good rapport."

When Ms B was asked to explain why it was not good practice for someone to work in private with someone also on the NHS case load, she replied:

Ms B: "Firstly it is in our professional guidelines that we are not allowed to manage a case where we are already seeing that particular individual on an NHS case load. Also for me, personally, it is unethical to be seeing somebody and then at another time to be taking money from them."

Is it just about money? Ms B said Mr V should also belong to the association for private practice. Then she mentioned note taking and liaison with other professionals involved. This allowed HPC Council to ask the purpose of note taking, which brought forth this revealing answer:

HPC Q: Why would you be taking clinical Notes?
Ms B: Just as a record really otherwise you will be leaving yourself open to be vulnerable.

When questioned by Council for Mr R, Ms B explained more clearly: 'it is recommended to protect you from suspicion.'

Ms B had not made her allegation against Mr R because his professional work was in question, but because she thought he was open to suspicion. What kind of suspicion, and from who? This brings us back to defining the idea of 'protection of the public'.

Protection of the Public. Who represents the public in this case? The family is implicitly ruled out as the case unfolds - they are described in ways that throw them into question, and which excludes their point of view. They become the group that tempt the professional off the straight and narrow. The public that is being protected here seems to be one that might be shocked to hear that someone employed by the NHS is not completely under control, and this would imply that they are being protected from that shock. This is clearly irrational, and cannot be the intention of anyone involved, but the accumulation of evidence does seem to point to this interpretation.

Ms B is not throwing doubt on the professional practice of her colleague. The family is pleased with the work, the young man in question is happy with the work. In fact Ms B went on to say "I think Mr R did a really good job".

When Ms B was questioned by the Panel, the lay member, Ms Lesley Hawksworth, brought her back to the point of how she interpreted the rules.

Ms Hawksworth: "You have already been referred to the guidelines on page 34. In paragraph 4 it says: "Therapists who have any current health service involvement may not normally undertake private therapy with that client." It does not say must never. "
Ms B: "Can you say that again?"
Ms H: "The sentence does not say 'must never' undertake private practice'
Ms B: I would have to clarify that with the independent practice to clarify exactly what that means.
There then followed a confusion between the panel members which brought to light two different versions of rules. Mr Duckworth (the panel member representing the Speech and Language Therapy profession) had a more recent version:

Mr D: "The statement from the Communicating Quality latest edition, would seem, from the text here that I have just read out, that the suggestion is, if you are treating the NHS client, you may not undertake private management of that case. Is that your understanding?
Ms B: "Yes, it is".

Mr D has re-established Ms B as a sensible woman, but only if you don't ask any questions about the validity of the text itself. There followed a brief confusion about the dates of the different versions of this text, as well as the authority which published them. It is published after the date Mr R's practice was called into question. It seems likely that the rule is written as a diplomatic matter between the Royal College and the Independent Practitioner bodies that each try to represent the Speech and Language therapists. Fair enough, they are carving out their respective territory of jurisdiction; but should this not be taken into account when interpreting the text? The lay member is right to pose her question here on the side of sense and reason rather than of management and trade. But she seems to have been side-lined quite quickly.

more to follow shortly,

habeas corpus - the case of missing Mr TH

Another missing man at the centre of this pernicious process. When I arrived this morning the waiting room was full of giggling women. It was as if they were out for a day's pleasure. The line manager, the line manager's line manager, and finally, the line manager's line manger's line manager (yes, another case from the NHS). Three women lining up to nail the coffin down of occupational therapist Mr TH.

The third in this happy parade was the one who submitted the complaint to the hpc. She did this about one or two years after Mr TH had left the employ of her team. Why? "he was a threat to public safety."

She spoke so quietly that I had to strain forward to hear her, so I stood up and moved forward to hear the rest of her statement. In the nano second it took for me to settle in the seat in front she was standing up and leaving. That was it! She had been called in order to recite this empty phrase! Bang, the final nail in the coffin.

At no point in this morning's proceedings did anyone mention what it was that he was doing with his patients that was such a threat. The entire discussion revolved around his note taking. The context of this is the computerisation of notes in the NHS - something which other occupational therapists are fed up about.

