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Police Surgeons – training for quality
Proceedings
Police Surgeons - training for quality
D McLay OBE Honorary Clinical Senior Lecturer (Forensic Medicine), University of Glasgow, United Kingdom A paper presented at the Forensic Science Society Autumn Meeting and AGM Nov 2002, Glasgow, Quality Matters
Among the ancient foundations in Glasgow is the Royal College of Physicians and Surgeons, founded in the reign of James VI as the Faculty of Physicians and Surgeons. At that time the two occupations, physicians and surgeons, could scarcely be said to represent branches of the same profession, so coming together in this way was a bold recognition of a congruence of interest. In these present days, the medical profession seems intent on ever deeper - or, perhaps, it should be wider - fission, with colleges devoted to yet narrower specialities. The Glasgow College rejoices in two mottoes. The first is conjurat amice, meaning they conspire as friends which has, at first glance, a somewhat sinister ring. The friends Horace is referring to are, on the one hand, inherent intelligence and, on the other, a propensity to study. Neither alone will bring success: you need to be born with natural potential, but you have to work at it too. In much the same way, both art and science are necessities, although the two are often put in opposition. Doctors have long been equivocal about their reliance on science. It is difficult to read some of the expert testimony given in trials a hundred years ago without a shudder. Evidence was often based on assertion, in turn depending on textbooks in which statements could be traced from edition to edition without serious challenge. The current emphasis on evidence-based medicine and therapeutics has come like a breath of fresh air. We must ensure that similar rigour applies to advice from doctors to investigators, then in evidence before the courts. That said, the evidence base may not be readily come by, for many points are difficult to research, particularly in the area of clinical forensic medicine where so much is done one to one, where no two cases are alike and where, heretofore, there has not been willing cooperation among branches of the sciences and arts that make up our particular field of endeavour. The clinical forensic practitioner's role What is the clinical practitioner's role? To begin with, the very title applied to doctors who involve themselves in assisting the police is unsettled. In 1988 Ralph Summers, a former president and one of the founders of the Association of Police Surgeons of Great Britain wrote a brief History of The Police Surgeon. Its publication coincided with two events: the establishment of a section of Clinical Forensic Medicine at the Royal Society of Medicine and the centenary of the Association of Metropolitan Police Surgeons (of which he was the last honorary secretary). In
science&.ji~sticevolume 42 N0.4 (2002) 235 - 238
1951 that exclusively London-based association became transformed under his influence to include police doctors throughout Great Britain. The 'Great Britain' was dropped more than ten years ago, not in early recognition of the possible effects of devolution, but more in the hope of attracting some recruits from beyond these shores. During the early years of the sectarian strife in Northern Ireland the doctors declared themselves 'forensic medical officers' to emphasise their independence from the Royal Ulster Constabulary. This designation was modified in metropolitan London when the term - now familiar from television soaps became 'forensic medical examiner' (FME). 'Police surgeon' was legitimated in the Codes of Practice promulgated under the Police and Criminal Evidence Act 1984, an Act which does not operate in Scotland. A review of code C was in preparation during 2002; this is intended to permit some persons who are not registered medical practitioners to perform some duties previously thought to require medical skills. There is a motion before the Association of Police Surgeons (APS) annual general meeting in 2003 to change the association's name to Association of Forensic Physicians. Dr Summers' booklet is written from a somewhat parochial viewpoint, for he celebrates the origin of the Metropolitan Police in 1829, forgetting that the Glasgow Police Act came into force in 1800. Applicants for the Metropolitan Police had to be less than 35 years of age, over 5 foot 7 inches in height and able both to read and write. A superintending surgeon was appointed in 1830. No doubt he would have a measuring stick, but I wonder if he had to test the literacy of candidates. I certainly found myself, a hundred and fifty odd years later, involved quite inappropriately in considering dyslexia as a factor in the suitability of candidates for Strathclyde Police. In the early days of the City of Glasgow Police, a duty of appointed doctors was to deal with cases of casual illness brought to the attention of the police, hence the term still persisting in the west of Scotland: 'police casualty surgeon'. Having concluded that we do not know who we are, we may have better luck in setting out what we do.
O The Forensic Science Society 2002 Key words Forensic science, police surgeon, training, clinical forensic medicine, Association of Police Surgeons.
