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.

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?

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?