Why is it a threat to patient safety for Mr TH to not write notes according to the computer developers protocol? 'in case he doesn't come in and someone else has to take over his work'. (We're talking about occupational therapy remember.) Is there an example of the danger that ensued when he did not turn up for work (he went off sick, then resigned a few months after this witch hunt began). No, no examples. No examples at all in fact, all we had were vague generalisations and examples of his administrative skills: did he make a phone call, did he write a note. His work as an occupational therapist was absolutely absent from the case.

The line of questions that were presented to the witnesses got nowhere near uncovering any kind of truth. The three women were vague, one was verbose, and all were well versed in newspeak: 'got to get up to speed', 'golden rule is to keep accurate and up to date records', 'I did an audit of notes', 'a random selection of his files', 'there was insufficient detail', 'notes were vague'. No substantive content whatsoever in any of the three womens allegations. No sign of any patient in trouble, no whisper of any complaint from any of the people he worked with. None. Repeat: NONE.

Yet another case of people occupying positions of power in the New NHS who are blatantly unworthy of the responsibility on their shoulders. No gravitas, no experience, no compassion, no speech of their own, nothing to say except to mouth empty phrases that knock around like bricks doing random damage, no idea except to cover their backs. Not professional.

I wonder what the Panel will decide. Decision so far not posted.

The right decision but the wrong reason

Mr W's panel agreed that the allegation against Mr R did not amount to a damnation of his fitness to practice. If you want to read their decision you will have to email the HPC because it won't be published on the website.

Why not? Because Mr R wants his name removed from any further damaging publicity. Fair enough.

I wonder, tho, whether the HPC would consider publishing an apology.

This seems only right. For it was they who thought that Ms B had uncovered a serious case of misconduct that amounted to a significant threat to the public's safety; and it was they who have made Mr R's life extremely unpleasant during the time it takes for the allegation to actually come to trial; and it was they who hired the legal counsel (Ms T) to attack Mr R on their behalf in public on January 5th, 2009. Yes, I would say she attacked and have asked for the full transcript so that I can describe it on a future blog where you may judge for yourself. From my seat in the public gallery it seemed almost obscene to allow her to hammer away for so long when the case was so obvious a non-starter. The law lost its position of objectivity and Ms T went out for her own satisfaction to get a positive result. Not professional, not competent. And Ms B? What might we think of her fitness to practise, judged on her actions in this case?

But the reason that the panel gave for coming to its conclusion continues to miss the point. To be charitable, I shall say that the HPC has been set up on a twisted logic which makes it very difficult for anyone to do a decent job there. The twist is of course difficult to reveal - it is concealed behind a facade which effectively corrupts the truth (hence my reference to George Smiley in the twitter bar) and it will be the subject of several more blog entries, I'm sure. But for now I need to focus on the point of the unfortunate Mr R's Kafkaesque experience.

If you remember, Mr R is a speech and language therapist. This work is not renowned for is life threatening qualities, unlike, say heart surgery, or administering morphine. Nor is it clear why only an NHS employee in office hours may administer a treatment. What is the evidence that giving extra sessions outside the jurisdiction of the NHS will present a danger to the public? Absolutely none in this case.

The taken for granted assumption behind the HPC's action against Mr R can be deduced: that professionals are greedy, money grabbing creatures who will deceive the public if they are not subject to close scrutiny by their colleagues and managers in the NHS together with the weight of authority of the HPC. Puerile.

Mr R is innocent even if he charges the going rate for extra sessions. In fact, by charging the going rate he enters into a relation where both he and his clients are protected. The financial arrangement between people is in itself a form of regulation. The HPC and the NHS here seem to think that money is a filthy contaminator which must be treated like excrement that only they have the expertise to manage. They have invented a new harm - money - against which the public must be protected. This idea is juvenile and has no place in an institution underwritten by the laws of this land.