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D McLay Police Surgeons - training for quality
To push forward its agenda of excellence, the Association of Police Surgeons has an Education and Research Committee. The present chairman is Dr Guy Norfolk who, in the midst of a busy life, acts as an adviser to the Police Complaints Authority on deaths in custody. I am indebted to him for allowing me to air some of his concerns about the Council for the Registration of Forensic Practitioners (CRFP) to which I will turn later. The Education and Research Committee has published many documents, sometimes in collaboration with others. These are designed not only for members but for any interested practitioners. Examples include a set of cards available to hand to prisoners and their carers on release from detention where there is a history of head injury. Packaging requirements for samples destined for forensic science laboratories are clearly set out in another. These can be seen on the APS website (www.apsweb.org.uk). The leaflet 1 wish in particular to mention here is entitled The Role of the Independent Forensic Physician. This is particularly useful to distribute to students, to doctors who aspire to work in the forensic field (or who simply telephone the Association office for information) and generally to publicise the functions to be expected of police surgeons. To quote: "Forensic physicians offer medical care and, when required, forensic assessment of prisoners and suspects in police custody, complainants (alleged victims) of crime, police officers injured on duty and attend scenes of death to pronounce life extinct. They provide interpretation of their findings to the police, courts and sometimes to social services verbally and in writing. Statements for court and presentation of their evidence in court is required in a proportion of these cases." The doctor's status is described as "self-employed, independent and individually appointed (usually contracted) to provide their services to relevant police authorities". A new sentence has had to be added, "They may hold further contracts of service with private security companies, acting as custodians of prisoners in court, to provide medical services to detainees" which takes into account the contracted out nature of the service that has been imposed by some police forces. The leaflet points out that most police doctors "are general practitioners who provide a part-time service in clinical forensic medicine; some are engaged in other medical specialities. A few, mainly in busy metropolitan areas, work exclusively as forensic physicians."
I must interpolate here that the part-time element has proved a stumbling block to recognition of any FME as a specialist by the Specialist Training Authority (STA) which regulates such matters in the National Health Service (NHS). Only doctors devoting at least half their time to the speciality are recognised. This appears to conflict with the European system, but the British authorities have yet to be won over. There are some anomalies, for example police surgeons in England and Wales may be recognised as having specialist skills under Section 12 of the Mental Health Act 1983. In dealing with training, the leaflet advises that doctors "should undergo an initial training course on commencement of this
Page 236
work and have the opportunity to attend further courses throughout their careers". Specific training is prescribed where the case concerns sexual assault, child sexual abuse or mental health assessment. Higher qualifications are available, a matter to which I shall return. The various relevant associations mentioned in the leaflet as able to assist doctors in learning their craft include the Forensic Science Society. Brief reference to the facilities provided by police forces is made. The deficiencies commonly found have been a matter of concern for many years. Despite national recommendations, there remain many police stations with poorly designed or adapted medical examination suites. However important the criminal investigation part of the doctor's work may be -especially to readers of this journal - the fact is that an overwhelming proportion of time is taken up in dealing with the examination of prisoners not for evidence but in the interests of their welfare [I]: fitness to be detained; fitness to be released; fitness to be charged; fitness to be transferred; fitness to be interviewed. What training is available? The APS has provided a guide for potential trainers, setting out the requirements they ought to fulfil, the topics to be covered and the standard to be achieved by apprentice police surgeons. Under the aegis of the Association of Chief Police Officers (ACPO) a week's course of training for new entrants is held three or four times a year at the National Scientific Support School in Durham with a mixture of input from the APS, from local police officers and Crown Prosecution Service personnel. This covers the basics in a systematic way, and gives practice in statement writing and answering questions in a mock court. The Diploma in Medical Jurisprudence (DMJ) was first offered in 1960. Since then, it has come to be regarded as the gold standard, indicating a degree of knowledge and experience allowing the holder to be considered able to give an expert view on the matter in issue. The examination is in two parts, the second requiring the compilation of a case book setting out and discussing a range of scenes and events met by the candidate. The first part of the examination is common to clinicians, pathologists and, now, odontologists, the second is particular to the speciality. Recently a Master's diploma has been instituted. Courses designed for the DMJ candidate have been held, but only one is in place at the moment, the DMJ Study Club in London. Another, in Manchester, ran for some years, but is now concentrating on the development of a university based qualification. Directed towards a broader range of interested people, the University of Glasgow offered a Diploma in Forensic Medicine (DFM) which teaches elements of medicine, science and the law in equal measure, rather than from a purely medical, hands-on, point of view. Many of those who attend the course are lawyers, police officers and scientists, as well as doctors who have no intention of practising forensic medicine. Teaching takes place
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D McLay Police Surgeons -training for quality
simultaneously in London for this qualification. Possession of the DFM allows a police surgeon to pass straight to the second part of the DMJ. In addition, the Association of Police Surgeons - now in partnership with Elsevier - publishes the Journal of Clinical Forensic Medicine. The APS also produces an authoritative textbook (in process of revision at the moment). As with the Forensic Science Society, we mount an annual conference and symposia. We encourage participation in meetings of the Section of Clinical Forensic and Legal Medicine of the Royal Society of Medicine and of bodies like IAFS. We are major supporters of the conferences on clinical forensic medicine of World Police Medical Officers. It may be argued that there are too many meetings: it is my own hope that WPM0 can combine after 2005 with IAFS, for our meetings are in the same three year cycle. There is, then, no lack of training opportunities. National cover The distribution of police surgeon cover across the United Kingdom (this information is for 1999, with 16 of the 50 forces not reporting figures) is uneven. Around seven forces get by with three doctors on call at any one time, with about a dozen reaching double figures. It is hardly surprising that Strathclyde had 22, considering the area covered, but I believe that Northern (based on Inverness) had four. Essex and Devon & Cornwall both large counties geographically - managed with ten, whereas Greater Manchester needed 11. It is easy to see that higher numbers should result from sparse population, but many of the doctors who do provide a service in rural areas see a tiny handful of cases in a year, compared with colleagues who may have to work ceaselessly for a whole shift in metropolitan areas.
