Clinical governance and the role of NHS boards: lessons from the Ian Paterson case

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In the wake of Ian Paterson’s conviction, medicine’s enduring professional “club” culture must be eradicated, say Kieran Walshe and Naomi Chambers.

Surgeon Ian Paterson was recently found guilty of 17 counts of wounding with intent to cause grievous bodily harm in relation to 10 patients who had needless surgery at the Spire hospitals in the Midlands.

These cases were just a sample of a larger number of patients he had harmed while working in the NHS and privately. The Heart of England NHS Foundation Trust (HEFT) has already spent almost £18m on 265 claims for compensation, while solicitors are bringing a civil class action on behalf of a further 350 women against both Spire Healthcare and the NHS.

Paterson did breast surgery on over 4400 women at HEFT during his time there, including 1207 mastectomies, and an unknown number of procedures in the private sector.

Inquiry

In 2013 the Trust published a report from an inquiry it commissioned from Sir Ian Kennedy which set out how problems with Paterson’s clinical performance were known about when he was appointed in 1998, how concerns were raised repeatedly from 2003 onwards, and why it took until 2011 for the organisation to suspend him and report him to the General

Medical Council.

In 2014 Verita, an independent investigations consultancy, published a report for Spire Healthcare examining how the two Spire hospitals where he worked first became aware of concerns about his NHS practice in 2007 but took little action either to investigate or to restrict his private practice.

It documents how the hospital directors and their medical advisory committees ignored repeated concerns and withdrew Paterson’s practising privileges only in 2011 after he had been suspended by HEFT and had restrictions placed on his practice by the GMC.

Yet another scandal

To anyone who is familiar with the litany of medical failures and scandals of the past two decades – Rodney Ledward, Richard Neale, Dick van Velzen, James Wisheart, Harold Shipman, and several others—the Paterson case will seem depressingly familiar. Once again we see a charismatic, powerful doctor whose incompetence, misconduct, and criminal behaviour went unchecked for years.

The Kennedy report describes an organisational culture at HEFT of secrecy, bullying, and professional control, in which whistleblowers (even senior clinicians) were wary of putting their heads above the parapet.

It outlines how senior leaders knew about serious concerns but repeatedly failed to act. It finds that governance systems and processes were ad hoc and informal. It describes a board that was out of touch and kept in the dark about what was going on.

And, most painfully, it shows that many women experienced serious avoidable harm as a consequence of Ian Paterson’s actions and the failures of the NHS and private sector hospitals where he worked.

Reforms

Some reforms introduced in recent years, particularly in the wake of the Francis inquiry into failures in care at the mid-Staffordshire Hospitals NHS Trust, have made it less likely

that this could happen again. They include:

*the requirement for fit and proper persons tests for NHS board members
*guidance on the conduct of NHS boards
*the statutory duties and powers given to responsible officers in organisations that employ doctors
*the requirement for all doctors to show their fitness to practice through revalidation in order to retain their licence
*the duty of candour obligations placed on all NHS organisations
*the appointment of guardians in NHS organisations to support and protect whistleblowers
*the establishment of the Healthcare Safety Investigation Branch in the Department of Health.

But how confident can we be that these latest reforms to policies and processes will overcome what seems to be a persistent and enduring professional “club” culture in medicine, which so often acts to protect doctors rather than patients? We should remember that the Paterson case happened after the Bristol Royal Infirmary inquiry and the Shipman inquiry and subsequent reforms.

There have been calls for a public inquiry into the latest case. Although governments are understandably reluctant to establish such inquiries, we think there is a strong case for three main reasons.

Firstly, we still do not know the scale of harm caused by Paterson, across both the NHS and private sector, and the various investigations to date do not provide a definitive answer.

Secondly, we need to examine forensically how both HEFT and the Spire hospitals failed to act on concerns about Paterson’s practice for years, and to hold these organisations and their leaders to account.

Thirdly, and perhaps most importantly, this terrible case needs to be used to drive current reforms forward and establish whether they are really working (and if not, what

more needs to be done).

We still have a long way to go before we can be confident that patients in the NHS are safe from such harms.

Kieran Walshe is Professor of Health Policy and Management at Alliance MBS and Naomi Chambers is Professor of Healthcare Management.

This blog first appeared as an editorial in the British Medical Journal, and is reproduced here with thanks to the BMJ.

 

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