Money, charity, the NHS and the case of Mr R

There was snow on the ground, and big flakes in the air this morning as I boarded the bus to Kennington. It is the 11th day of Christmas, and the first day back at work for many people in the country. There are quite a few cases beginning today in the Fitness to Practice rooms, so many indeed that the HPC was renting some from its neighbour the Evangelical Alliance. As I walked through the doors I was greeted by a flat screen tv display telling me 'Kind words are like honey, sweet to the taste and good for your health'. Proverbs 16 24

Kind words can cost you your reputation as an HPC health professional, or at least, a kind act can if today's case is a typical example.

The allegation in this case is a short one: "that Mr R provided private speech and language therapy treatment to [a client] whilst also treating them on NHS caseload at [a PCT]". When I popped my head round the door to see if the business had begun the Chair was quizzing the Barrister on the use of the word 'them'.

The writer of the allegation had been at pains to avoid bringing the patient into view. For this reason she had avoided the word 'him' and used 'them' in its place. This switch from single to plural had created the impression that Mr R was in the habit of taking his patients into his private practice. The point clarified that only one patient was in question, and that language might be used for other purposes than simply stating facts.

There was only one witness in today's case: Ms B. She had been employed to replace Mr R when he resigned at the end of Sabbatical. They had never met. Mr R had seen his patient for the standard 5 sessions and was closing the case. However, he had not filled in the last form before going off on leave. So, when Ms B turned up she acquired a case that was all but closed, needing only one final act to make it so. She visited the patient at home to make her assessment, and agreed to close the case.

In this morning's part of the hearing a lot of context and detail was revealed. For example, it turns out that the patient is a young man, probably in his twenties. He is married, but still lives at home with his mum and dad whose culture and religion happens to be the same as Mr R. They all speak the same two home languages as well as English. In the detail of the discussions this morning, I understood that mum and dad were doing their best to 'normalise' their Down Syndrome son, and had high hopes that the 'articulation process' of the speech and language therapy would make him just like anyone else. In the meantime dad often spoke on his behalf, jumping in to answer questions and give opinions instead of leaving a space for his son to struggle in. Mr R put it like this - he said there was a lot of energy in the room when the parents were present. In fact, as the case unfolded, Mr R said that his own intervention was less to do with administering the standard procedure and more focused on working with the family to create space in which the young man could find his own way to communicate.

By all accounts the work was successful but the STAP [the South Tyneside Assessment of Phonology] showed that further standardised treatment was unlikely to match target outcomes. The patient and his parents all wanted to carry on with the work, and all agreed that Mr R was the man to do it. The parents were particularly keen, and asked Mr R several times if he would carry on - never mind the rule about 5 sessions, they would pay they were so pleased with the results.

When Ms Betts turned up to make her assessment, the patient's parents let slip that Mr R had done some work with their son outside the domain of the NHS. As soon as they had said this they realised they had dumped their man in trouble and clammed up. But Ms B was not to be deflected. She wanted to know how often this had happened and how much he had been paid. The more she asked the less they said, the message had been instantly transmitted! Something unspeakable had happened, and now the family began to worry that they had caused Mr R to be sacked.

In a way they were right. They had not reckoned on Ms B clinging so tenaciously to the rule book, nor indeed that such a rule book had in fact been written, and they certainly never imagined anything like the HPC who would use such a book to purge the profession of any imaginary stain.

As it turned out Mr R did see this family about four more times outside the NHS protocol. He accepted about £6 from them to avoid the embarrassment that was created through his refusal to accept a proper fee. Today, 2 or 3 years later he says he would definitely never do that again.

Quite right; if he does work in private, he should participate directly in the symbolic exchange that regulates it. He might negotiate a proper price for himself, refer the case to a colleague in private practice, or perhaps he could channel the money to a charity.

No! None of these ideas were considered. Mr R now knows not to accept private work because it would catch him in this dreadful process that might ultimately prevent him from working. For if he is struck off (and that is the HPCs intention - 'a clear case of misconduct'), then he will be legally prevented from practice. In future, he will not try to help a family in need, he will attend only to the requirements of his cv.