The implication for income is obvious. It is equally obvious that experience gained will vary, too. If a doctor's income for coming out when called by the police is no more than a few hundred pounds a year, there is little incentive to undergo extensive training when the doctor is aware that experience must be limited, and that skills wither, or are never acquired in the first place. A doctor in this position is unlikely to join the APS, even less likely to see the need for higher qualification. How can any force insist that such doctors study to obtain a diploma? The financial return compared with the inconvenience of being frequently on call at unsocial hours could as easily make the doctor resign from the list. Indeed, many doctors in rural areas adopt the stance that they respond to police calls simply as a matter of social responsibility. This particular circle has not been squared, nor do I see how it can be. That has serious implications for the imposition of national standards. Professional regulation Doctors in the United Kingdom are subject to regulation by the General Medical Council (GMC) (www.gmc-uk.org). The GMC is a statutory body answerable to the Privy Council. In older, more leisurely days, it gained notoriety from the salacious details printed in the press about practitioners appearing before the Disciplinary Committee to answer allegations that they had committed adultery with patients. Over recent years, the Council
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has become much more concerned - and quite rightly - with allegations that a doctor's practice has fallen below tolerable clinical standards. The power to intervene on such grounds is quite new. A casual reading of press reports about these cases may suggest that the exercise of what is draconian power is capricious, but onlookers seldom have the full facts. The Council produced a flurry of proposals for appraisal, then revalidation, but these were conceived in haste. The Council has a new president and the hope must be that a more practicable scheme is to be promulgated (www.revalidationuk.org). Few doctors are not also subject to supervision by their professional peers in one or other of the colleges that rule practice in the specialities. Fierce criticism was directed at both the GMC and the relevant college following the inquiries into clinical practice in paediatric cardiac surgery at Bristol. These bodies have little defence if they are not geared up to tackle deficiencies at an early stage. There is certainly little complacency now. No disinterested commentator on these matters as they affect the medical profession could deny that a profound rethink was needed. As with all such revisions, however, the danger is that the baby gets thrown out with the bath water. To be workable, any scheme must be simple and not so onerous that people look for ways to circumvent it. When the Council for the Registration of Forensic Practitioners (CRFP) was instituted the APS very soon became involved, for here seemed to be a long sought opportunity to make a real difference in the standard of work undertaken by police surgeons. The Association co-operated keenly with the CRFP programme; indeed, one of our members chairs the Council's medical working group. As time has passed, however, the practical difficulties, perhaps a confusion of aims, came to the fore. What was the prime objective of the Council? Surely its genesis lay in a dissatisfaction with the reliability of evidence given in the courts by those whose expertise was made use of by one side or another in our adversarial system? Not only the reliability of evidence and its scientific base were questionable, so was the corpus of expert and professional witnesses. Some were thought to be carpetbaggers ready to give evidence as required in return for adequate fees. At any rate, the APS supported any scheme to accredit experts, to underpin the work of such bodies as the Expert Witness Institute which catered mostly for those practising in the civil sphere. The relevance of this to the jobbing police surgeon was less evident. Nevertheless, uncountable hours of work have gone into the attempt to devise a suitable (and unassailable) means of assessing our colleagues. As I have set out before, the content of police surgeons' work varies enormously across the country. For instance, in some areas, no child sexual abuse examinations are done by police surgeons, in some these examinations are always performed jointly with paediatricians. Some police surgeons could not comply with a demand to send for review a set number of case papers, or statements relating to a particular class of investigation.
