The act, and the responsibility for the act.

When the panel returned its verdict on the absent Mr S this week Mr W jumped in very sharply to press the panel to enact the suspension immediately in order to 'protect the public'. The panel retired to consider this, and took Mr P with them for advice. In the lull I asked Mr W in what way he was responsible for his work, and whether he could say why he had decided to ask for this measure to be brought into play so swiftly. Mr W assured me that it was not his decision, but a general policy, made by a committee.

Mundane details

On this bright winter's morning the action in the HPC FTP rooms was slow. The only hearing in progress was that of Mr S (paramedic) whose case had come to the HPC from the police. There had been a traffic accident, a breathaliser, an admission of alcoholism. This had led to a conviction. Mr S was not present at the HPC hearing, which begun today and was over by lunch time. The Panel's verdict was flying from the web-site by the middle of the afternoon. No witnesses were involved, and no legal representation had been engaged from outside to present or defend the case. It seemed to be a straight forward regurgitation of a case already held. The only people on stage when I entered the room were the court stenographer, the HPC case presenter (Mr W), the HPC Hearing Officer (Mr S), and the legal adviser (Mr P). They were discussing their luck in the office secret santa.

After a short while the chairman of the Panel popped his head round the door to ask the legal adviser to come and give his legal advice in the little room round the corner where the panel are able to discuss things in private.

In the wait I was able to address a few questions to Mr W who had been good enough to introduce himself. He recognised my name from a series of email exchanges over the previous weeks.

Mr W is one of 12 officers employed at the HPC in this function. They are drawn from a range of different backgrounds, many of them from other regulatory bodies (Financial Services, Border Control, some ex-police, and so on). Some of them also have legal training but Mr W does not. This confused me. I have been impressed by the highly stylised way this role had been filled in the other cases I had observed, and had become quite sure this function was brought in from the outside. One of the registrant's representatives had told me this as a matter of self-evident fact, in fact. But no.

Mr W said that when a case came through from the Police there was seldom any need for the HPC to engage a solicitor as they could rely on the evidence that had been produced through this other legal procedure. This also confused me, and in fact I understood him to tell me the exact opposite. I had assumed that a case coming from the courts would need a professional law person to understand the translation necessary to bring something from one domain of law into another. As it turns out, the administrators at the HPC appear to simply be picking up a case and repeating it: a sort of empty echo, but one with serious consequences for the person in question.

I asked if he was also a kind of researcher, someone who must go out and discover the facts of a case and find the witnesses who would come and speak. Not really. This was more likely delegated to a solicitor who would be instructed to act on behalf of the HPC. It was less 'research', and more 'investigation', of course. The kinds of facts that are produced through this process are not on the side of knowledge and truth as we know them in science and practice. They are a different quality of knowledge, and will ultimately be written with the weight of State law, not with the weight of the real - something that interests me a lot.

After the panel had presented its conclusions (click the heading of this blog to read them for yourself) they withdrew once more to consider the sanction. Before they left the room they were reminded that a new set of sanctions had been issued by the HPC and had come into force today. The new sanctions had been created by the Conduct and Competence Panel (made up of all kinds of professions and lay people), and written in the Indicative Sanctions Policy, both of which (no doubt) can be consulted on the web.


Post script. When the Panel exited they stopped and said hello. They were returning at 1.30pm to be the Panel for the next hearing of the day. This gave the Chairman of the Panel the chance to say a little about themselves. He was a Chairman. He would be Chairman again this afternoon.The Lay Member would also be returning. The other gentleman was the Paramedic Panel Member, so he won't be returning. They would slot in the relevant Panel member to represent the next registrant. So, out of the 7 people present (8 including me), only one has any idea of the realities and practicalities of the registrants actual real work.

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.

State Imposition and Statutory Regulation

The British Psychological Society web-site says: "Statutory regulation of psychologists is a stronger form of regulation than the current voluntary system and is therefore potentially a better means of protecting the public. The Society has argued for a long time that a statutory system is necessary to protect the public from charlatans and poor practice."

