When the problems surrounding the work of Ian Paterson, a consultant surgeon in the midlands emerged, there was hardly a surprised face amongst my colleagues. We know that standards are falling. We know there are far too few doctors and nurses to care for the future, and we know that it has to get worse before it gets better. We know that because of the inhuman pace at which the doctors work, they get jaded, and disengage from the managerial process.
Consultants failed to get involved in management many years ago, and GPs are seen as mavericks who only look after their own businesses: because they are self employed. Gps should be on health boards, but almost everywhere they have been excluded. Other countries have better consultant involvement, as many elect to serve their colleagues by getting involved. This is relatively rare in the UK, where managing doctors are seen as “going to the dark side”. This is the iceberg of denial and reluctance – a cultural black hole is revealed, and it is probably in every DGH
It is devastating for a patient to receive a diagnosis of cancer and undergo invasive surgery. To learn retrospectively that the diagnosis was fraudulent and the surgery unnecessary is a trauma beyond words. It happened to hundreds of victims of the surgeon Ian Paterson, who carried out needless operations for breast cancer on women who did not have the disease. He was given a 20-year jail sentence in 2017 for wounding with intent.
Yesterday an inquiry chaired by the Right Rev Graham James, Bishop of Norwich, concluded that Paterson’s victims had been “let down, not only by Paterson himself but by a system that proved to be dysfunctional at every level”. It noted that many opportunities to stop him were missed. The report uncovers specific and grievous lapses in the system of healthcare that must be remedied.
Paterson worked at five hospitals in the West Midlands, of which three were in the National Health Service and two were run by the private healthcare company Spire. The inquiry found that between 1998 and 2011 Paterson operated on more than 6,600 patients at Spire and more than 4,400 at the NHS hospitals. Some of these were children. The most visible victims were more than 750 women whom he is thought to have wounded after giving bogus diagnoses.
Guilt lies with Paterson. The report refers to his lies and reckless flouting of rules. Yet patients were failed too by the reluctance of those in charge to investigate. The report notes that there are many layers of regulation in the health service but that these were inadequate to cope with “poor behaviour and a culture of avoidance and denial”.
Denial and a refusal to confront warning signs are a recurring theme in big institutions. An inquiry into the scandal in the 1990s at Bristol Royal Infirmary, where babies died at high rates after heart surgery, identified an “old boys’ culture” among doctors. More recently, the Church of England has been forced to acknowledge the institutional laxity that allowed Peter Ball, former Bishop of Gloucester, to sexually assault many young men. Subjecting such closed circles to scrutiny is vital to protecting vulnerable people.
Yet scrutiny is not enough if regulators fail in the task. The report recommends 15 reforms, of which two areas stand out. First, there is a problem with the private sector. Spire attempted to evade responsibility by saying that Paterson was not employed by them and was merely renting a room in their facilities. This system, known as “practising privileges”, needs reform, alongside the fact that in the private sector consultants are not required to share data with the NHS.
Second, medical indemnity is a mess. It is, contrary to common sense, not a system of insurance. Payouts are discretionary. The Medical Defence Union, which provides indemnity to medical practitioners, refused to pay out in the case of Paterson when it became clear that his actions were criminal. The system, by design, does not cover the very worst cases of malpractice. The union then declined to appear before the inquiry. As the report said, this needs to change.
The Paterson case recalls scandals in which an organisation defensively closed ranks, yet there is particular horror when the issue is medical malpractice. Such cases strike at the social contract under which patients trust in their treatment by medical experts. The gaps in healthcare identified by the report need to be plugged fast.
Sir, Your leading article (Feb 5) mentions the failure of the medical indemnity that the surgeon Ian Paterson paid towards. Many surgeons and physicians pay tens of thousands of pounds each year for this type of cover and most of us are members of one of the three big mutual associations (the Medical Defence Union, the Medical Protection Society and the Medical and Dental Defence Union of Scotland). Amazingly such schemes are not covered by existing insurance regulation and are entirely discretionary. Hence the patients were refused compensation by his insurer. The Department of Health published a consultation on this issue more than a year ago but no progress is visible; in the meantime everyone loses.
Tony Narula, FRCS, Wargrave, Berks
Raj Persaud, FRCPsych, London W1