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D McLay Police Surgeons - training for quality
Looking at the origins of the CRFP, a need to reassure the courts that witnesses giving expert evidence were really expert was identified. A quotation from Lord Bingham "By promoting high standards of integrity and skill in giving expert evidence on which judges and juries depend when making important decisions, CRFP will contribute directly to the quality of justice" features prominently in the Council's publicity material. In the case of police surgeons, it seems likely that registration will be based on competence to practise as police surgeons, not on their capacity to give expert evidence. If this is a correct understanding, the courts will be misled. The stance of the APS is that only some police surgeons may properly be considered competent to give expert evidence, although all ought to be capable to give professional evidence. In addition, we know that a significant number are inadequately trained and lack expertise, notwithstanding that some of these have 'done the job' for years.
In the wake of Shipman, three separate inquiries undertaken by, respectively, the Home Office, the Coroners Review and the Shipman Inquiry itself, have looked at death certification procedures. The last to issue its consultation document [3] proposes a monstrous bureaucracy. Where, one may ask, are we to get the paper? Where are we to get the personnel for a whole new corpus of officialdom? Its intended auditing function will, in turn, need to be audited. The doctors now acting (not very effectively) as longstop before cremation is permitted are cavalierly set aside rather than have their powers and support strengthened. The suggested procedure makes further delay in disposal of the body inevitable. In the interests of involving the deceased's family - and the prior events giving rise to this desire are readily understood - we are to ride roughshod over obligations of confidentiality, even after the patient's death, laid upon doctors by the GMC. Is this really the best we can do?
It may be said that self regulation of the medical profession has led to the current crisis in confidence - both in doctors and by doctors. In fact, regulation by the GMC has improved immeasurably. An increased proportion of its members are appointed from outside the profession. It concentrates large resources on maintaining standards that it used to believe outside its remit. These large resources derive, of course, from the fees paid by doctors. We must be sure that the financial cost of the CRFP confers benefit on those paying the registration fees and does not mislead the courts, as seems possible.
Second motto! I did tell you that the Royal College of Physicians and Surgeons had two mottoes. The second, dating from the time when it acquired royal status and a coat of arms, is a truncated version of an epigram of Martial meaning life is not just for living, but to be healthy, wording that bears a remarkable resemblance to the World Health Organisation's admonition that a healthy life comes not simply from the absence of disease, but is a positive state requiring good nutrition, clean water and freedom from want. Clinical forensic medicine may not have these grand aims, but it can contribute by ensuring that conditions for those detained in police custody are reasonable, that they are treated humanely and are capable of responding to fair questioning. Perhaps, at the end of the day, standards in matters such as these are no less important in the interests of justice.
How closely we continue to work with the CRFP remains in the balance. The Home Office appears to have credited [2] the CRFP with the capacity to become involved in accrediting training establishments and courses. This seems to the APS a mistaken view. Forensic pathologists are answerable to the Royal College of Pathologists and, in England, to the Home Office if they are on the approved list, as well as to the courts. They see little benefit from another layer imposed by CRFP. Only just over 30 active forensic pathologists practise in England. Certainly since the privatisation or contracting out arrangements began, there is little sign of active training, teaching or research. Facilities for specialised examination are limited. In the case of police surgeons (if we remove the GMC from consideration) no one, other than the courts and contracting police forces can impose sanctions. Who, or which body, has the legitimate interest? I stated earlier that the medical profession was fissiparous, but these questions may point to our need to fill the deficiency by establishing a college of our own. The standards required of groups of doctors in a specialised field have always been set by these doctors. With the undoubted disasters visited on patients, what right has any doctor to contend that the profession can clear up the mess? Stripped of mediaeval secrecy, working to a clear agenda with the transparency rightly demanded of publicly accountable bodies, and in consultation with other organisations intimately involved in the justice systems in this country, who more than forensic clinicians have an interest in improved outcomes?
Page 238
References 1
Robertson G. Role of Pol~ceSurgeons - Research Study no 6 Ev~denceto the Royal Commission on Criminal Justice. London: HMSO, 1992
2
Report of the Home Off~ceWorking Group on Police Surgeons. Pollce Leadership and Powers Un~t,April 2001.
3
Developing a New System for Death Cert~fication, a discussion paper. The Shipman
4
Crooks C. News & Views. Royal College of Physic~ansand Surgeons of Glasgow.
Inquiry, October 2002.