From where I sat in this proceeding, I would say there's a very strong possibility that money is a tabu topic in the NHS and forecloses any sensible discussion about working effectively with patients. It certainly muddied the discussion at the HPC. (Was he accused because he took money - sub-text because was greedy? Or because he gave charity - sub-text that he was naive? The prosecuting agent didn't mind which, so long as she nailed him with one.) What was quite clear from this morning's discussion was that the family made direct and repeated demands for treatment that the NHS protocol ruled out. Mr R however, could see that something less rigid and more responsive could and would have a good effect. For goodness sake! What on earth is wrong with that? That Mr R will never do that again is, well, it's a shame. And if The Public conjured up colludes with this ruse then we are in bigger trouble than I had thought.

It was said several times by Ms B that a professional must act ethically to protect himself from suspicion. This puts a curious twist on the question "who is being protected by the HPC, and from what?" Listening to Ms B it seems that 'the public' that is protected is the one that belongs to a profession. What the HPC is protecting this public from is the accusation from an ill-informed mob who might otherwise point the finger of suspicion. There are two kinds of public here. One is being protected from the truth, the other is being protected from any possible accusation of suspicion.

Poor show. Doubly so, for in another time or another place it would be quite normal to deal with this question in an ordinary conversation between people (supervision? seminar? collegiate conversation? quiet personal reflection?), or even just getting on with the job and accepting a fee for it. What we have instead is an elaborate construction of something approaching a kangaroo court dressed up as respectable profession.

Mr H & facts 1, 2, 3(a), (b), (c), (d), (e), 4(a), (b), and (c) etc

Poor Mr H. I hope he has a sense of humour. A dyslexic man, qualified by some regulated and audited educational body to work as a physiotherapist, faced with a panel of people who prove facts 1, 2, 3, etc and write that "the HPC Standards of proficiency were breached, viz: Standards 1a 4, 1a 5, 1b, 1 1b4, 1b5, 2a.1, 2a.2, 2a.3, 2a.4, 2b.1, 2b.2, 2b.3, 2b.4, 2b.5, 2c.1, and 2c.2."

Sitting in the crammed up seats in a cold draft near the door, (which might well appear - misleadingly - in the minutes of this meeting as the 'public gallery') I would say that there are good grounds to suppose that the educational body that granted Mr H the qualification might be unfit for practice. Furthermore, I think that the NHS Trust who employed Mr H also has a little case to answer. The permanent shortage of staff, which is well known to be worse over the Christmas and New Year period, is the context in which Mr H was first offered the job which he had refused. He recognised that he would be in difficulties in such a particular context as this (it was a 'respiratory' rotation, and Mr H knew he had no expertise in this). The job was offered to him again later as no-one else had been found for it, and this time he accepted it. Perhaps he thought he was helping out, and that this spirit of charity on his part would be met with by staff around him.

In fact one of the witnesses, the Band 6, said she had a good working relationship with Mr H, and had been happy to spend time teaching him on the job. So what changed her mind?

The Band 7, another young woman, and responsible for quite a lot (it seemed to me) in this NHS Trust, spoke in a way that did not inspire much confidence. She seemed to reproach Mr H, and to resent his presence - I don't think she can have been part of the process to recruit him to her team. He seemed to represent a threat to her reputation, and to require more from her than she was able to give.

Now, this could mean that she was not fit for purpose, not capable of dealing with the perennial staff shortages, not capable of coping with the level of qualifications produced by contemporary educational bodies, not capable of accommodating the differences amongst the people she is required to work with. Not capable of holding her ground in the face of potential allegations of failure that might be aimed at her.

Or is there another way of thinking about this? As it happens, I studied business 30 years ago. This was when the function 'Personnel' still enjoyed a position. At that time there was much excitement at the new phrase 'Human Resources Management' and the academics in the business schools at the time wondered what effect such a shift in terms signified. Tony Watson (now Prof at Nottingham Trent University) taught me that 'personnel' derived from the French duality born of war-fare: personnel/material. It indicated a human being as opposed to an object. The term Human Resource, however, rather put the person on the same side as an object. Essays and exams were written by hundreds at the time on the question of possible future consequences.

