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

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.