February 2002.
science&.justice Volume 42 N0.4 (2002) 235 - 238
Police Surgeons - training for quality
D McLay OBE Honorary Clinical Senior Lecturer (Forensic Medicine), University of Glasgow, United Kingdom A paper presented at the Forensic Science Society Autumn Meeting and AGM Nov 2002, Glasgow, Quality Matters
Among the ancient foundations in Glasgow is the Royal College of Physicians and Surgeons, founded in the reign of James VI as the Faculty of Physicians and Surgeons. At that time the two occupations, physicians and surgeons, could scarcely be said to represent branches of the same profession, so coming together in this way was a bold recognition of a congruence of interest. In these present days, the medical profession seems intent on ever deeper - or, perhaps, it should be wider - fission, with colleges devoted to yet narrower specialities. The Glasgow College rejoices in two mottoes. The first is conjurat amice, meaning they conspire as friends which has, at first glance, a somewhat sinister ring. The friends Horace is referring to are, on the one hand, inherent intelligence and, on the other, a propensity to study. Neither alone will bring success: you need to be born with natural potential, but you have to work at it too. In much the same way, both art and science are necessities, although the two are often put in opposition. Doctors have long been equivocal about their reliance on science. It is difficult to read some of the expert testimony given in trials a hundred years ago without a shudder. Evidence was often based on assertion, in turn depending on textbooks in which statements could be traced from edition to edition without serious challenge. The current emphasis on evidence-based medicine and therapeutics has come like a breath of fresh air. We must ensure that similar rigour applies to advice from doctors to investigators, then in evidence before the courts. That said, the evidence base may not be readily come by, for many points are difficult to research, particularly in the area of clinical forensic medicine where so much is done one to one, where no two cases are alike and where, heretofore, there has not been willing cooperation among branches of the sciences and arts that make up our particular field of endeavour. The clinical forensic practitioner's role What is the clinical practitioner's role? To begin with, the very title applied to doctors who involve themselves in assisting the police is unsettled. In 1988 Ralph Summers, a former president and one of the founders of the Association of Police Surgeons of Great Britain wrote a brief History of The Police Surgeon. Its publication coincided with two events: the establishment of a section of Clinical Forensic Medicine at the Royal Society of Medicine and the centenary of the Association of Metropolitan Police Surgeons (of which he was the last honorary secretary). In
science&.ji~sticevolume 42 N0.4 (2002) 235 - 238
1951 that exclusively London-based association became transformed under his influence to include police doctors throughout Great Britain. The 'Great Britain' was dropped more than ten years ago, not in early recognition of the possible effects of devolution, but more in the hope of attracting some recruits from beyond these shores. During the early years of the sectarian strife in Northern Ireland the doctors declared themselves 'forensic medical officers' to emphasise their independence from the Royal Ulster Constabulary. This designation was modified in metropolitan London when the term - now familiar from television soaps became 'forensic medical examiner' (FME). 'Police surgeon' was legitimated in the Codes of Practice promulgated under the Police and Criminal Evidence Act 1984, an Act which does not operate in Scotland. A review of code C was in preparation during 2002; this is intended to permit some persons who are not registered medical practitioners to perform some duties previously thought to require medical skills. There is a motion before the Association of Police Surgeons (APS) annual general meeting in 2003 to change the association's name to Association of Forensic Physicians. Dr Summers' booklet is written from a somewhat parochial viewpoint, for he celebrates the origin of the Metropolitan Police in 1829, forgetting that the Glasgow Police Act came into force in 1800. Applicants for the Metropolitan Police had to be less than 35 years of age, over 5 foot 7 inches in height and able both to read and write. A superintending surgeon was appointed in 1830. No doubt he would have a measuring stick, but I wonder if he had to test the literacy of candidates. I certainly found myself, a hundred and fifty odd years later, involved quite inappropriately in considering dyslexia as a factor in the suitability of candidates for Strathclyde Police. In the early days of the City of Glasgow Police, a duty of appointed doctors was to deal with cases of casual illness brought to the attention of the police, hence the term still persisting in the west of Scotland: 'police casualty surgeon'. Having concluded that we do not know who we are, we may have better luck in setting out what we do.
O The Forensic Science Society 2002 Key words Forensic science, police surgeon, training, clinical forensic medicine, Association of Police Surgeons.