Statutory regulation, as it is implied here, is strong because it has the force of law pulsing through its veins. To be very clear, tho, this law may be local (pertaining to rules of the organisation itself) if the statutes are those of the organisation. Or it may be State Law, the law of the land, if the statutes are then written into the books of the Houses of Parliament.

What is happening currently, however, is State Regulation of psychological profession, and this is another thing again. State Regulation is imposed by the Government onto the professional organisation.

What protects the public from poorly functioning professionals, however, is not the enforcement of centralised rules (which is an excellent method of producing rule bound functionaries, and people too timid to use their own common sense). On the contrary, what is needed is strong networks of knowledge producing communities who maintain a clear emphasis on the realities of practice.

Here we have the two elements that make up Popper's nightmare. First, how can we make a system that supports the vibrant creation of practical knowledge, distributed as it is, in the minds of the may people that make up the community? Second, how does this relate to the FW Taylor's principle of efficiency, or to the legal notion of the nation state.

In the case of Statutory regulation, it can happen that a profession underwrites the structures of its organisation by getting them written into the Statute books of parliament, thus creating a powerful closed shop.

In the case of State regulation, it is the Government that imposes a system of regulation on a profession. This puts the professionals into a position of either having to pretend it was their idea in the first place, or risk themselves by opposing the law of the land. In 2001 suddenly the Labour Government decided this would be its course of action.

This means that in the current scenario relating to the so-called health professions, things are muddied precisely on this point.

The Government decided to impose State regulation on a whole range of professions. To do this, it first created two new bodies with the Health Professions Order 2001: The CHRE and the HPC. This followed the advice of the report of the Bristol Royal Infirmary Inquiry. It was imagined that these bodies would be able to operate independently of Government and of professionals, and would take over the management of a whole range of practitioner bodies. Once in this position, the HPC would itself apply to the Government to turn the newly written 'statutes' into Statutory Law. In this way, the Government would avoid the accusation of imposing State Regulation on an unwilling body of practitioners. That is, the HPC would be able to claim that it was involved in a process of statutory regulation.

This, however, is stretching the truth exceeding thin.

Psychotherapy & Counselling, 1st meeting of the Professional Liaison Group .

At the Professional Liaison Group for Psychotherapy and Counselling held on Thursday 4th December the central difficulty - resolving the tensions between imposing government policy from the top down and listening to bottom up, democratically expressed opposition - was raised and then avoided before calling the meeting to an unexpected early end: 2 hours before schedule.

Niall McDermott, Head of Policy & Standards from the Dept of Health, presented the legal frame of the group, explaining the role and process of Section 60 of the Health Act 1999. The work of the PLG will result in recommendations that go to the HPC Council, from where it goes to his team of lawyers to be turned into law. He also spoke of the links between the various governmental bodies, saying that he saw no reason why Skills for Health shouldn't inform HPC - the correct steps had been taken to make that 'read across' work.

Micheal Guthrie, Head of Policy and Standards at HPC said 'there's a clear policy direction from the Government, full stop' and ended his presentation by pointing to the not inconsiderable benefits to the professional bodies who join this process. He added that the PLG were faced with a very difficult and ambitious process, and that they would be 'asked to make pragmatic decisions' in order to 'move things forward'.

Jonathan Coe, CE of Witness supported this line and said 'opposition to the process is a misperception - our job is to move away from left field views' and implement the government's policy. This line was repeated by other HPC Council members on the group (notably Annie Turner representing Occupatonal Therapy and Eileen Thornton for the Physiotherapists) who made long and frequent interventions to reassure those representing the new profession of psychotherapy that there is always dissension to the process, but it would all get suppressed in the end: someone said 'we have a task to do, we have to manage the task'. This was more clearly stated later by another HPC representative, this one appointed as chair of this committee, arts therapist Diane Waller; she said: 'this is the HPC's task: the Government has made a decision, if we don't do it to ourselves, it will be done to us.'

Kathi Murphy (UKCP rep and psychotherapist with Metanoia) had to remind the group that she was not filibustering (a political point set up by the Skills For Health spokesman, and knocked home by the representative for Relate) but was in fact raising important arguments thoughtfully made by large groups she was there to represent. This was the most clear statement that the meeting actually had some work to do to take on board the different positions within the profession.

