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,

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.