Page 235
D McLay Police Surgeons - training for quality
To push forward its agenda of excellence, the Association of Police Surgeons has an Education and Research Committee. The present chairman is Dr Guy Norfolk who, in the midst of a busy life, acts as an adviser to the Police Complaints Authority on deaths in custody. I am indebted to him for allowing me to air some of his concerns about the Council for the Registration of Forensic Practitioners (CRFP) to which I will turn later. The Education and Research Committee has published many documents, sometimes in collaboration with others. These are designed not only for members but for any interested practitioners. Examples include a set of cards available to hand to prisoners and their carers on release from detention where there is a history of head injury. Packaging requirements for samples destined for forensic science laboratories are clearly set out in another. These can be seen on the APS website (www.apsweb.org.uk). The leaflet 1 wish in particular to mention here is entitled The Role of the Independent Forensic Physician. This is particularly useful to distribute to students, to doctors who aspire to work in the forensic field (or who simply telephone the Association office for information) and generally to publicise the functions to be expected of police surgeons. To quote: "Forensic physicians offer medical care and, when required, forensic assessment of prisoners and suspects in police custody, complainants (alleged victims) of crime, police officers injured on duty and attend scenes of death to pronounce life extinct. They provide interpretation of their findings to the police, courts and sometimes to social services verbally and in writing. Statements for court and presentation of their evidence in court is required in a proportion of these cases." The doctor's status is described as "self-employed, independent and individually appointed (usually contracted) to provide their services to relevant police authorities". A new sentence has had to be added, "They may hold further contracts of service with private security companies, acting as custodians of prisoners in court, to provide medical services to detainees" which takes into account the contracted out nature of the service that has been imposed by some police forces. The leaflet points out that most police doctors "are general practitioners who provide a part-time service in clinical forensic medicine; some are engaged in other medical specialities. A few, mainly in busy metropolitan areas, work exclusively as forensic physicians."
I must interpolate here that the part-time element has proved a stumbling block to recognition of any FME as a specialist by the Specialist Training Authority (STA) which regulates such matters in the National Health Service (NHS). Only doctors devoting at least half their time to the speciality are recognised. This appears to conflict with the European system, but the British authorities have yet to be won over. There are some anomalies, for example police surgeons in England and Wales may be recognised as having specialist skills under Section 12 of the Mental Health Act 1983. In dealing with training, the leaflet advises that doctors "should undergo an initial training course on commencement of this
Page 236
work and have the opportunity to attend further courses throughout their careers". Specific training is prescribed where the case concerns sexual assault, child sexual abuse or mental health assessment. Higher qualifications are available, a matter to which I shall return. The various relevant associations mentioned in the leaflet as able to assist doctors in learning their craft include the Forensic Science Society. Brief reference to the facilities provided by police forces is made. The deficiencies commonly found have been a matter of concern for many years. Despite national recommendations, there remain many police stations with poorly designed or adapted medical examination suites. However important the criminal investigation part of the doctor's work may be -especially to readers of this journal - the fact is that an overwhelming proportion of time is taken up in dealing with the examination of prisoners not for evidence but in the interests of their welfare [I]: fitness to be detained; fitness to be released; fitness to be charged; fitness to be transferred; fitness to be interviewed. What training is available? The APS has provided a guide for potential trainers, setting out the requirements they ought to fulfil, the topics to be covered and the standard to be achieved by apprentice police surgeons. Under the aegis of the Association of Chief Police Officers (ACPO) a week's course of training for new entrants is held three or four times a year at the National Scientific Support School in Durham with a mixture of input from the APS, from local police officers and Crown Prosecution Service personnel. This covers the basics in a systematic way, and gives practice in statement writing and answering questions in a mock court. The Diploma in Medical Jurisprudence (DMJ) was first offered in 1960. Since then, it has come to be regarded as the gold standard, indicating a degree of knowledge and experience allowing the holder to be considered able to give an expert view on the matter in issue. The examination is in two parts, the second requiring the compilation of a case book setting out and discussing a range of scenes and events met by the candidate. The first part of the examination is common to clinicians, pathologists and, now, odontologists, the second is particular to the speciality. Recently a Master's diploma has been instituted. Courses designed for the DMJ candidate have been held, but only one is in place at the moment, the DMJ Study Club in London. Another, in Manchester, ran for some years, but is now concentrating on the development of a university based qualification. Directed towards a broader range of interested people, the University of Glasgow offered a Diploma in Forensic Medicine (DFM) which teaches elements of medicine, science and the law in equal measure, rather than from a purely medical, hands-on, point of view. Many of those who attend the course are lawyers, police officers and scientists, as well as doctors who have no intention of practising forensic medicine. Teaching takes place
science&justice Volume 42 ~ o . (2002) 4 235 - 238
D McLay Police Surgeons -training for quality
simultaneously in London for this qualification. Possession of the DFM allows a police surgeon to pass straight to the second part of the DMJ. In addition, the Association of Police Surgeons - now in partnership with Elsevier - publishes the Journal of Clinical Forensic Medicine. The APS also produces an authoritative textbook (in process of revision at the moment). As with the Forensic Science Society, we mount an annual conference and symposia. We encourage participation in meetings of the Section of Clinical Forensic and Legal Medicine of the Royal Society of Medicine and of bodies like IAFS. We are major supporters of the conferences on clinical forensic medicine of World Police Medical Officers. It may be argued that there are too many meetings: it is my own hope that WPM0 can combine after 2005 with IAFS, for our meetings are in the same three year cycle. There is, then, no lack of training opportunities. National cover The distribution of police surgeon cover across the United Kingdom (this information is for 1999, with 16 of the 50 forces not reporting figures) is uneven. Around seven forces get by with three doctors on call at any one time, with about a dozen reaching double figures. It is hardly surprising that Strathclyde had 22, considering the area covered, but I believe that Northern (based on Inverness) had four. Essex and Devon & Cornwall both large counties geographically - managed with ten, whereas Greater Manchester needed 11. It is easy to see that higher numbers should result from sparse population, but many of the doctors who do provide a service in rural areas see a tiny handful of cases in a year, compared with colleagues who may have to work ceaselessly for a whole shift in metropolitan areas.