Sally Aldridge, Head of Regulatory Policy for the BACP, quietly asked how they would resolve the difficulties of dual registration. This deceptively simple question conceals not only the fight for status that might wreck the work of this committee, but also the unwelcome news that there is no way of stipulating when the work of this profession is simply one thing or the other. Brian Magee, representing counselling and psychotherapy for Scotland gave voice to another small question that cuts right across this one, but from a very different starting point. He asked whether the group was entitled to decide that regulation was not in service users’ interests. This question triggered the chair to stop the meeting for lunch. It was a little after 12 midday.

Popper's Nightmare

At the Rally of Impossible Professions, held in London on 20 September, Richard Gombrich had occasion to remind us all of the pertinance of Popper's Nightmare. Click the link for a short snippet of this on you-tube

“The holistic planner overlooks the fact that it is easy to centralize power but impossible to centralize all knowledge which is distributed over many individual minds, and whose centralisation would be necessary for the wise wielding of centralised power. But this fact has far-reaching consequences. Unable to ascertain what is in the minds of many individuals, he must try to control and stereotype interests and beliefs by education and propaganda. But this attempt to exercise power over minds must destroy the last possibility of finding out what people really think, for it is clearly incompatible with the free expression of thought, especially of critical thought. Ultimately it must destroy knowledge; and the greater the gain in power, the greater will be the loss of knowledge.” Karl Popper

Newshounds and the public's right to know

My trip today to the HPC revealed some very different knowledge. The Fitness to Practice Hearing was for an Art Therapist who works with children. The practitioner is alleged to have said things about children, sex and death. This counts sufficiently as a story for the Daily Mail to send a reporter, and for two Agency journalists to turn up too. They, however, took off for Great Ormond Street as soon as the news broke about baby Hope's death after the operation to separate her from her twin sister Faith. This left the unfortunate Daily Mail hound to wait, and wait, and wait... and pass the time with me.

I learned a lot from her.

For a start, in a regular court, there is no need to hang around in the reception waiting to be called. You can just march right on in and watch what goes on while waiting for the real action to start. Second, if someone asks you to leave because a witness prefers to speak in private, you can sit tight - after all, what the witness says is not private. Third, well the third point requires a bit more background.

This morning's case alleges that the therapist tried to make jokes to a colleague about children in relation to sex and death. His case is now heard in the week where the news is all about the aftermath of the tragedy of Baby P. So, Mr D's representative moved to remove the press and the public from the gallery, and petitioned for the case to be heard in private.

So I learned another detail: first, the appeal was made to section 10, 1, a. This is written in Statutory Instrument 2003 No 1575, The Health Professions Council (Conduct and Competence Committee) (Procedure) Rules Order of Council 2003. Here it is:

"(a) the proceedings shall be held in public unless the Committee is satisfied that, in the interests of justice or for the protection of the private life of the health professional, the complainant, any person giving evidence or of any patient or client, the public should be excluded from all or part of the hearing"

What the Daily Mail reporter then wanted to know was under what power she could challenge this. For her our exclusion was an outrageous breach of civil liberties, and might be a contravention of the Human Rights Act.

I stuck close by as she refused to be ushered back to the dullness of the reception, and while she phoned around to see if she could muscle her way back into the room,I noticed the coming and going in the corridor. Three middle aged men in grey walked by and back again, two in their outdoor macs. The indoor man was pointing out the hearing in this room, and the other one in that, and seemed to boast that they always had two or three going on at the same time. As he brought them back down the corridor he said, 'we shall have much more in a few months, maybe 20 or so at the same time, when the psychologists come onto our books. They tend to have better insurance, so the cases will go on for longer'. Never had the place felt more like a factory where registrants are dumped by colleagues and bosses into the mill for the pleasure of the legal profession and the administrators.

