Conflicting Concepts?

Eileen Marshall       Margaret Williams

28th May 2005

On 26th May 2005 we noted our concern about the intended approach of the UK Prime Minister’s Strategy Unit towards those with health problems that have been tactically designated as “mental” in origin, not least because included amongst people who are to be specifically targeted by the Strategy Unit’s plan are those who suffer from “the creation of ‘diseases’ like chronic fatigue syndrome for which no evidence of physical pathology can be found”.

(See )

“Chronic Fatigue Syndrome” (CFS, also known as ME) is not a psychiatric disorder, yet such “mental” patients are to be “treated” by the imposition of a blanket psychiatric management regime of cognitive behavioural therapy (CBT) that is to be implemented by five thousand extra psychotherapists trained in CBT and by a doubling of the number of psychiatrists.

This expansion of the therapeutic apparatus of the State is apparently warmly welcomed by Government, even though such State control is likely to result not only in the increased categorisation of physically sick and disabled people as “mental” patients without any moral or scientific justification, but also in sufferers being required to surrender a degree of sovereignty over their mental life.  This will inevitably result in fundamentally diminished autonomy because these patients are being hounded into becoming unwilling victims of the State.

How does this Government policy accord with the rosy portrait of patients’ entitlement to good doctoring as promoted in the current British Medical Journal? (ref: “Patients, professionalism, and revalidation”: Donald Irvine. BMJ. 28th May 2005:330:1265-1268).  Sir Donald Irvine is Past President of the General Medical Council and his message is clear:

“Revalidation is an essential part of professionalism directed at meeting patients’ expectations of good care.  The GMC must rise to the challenge”. 

“All patients want to be looked after by a good doctor. When patients and their loved ones are preoccupied with illness, they want to take their doctor’s professionalism for granted; they want doctors they can trust.  However, although patients can judge a doctor’s personal qualities, they have to take clinical competence on trust.  So they rely on medical regulation to ensure both good medical practice and protection from substandard practice (but) patients now know that their unquestioning trust in the regulatory system was not justified. Evidence suggests that an important minority of practising doctors are clinically inadequate or cannot relate appropriately to patients (but) doctors and their regulating bodies, through a misplaced sense of professional solidarity, have tolerated such practice because it avoided confronting colleagues.  Successive governments colluded.  Consequently, patients have been exposed to risky doctors.  This position is indefensible.  This applies particularly to specialists, general practitioners and locums whose practice is unsupervised”.

“Ensuring good doctoring is vital to patients and should be equally important to good doctors”.

“Professionalism should epitomise good practice.  It embraces doctors’ personal responsibility for their competence and conduct (and) is unsurpassed in delivering high standards of performance, conduct and service, because true professionals are motivated by conscience”.

“Medicine is in transition from a predominantly doctor orientated culture to a patient centred culture of professional values founded on the principle of patient autonomy. This requires doctors to treat patients with dignity and respect and involve them as fully as they wish in decisions about their medical care”.

“The profession and the GMC have much to gain from seeing the principles of accountability as precious assets rather than a threat”.

“The public and the profession both have powerful reasons for putting patient centred  professionalism at the heart of their vision of medical care.  It must assume a top priority in professional life, practice, education, regulation and research in order to achieve good doctoring for all patients”.

“It is essential for all doctors to accept, as the public does, that the standards in ‘Good Medical Practice’ (the GMC code of practice) are for real.  They were intended to be attainable by any reasonable doctor.  The underlying problem is doctors’ fear of assessment.  This is a nettle that the profession now has to grasp”.

“Sound licensure requires a strongly proactive GMC that is fearless in confronting vested interests (whether of the profession, government, or employers) which might seek to deflect it from its prime duty of ensuring that all licensed doctors provide a good standard of practice.  The public and the profession should insist on this (so that) the profession would be in a strong position to join with the public in a new partnership that could transform the outlook for patient centred health care in this country”.

Worthy words indeed from Sir Donald: who could disagree with them, apart from doctors who for decades have been accustomed to demand and receive unquestioning deference as of right and who would not be willing to lay themselves open to scrutiny of their professionalism?

Even if doctors’ resistance to quality control were ultimately to be overcome by regulation, what hope is there of the implementation of Sir Donald’s aspiration for professional partnership with patients? 

Of particular note is the use of the word “autonomy”:  it seems that whereas Sir Donald’s intention is to increase all patients’ autonomy by involving them as fully as they wish in decisions about their medical care, the Prime Minister’s Strategy Unit is intent on removing ME/ICD-CFS patients’ autonomy by the pre-determined political tactic of classifying them as “mental” patients who are not to be allowed any investigations other than basic screening.

Does Sir Donald’s “professionalism” include the requirement for doctors to keep up-to-date with evolving scientific evidence about “controversial” disorders such as ME/ICD-CFS so that sufferers are no longer wrongly deprived of their basic rights by doctors who are intent on furthering their own careers at the expense of patients, even to the extent that (against sound evidence which these doctors continue to ignore) they deliberately create “mental” disorders designed to require “lifestyle” interventions that do not work?

The problem is that in the real world, as Sir Donald must know, Government propaganda does not equate with Government policy, and it is policy, not “professionalism”, that ultimately decides how patients are treated, as many ME patients already know to their cost and as many more will doubtless soon discover.