The implication for income is obvious. It is equally obvious that experience gained will vary, too. If a doctor's income for coming out when called by the police is no more than a few hundred pounds a year, there is little incentive to undergo extensive training when the doctor is aware that experience must be limited, and that skills wither, or are never acquired in the first place. A doctor in this position is unlikely to join the APS, even less likely to see the need for higher qualification. How can any force insist that such doctors study to obtain a diploma? The financial return compared with the inconvenience of being frequently on call at unsocial hours could as easily make the doctor resign from the list. Indeed, many doctors in rural areas adopt the stance that they respond to police calls simply as a matter of social responsibility. This particular circle has not been squared, nor do I see how it can be. That has serious implications for the imposition of national standards. Professional regulation Doctors in the United Kingdom are subject to regulation by the General Medical Council (GMC) (www.gmc-uk.org). The GMC is a statutory body answerable to the Privy Council. In older, more leisurely days, it gained notoriety from the salacious details printed in the press about practitioners appearing before the Disciplinary Committee to answer allegations that they had committed adultery with patients. Over recent years, the Council
science&)u\t~ccVolume 42 N0.4 (2002) 235 - 238
has become much more concerned - and quite rightly - with allegations that a doctor's practice has fallen below tolerable clinical standards. The power to intervene on such grounds is quite new. A casual reading of press reports about these cases may suggest that the exercise of what is draconian power is capricious, but onlookers seldom have the full facts. The Council produced a flurry of proposals for appraisal, then revalidation, but these were conceived in haste. The Council has a new president and the hope must be that a more practicable scheme is to be promulgated (www.revalidationuk.org). Few doctors are not also subject to supervision by their professional peers in one or other of the colleges that rule practice in the specialities. Fierce criticism was directed at both the GMC and the relevant college following the inquiries into clinical practice in paediatric cardiac surgery at Bristol. These bodies have little defence if they are not geared up to tackle deficiencies at an early stage. There is certainly little complacency now. No disinterested commentator on these matters as they affect the medical profession could deny that a profound rethink was needed. As with all such revisions, however, the danger is that the baby gets thrown out with the bath water. To be workable, any scheme must be simple and not so onerous that people look for ways to circumvent it. When the Council for the Registration of Forensic Practitioners (CRFP) was instituted the APS very soon became involved, for here seemed to be a long sought opportunity to make a real difference in the standard of work undertaken by police surgeons. The Association co-operated keenly with the CRFP programme; indeed, one of our members chairs the Council's medical working group. As time has passed, however, the practical difficulties, perhaps a confusion of aims, came to the fore. What was the prime objective of the Council? Surely its genesis lay in a dissatisfaction with the reliability of evidence given in the courts by those whose expertise was made use of by one side or another in our adversarial system? Not only the reliability of evidence and its scientific base were questionable, so was the corpus of expert and professional witnesses. Some were thought to be carpetbaggers ready to give evidence as required in return for adequate fees. At any rate, the APS supported any scheme to accredit experts, to underpin the work of such bodies as the Expert Witness Institute which catered mostly for those practising in the civil sphere. The relevance of this to the jobbing police surgeon was less evident. Nevertheless, uncountable hours of work have gone into the attempt to devise a suitable (and unassailable) means of assessing our colleagues. As I have set out before, the content of police surgeons' work varies enormously across the country. For instance, in some areas, no child sexual abuse examinations are done by police surgeons, in some these examinations are always performed jointly with paediatricians. Some police surgeons could not comply with a demand to send for review a set number of case papers, or statements relating to a particular class of investigation.