The HPC staff don't get involved at all in the nasty business. It is central part of the process that a false objectivity is constructed, and it is here that we can see most clearly the mechanism for producing proliferating unintended unheeded consequences. The 'court gimp' as the hack called him, just trawls through paperwork to collect complaints, then organises the paperwork and room bookings. An IPC is convened (independence practitioners) and it is up to them to gather evidence and find witnesses. The administrator can shrug, and smile, and go home with a clear conscience. These details are spelled out in the Health Professions Order 2001, the legal instrument passed by an elite group, the Privy Council, late in the year 2001.

The journalist was on a 'steep learning curve' trying to figure out her place in the law at the HPC. I am giving myself - and you, if you are there - a more gentle, longer slope to get the hang of the thing, for there is a twist in the logic of it which is pernicious, and which I believe is already producing unitended consequences of a kind that must be stopped.

One more thing: the law that this process is set up on is no ordinary kind of law. It is apparently called 'regulatory law' and has it's own kind of logic.

Bit by bit, in this ordinary way, I am trying to learn and to pass on the peculiar nature of the thing that is taking over as 'task master' for an extraordinary and diverse range of practitioners. I believe it to be the public's duty to join in. Especially as all this is done in our name.

Newsworthiness and children.

A shock expose was trumpeted on Radio 4's pm last night (Tuesday 2 December). The reporting was all indignant self-righteousness and puffed up pride: Radio 4 PM had played a vital role in ... well, from the tone, it must have been tracking down a seriously criminal and saving the lives of at least a dozen children. An undercover reporter had got himself a job in a private ambulance firm and found himself on a shift with a loud bragging bore. He captured this on tape and took it back to base like a hunter in a tribe released into the wild as part of an initiation into man-hood. The bore bragged that he had once had a criminal record. The conclusion that the BBC jumped to was that this man was in close proximity with sick children ... err, and, well what? What the story lacked in facts and reason, the presenter made up with huff and puff.

Reading the small print it turns out that this man is an excellent employee, and the conviction was seven years ago. But, well, this is news in a week of children stories.

As the hospital manager began speaking the journalist suddenly jumped in and urgently and excitedly stated 'and you didn't know about it until the BBC brought it to your attention, is that correct'. For goodness sake. The news and the agitation here is all produced by an over zealous BBC anxious to claim its place among the 'winners' who
save the life of an innocent child. For shame.

In amongst the story a Unison Union rep gives an opinion. It turns out that the ambulance firm is subcontracted to a contractor 'outside' the NHS. This frames his statement as: private company bad, NHS good. He adds "We are seeing the growth of an uncontrolled and unregulated industry." These two lines serve as shorthand for bringing everyone back under the tight control of the State.

Yet, wait, what's this: a small fact emerges. Private ambulance operators are used throughout England, but they are not used at all in Wales and only rarely in Scotland and Northern Ireland. So what, then, is happening in England?

Let's hold off with the sensationalism and short cuts shall we, and take things a bit more slowly and carefully. Its crucial now for us to think and to see what's really going on.

Striking is not a punishment; Mr M

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

Striking off

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

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

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

Interpreting the texts: Mr M

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

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

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

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

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

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

Struck off.

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

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

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

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

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

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

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

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

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

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

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

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

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

Mr M, paramedic, ambulance driver.

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

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

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

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

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

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

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

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

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

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

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

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

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

The Professional Liaison Group for Counselling & Psychotherapy

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

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

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

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

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

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

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

How come I didn't know that?

He suggested I read their web-site.

Struck Off in order to protect the public

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Another day at the HPC FTP hearings.

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

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

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

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

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

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

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

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

Prof Michael Rawlins comes out against hierarchies of knowledge

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Fonagy's faith in the chemicals of the brain

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

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

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

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

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

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

Careful analysis needed in cases of complaints

Tuesday, July 29th, 2008. Letter to the Times, unpublished.