That was a very different context. It was not so unusual to consider it rather dishonest to scape-goat an individual for the failings of the group.

Now it seems that we, the British, think it a virtue to single someone out for a public show trial.

No patient was harmed as a consequence of Mr H's employment.

So what is going on in our name, and from what are we being protected?

Is it not knowledge, or better yet, truth that we are being shielded from? The truth not only of the complexity of reality constructed by us and by government policies over the last 30 years, but also of the truth of human subjectivity and the impossibility to actually turn us all into a fantastically efficient machine.

Physiotherapists and their notes: Mr H's FTP hearing

Today's Fitness to Practice Hearing focused mainly on the question: can Mr H write notes according to the rule book. His chosen practice is Physiotherapy.

The case opened this morning, and is expected to unfold over three days. I stayed for four hours and listened to the cross examination of two witnesses, who seemed to be the whistle blowers in this case. They had been his Band 6 and Band 7 supervisors in a rotation he (Band 5) undertook a year ago.

There was no word of a problem with his actual practice, but a lot of trouble with his ability to recite the rules, and especially with writing them down in the case notes. This is how the two women want to invest their trust in him - can he write notes the way they can?

He is not like them. He is dyslexic, and he has a different relation to the written world.

One witness coughed her way through her performance, and sprinkled it with so many generalisations and ready made phrases that I wondered whether she might inadvertently prove herself unfit for practice.

She and her colleague were effectively questioning the man's qualification, which had been awarded by some other body. This opens up a can of worms. Clearly something had shaken their trust and he had become the object of their fear. So much so indeed that they had decided he must be excluded not just from their work environment, but from their profession and his chosen trade. They had, however, a great deal of difficulty making their case clear.

A lot of the talk and cross-questioning concerned the grading of the jobs, the level of staffing, the role of a crisis team, bits of specialist equipment, and other NHS organisational details. This gave a glimpse context within which this drama was taking place, and opens up another can of worms.

Times have indeed changed, and the structural context of both universities and hospitals have been transformed radically by successive government policies. One upshot of this is that today we can watch witch hunts and construct scape goats rather than think about the process, the system, the context or the way people end up scrapping when they feel under threat themselves. This may not be the intention, but it requires a lot of effort to subvert that 'natural' effect. The arena in which our assembly are obliged to meet is structured in such a way to exclude any other kind of outcome. It was a relief, then, to hear the Panel ask for details of the context that threw some real light on situation in question.

The much respected GP George Freeman (trainer, teacher, and practitioner) told me earlier this year that now, for the first time in his long experience, the British Government was supporting a glut of students in the medical profession. He said that many more were going through medical school than there were jobs in hospitals, and in rotations etc. This is a kind of State induced over-production which is often justified by reference to a false kind of 'natural selection'. You don't need me to spell out the kind of benefits that arise for the Government, and the inconvenience to the students that this nonsense implies. (click here to find the full text of that conversation).

It is the kind of competition that Chris Woodhead and Margaret Thatcher enjoyed provoking. It is based on the mistaken belief that you bring out the best in people by artificially undermining the basis of their trust and then injecting fear.

The way the two women spoke in this case revealed lots of inconsistencies and incoherences that left me thinking that they simply didn't understand the way Mr H worked, and couldn't appreciate the value he was providing. He is just not like them.

For example, one of the 'cases' they brought against him was an incident with a patient who was, as it turned out, about to die. It seems that Mr H had read the situation quickly and correctly from the social relations in the room - the family were assembled around the bed of the patient - so when he entered, he let them tell him what had happened (a stroke), listened to the patient's chest through his stethoscope (perhaps to give comfort, it was suggested) before leaving without conducting the planned physiotherapy treatment.

His supervisors complained that he didn't read the information from the file but got it from the relatives, furthermore he should have collected all the 'objective and subjective data' and he should have talked to the medics involved in the case. This was indeed the course of action then taken by the Grade 5 (a woman who knows what is required) after which she arrived at the same conclusion - that today's regime of physiotherapy would be completely out of place.

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.

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

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.

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.