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D McLay Police Surgeons - training for quality
Looking at the origins of the CRFP, a need to reassure the courts that witnesses giving expert evidence were really expert was identified. A quotation from Lord Bingham "By promoting high standards of integrity and skill in giving expert evidence on which judges and juries depend when making important decisions, CRFP will contribute directly to the quality of justice" features prominently in the Council's publicity material. In the case of police surgeons, it seems likely that registration will be based on competence to practise as police surgeons, not on their capacity to give expert evidence. If this is a correct understanding, the courts will be misled. The stance of the APS is that only some police surgeons may properly be considered competent to give expert evidence, although all ought to be capable to give professional evidence. In addition, we know that a significant number are inadequately trained and lack expertise, notwithstanding that some of these have 'done the job' for years.
In the wake of Shipman, three separate inquiries undertaken by, respectively, the Home Office, the Coroners Review and the Shipman Inquiry itself, have looked at death certification procedures. The last to issue its consultation document [3] proposes a monstrous bureaucracy. Where, one may ask, are we to get the paper? Where are we to get the personnel for a whole new corpus of officialdom? Its intended auditing function will, in turn, need to be audited. The doctors now acting (not very effectively) as longstop before cremation is permitted are cavalierly set aside rather than have their powers and support strengthened. The suggested procedure makes further delay in disposal of the body inevitable. In the interests of involving the deceased's family - and the prior events giving rise to this desire are readily understood - we are to ride roughshod over obligations of confidentiality, even after the patient's death, laid upon doctors by the GMC. Is this really the best we can do?
It may be said that self regulation of the medical profession has led to the current crisis in confidence - both in doctors and by doctors. In fact, regulation by the GMC has improved immeasurably. An increased proportion of its members are appointed from outside the profession. It concentrates large resources on maintaining standards that it used to believe outside its remit. These large resources derive, of course, from the fees paid by doctors. We must be sure that the financial cost of the CRFP confers benefit on those paying the registration fees and does not mislead the courts, as seems possible.
Second motto! I did tell you that the Royal College of Physicians and Surgeons had two mottoes. The second, dating from the time when it acquired royal status and a coat of arms, is a truncated version of an epigram of Martial meaning life is not just for living, but to be healthy, wording that bears a remarkable resemblance to the World Health Organisation's admonition that a healthy life comes not simply from the absence of disease, but is a positive state requiring good nutrition, clean water and freedom from want. Clinical forensic medicine may not have these grand aims, but it can contribute by ensuring that conditions for those detained in police custody are reasonable, that they are treated humanely and are capable of responding to fair questioning. Perhaps, at the end of the day, standards in matters such as these are no less important in the interests of justice.
How closely we continue to work with the CRFP remains in the balance. The Home Office appears to have credited [2] the CRFP with the capacity to become involved in accrediting training establishments and courses. This seems to the APS a mistaken view. Forensic pathologists are answerable to the Royal College of Pathologists and, in England, to the Home Office if they are on the approved list, as well as to the courts. They see little benefit from another layer imposed by CRFP. Only just over 30 active forensic pathologists practise in England. Certainly since the privatisation or contracting out arrangements began, there is little sign of active training, teaching or research. Facilities for specialised examination are limited. In the case of police surgeons (if we remove the GMC from consideration) no one, other than the courts and contracting police forces can impose sanctions. Who, or which body, has the legitimate interest? I stated earlier that the medical profession was fissiparous, but these questions may point to our need to fill the deficiency by establishing a college of our own. The standards required of groups of doctors in a specialised field have always been set by these doctors. With the undoubted disasters visited on patients, what right has any doctor to contend that the profession can clear up the mess? Stripped of mediaeval secrecy, working to a clear agenda with the transparency rightly demanded of publicly accountable bodies, and in consultation with other organisations intimately involved in the justice systems in this country, who more than forensic clinicians have an interest in improved outcomes?
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References 1
Robertson G. Role of Pol~ceSurgeons - Research Study no 6 Ev~denceto the Royal Commission on Criminal Justice. London: HMSO, 1992
2
Report of the Home Off~ceWorking Group on Police Surgeons. Pollce Leadership and Powers Un~t,April 2001.
3
Developing a New System for Death Cert~fication, a discussion paper. The Shipman
4
Crooks C. News & Views. Royal College of Physic~ansand Surgeons of Glasgow.
Inquiry, October 2002.
February 2002.
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