Sir,
I was sorry to read of Ms B's experience with a therapist
and glad to see it reach the light of day in the Times
[http://www.timesonline.co.uk/tol/comment/letters/article4418189.ece],
it touches on a central point. Is State Regulation of the profession going to
improve the practice or will it simply make it more difficult for
aggrieved patients to get their voices heard? The kind of regulation
that is likely to result from Ms B's demand will probably lead
to two linked outcomes: to scape-goat someone in a public show trial
whilst closing the ranks not only of the practitioners but also of
the bureaucrats who she suggests should regulate them. Actually this
kind of thing is already happening through the work of the Health
Professionals Council and Skills for Health. The perverse outcome is
the creation of rules that claim to define ‘best practice’. This
leaves the poor patient with absolutely nowhere to go – so long as
the rules are followed, the practitioner is safe. It also leads this
country back into the dark ages, for this is neither art not science.
It is the worse kind of bureaucracy. The practical answer can only be
enlightenment: the long slog through the difficult terrain of
analysing the theories that channel the actions of people caught up
in conflict. There are no easy answers, but nor is there need for Ms
B or the rest of us, to give up working on the process.

Yours faithfully
Janet Low
SE27

Paul Atkinson's response to Malcolm Allen - letter to the Times

From: Paul Atkinson
Date: Fri, 18 Jul 2008 12:42:50 +0100
To:
Conversation: Therapy requires the right type of regulation
Subject: Therapy requires the right type of regulation

Sir,

Malcolm Allen [Times letters 18th July] is wrong to say that all mainstream professional bodies of psychotherapy and counselling actively support statutory regulation, if he is referring to the Government's current imposition of regulation by the Health Professions Council [HPC]. The United Kingdom Council for Psychotherapists [UKCP], the major national organisation of psychotherapists, states on its website that "the HPC is primarily a medical and NHS model of regulation and the UKCP considers that the model proposed cannot effectively regulate psychotherapy". In a recent survey of the individual membership of the psychoanalytic section of the UKCP 48% of respondents were opposed to HPC regulation and only 27% in favour. A poll of the British Psychological Society's membership also rejected regulation by the HPC recently. Psychotherapists opposed to this form of regulation are not opposed to regulation in principle. We are arguing for a regulatory process fit for purpose.

Nor is it helpful for Malcolm Allen to imply that the Skills for Health exercise is confined to 'publicly funded therapy available on the NHS'. The HPC is set to regulate private as well as public sector practitioners and we have no guarantees whatsoever how the bank of Skills for Health competency statements will be used by the Department of Health over time [Andrew Billen's article, times2 July 15]. In light of the impact of constant interventions in the working relationships of say GP's or teachers, are psychotherapists wrong to be fearful for the integrity of their work? The evidence-base of the Skills for Health project has been used to severely restrict and misrepresent the profession's pluralistic culture in the pursuit of political aims, not to guarantee the work's efficacy.
Paul Atkinson
Chair, Guild of Psychotherapists

Tim Brown spots the flaw in HPC rationale

"The Government proposes to impose state regulation of psychological therapies through the Health Professions Council (HPC).
The proposal would grant a closed shop to some of the existing accrediting organisations, and encourage a medical model of psychotherapy. " [click title for full article]

Professor Ian Parker: 10 reasons to resist the HPC

Ian Parker is Professor of Psychology at Manchester's Metropolitan University. He has put together 10 pithy points which make a strong argument against the HPC. Published in full on Ipnsosis, here they are in brief:

"The Health Professions Council (HPC) ... reassured those about to be brought into this regulator that all practitioners need to do is pay their money and carry on much as before. The problem, however, is much deeper than this, for the HPC threatens to close down psychoanalytic practice as we understand it today...

1. Surveillance of each individual's activity against a presumed moral standard
2. A notion of moral character defined by conformity and collusion with current questionable practice
3. Training reduced to the logic of compliance to a programme of study
4. Training reduced to the progression through a course of study
5. Knowledge treated as something packaged and applied
6. Thresholds treated as grounding for practice then operate as limits
7. The subordination of independent trainings to the universities
8. Turning of analytic organisations into monitoring bodies that are compliant with regulators
9. Destruction of existing professional spaces and replacement with individual accountability to regulatory apparatuses.
10. An illusion of safety guaranteed by equally illusory attempts to predict and control innovative human activity

Lord Alderdice worried whether HPC is fit to practice

quote from Lord Alderdice, House of Lords February 2007 7.35 pm:

"Why this dissatisfaction with the HPC? The membership of the HPC is primarily concerned with those who treat physical illnesses, and the way that they deal with training and skills is much less variable. In general terms—and I know that I am not doing justice here—while there is largely a right way of doing physiotherapy, chiropody or microbiological or histopathological tests, there is much wider variation in psychological treatments. The HPC professions are also much more able to set out their skills in the form of protocols which can be followed by people of a range of personalities. It matters relatively little if one technician or physiotherapist has to be replaced with another. The personality of the therapist and the relationship with the client is, however, crucial—indeed sometimes central—to psychological treatments."

for more of this, click the title - it provides a link to Ipnosis, where Denis Postle has collected together a wealth of relevant material, including this extract from Hansards.

Marc Seale (HPC CEO) talks to Denis Postle, Ipnosis

Here is a link to an important conversation between Denis Postle and Marc Seale, quoted from eIpnsosis (click the title to link to full report)

Report on eIpnosis meeting with Marc Seale, CEO of the Health Professions Council, October 3rd 2008
"At the end of August eIpnosis received a pair of messages that offered very contradictory views on the HPC's reputation. I emailed extracts of them to Marc Seale, his response was to invite me in for a meeting.

Marc met me in reception and led the way down to a basement room at HPC ‘s Kennington headquarters where we occupied two red settees. Tea was served, and Michael Guthrie, Director of Policy & Standards, joined us. Marc Seale is a genial, vigorous conversationalist and he began with an outline of the HPC’s current process." [click the title of this blog to read the full report. If you would like to make a comment, use this blog...]

Copy of the HPO 2001

Follow this link to get your own copy of the HPO 2001

Daniel Hogan's study: regulating psychotherapy in USA

This is taken from a paper written by AM
"Has the government has considered the use of the criminal law. Daniel Hogan's 4 volume study of regulation of psychotherapists in USA has the idea that -

"Where special dangers are identified in the psychotherapeutic process and where traditional avenues of dealing with them are ineffective, special laws should be enacted. Existing fraud and sexual harassment laws should be strengthened and used to prevent some of the abuses that currently occur in professional practice. This alone would obviate much of the need for licensing."
('Professional Regulation as Facilitation, not Control' in Ethically Challenged Professions...enabling innovation and diversity in psychotherapy and counselling - Bates and House - PCCS Books, 2003

Hogan devoted Volume III of his massive 4 volume study The Regulation of Psychotherapists to a description of malpractice law and a review of malpractice suits on professional practice in particular (Volume II provided a comprehensive analysis of all laws potentially regulating psychotherapists in the USA at the time of writing). Volume III involved analysing 300 decisions from the different legal systems of the different US states. In other words his recommendation that the criminal law is examined in this way arises out of a very detailed understanding of the ways the law can be used.

What have others said? And has there been any statement by Government that this path has been considered and rejected? AM

Character control - power of HPC

When Richard Reeves did some research for a paper (co-written with Phil Mollon) on state regulation he reviewed cases from the HPC complaint hearings.

He was struck by several instances where police cautions had been issued to an individual which were non-related to professional work (e.g a chiropodist who had been involved in a ‘punch-up’ with his parents). He wondered how HPC had obtained this information – below is their reply.
------------------------------------------
Dear Sir,

Thank you for your email.

The HPC is involved in the Notifiable Occupations Scheme, in relation to the Home Office Circular 6 / 2006.

Notifiable Occupations are those in which the public interest in the disclosure of conviction and other information by the police or other officials, generally outweighs the normal duty of confidentiality owed to the individual.
Our thirteen professions are included in the list of occupations that carry special trust or responsibility under the Scheme.

Notifying bodies, such as the police, courts and other bodies, send us information about criminal offences committed by registrants if the offence is relevant to HPC registration.

I hope this information is useful to you.

With regards

Simon Thompson
Case Manager
Health Professions Council
Park House
184 Kennington Park Road
London SE11 4BU
www.hpc-uk.org

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There is something rather troubling about this - the creation of the HPC seems to be leading to the invention of a pseudo-legal platform that is essentially moral in character. It is this that I noticed at the CHRE meeting earlier in the year, and that makes me wonder whether an unintended consequence of this mistaken endeavour is to lead to the re-invention of a psuedo state related religion.

an informal opinion from someone in law

"From a legal perspective I am struck by various statements that the scale of the risk is exaggerated and there is insufficient evidence that therapists abuse clients on a scale that warrants the costs of state intervention. That could be an interesting area to focus on:

I haven't looked at the evidence but my guess is that it might be an uphill struggle to persuade a court that the evidence is so weak as to make a govt decision to introduce some form of state regulation irrational or unreasonable. That said however it might be worth really going into the evidence issues as part of the lobbying process and if their answers are insufficient they could form part of a later legal challenge. At this stage you could ask for more detail about what evidence has the government put forward and have they yet done a cost benefit analysis (which they should do for any legislative proposal)

- i.e. sending the Dept of Health a letter saying you would like to know what evidence they are relying upon, e.g. any independent studies as to the scale of the problem, and asking when /whether they have done a cost benefit analysis for the legislative proposals (my guess is that it is still early days and because the exact form of regulation for the different sectors hasn't been decided they haven't yet had to do that sort of analysis). Even worth considering a freedom of information request along those lines (perhaps at a later stage) if you don't get a decent response. And when it comes to deciding on costs for the purpose of the cost benefit analysis it would be interesting to see what they consider to be costs - are they taking into account both economic costs and potential cost to innovation etc. This could be a weak spot to look at and lobby on.

The debate around evidence and lack of sufficient evidence might also be used to help shape the form of the state regulation if it comes to that - there are lots of different sorts of regulation and, for example, the tick box approach, at least in the financial services field, has tended to be replaced by a principles based approach which is less reductive and is better at encouraging innovation. So don't assume that there is only one sort of regulation - it might be possible to have something much more light touch and more suited to innovation and all the different sorts of therapies available. Seems to me that in bringing in this regulation idea, the govt is probably concerned about (1) inflated claims that I can cure you and (2) the range of potential unethical practices. Although in theory the courts can deal with concerns like this the fact is that the courts are expensive and scary and the govt tends to want individual complaints of malpractice to be dealt with by the professional bodies. Perhaps the key is to try to shape the regulation that comes out so that it focuses on misrepresentation (arguably already covered by the common law anyway) and proper ethics (ditto), to keep encouraging something which is very light touch."

Regulating counselling and psychotherapy via HPC

Excerpts from the HPC doc. I include it here because I am surprised by the rather grand way it states its right to intervene in other people's practise in the name of public safety without saying what that means nor why they (the HPC) are less of a threat than any one else. There are many questions begged by this document which I hope to gradually unpack.

Introduction
We are seeking the views of stakeholders on the potential statutory regulation of psychotherapists and counsellors.
About us:
We are the Health Professions Council (HPC). We are a regulator and our job is to protect the health and wellbeing of people who use the services of the health professionals registered with us. To protect the public, we set standards that health professionals must meet. Our standards cover health professionals’ education and training, behaviour, professional skills, and their health. We publish a Register of health professionals who meet our standards.

Health professionals on our Register are called ‘registrants’. If registrants do not meet our standards, we can take action against them which may include removing them from the Register so that they can no longer practise.

About statutory regulation
• Statutory regulation of psychotherapists and counsellors
In February 2007, the government published a White Paper on the future of regulation, ‘Trust, Assurance and Safety – The Regulation of Health Professionals in the 21st Century’.
The White Paper said: ‘The government is planning to introduce statutory regulation
for…psychotherapists and counsellors…’ (page 81) ‘…psychotherapists and counsellors will be regulated by the Health Professions Council, following that Council’s rigorous process of assessing their regulatory needs and ensuring that its system is capable of accommodating them. This will be the first priority for future regulation.’ (page 85)
Subject to the necessary legislative approval, the White Paper indicated that psychotherapists and counsellors would be regulated by the HPC in the future.
We are therefore undertaking this project in anticipation of that legislative approval. [emphasis added] However, please note that the outcome will be subject to any final decisions made by the UK and Scottish Parliaments.