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Qualifications and quality of care
1352
British support for Caribbean research SIR,-Your Round the World correspondent (March 16, p 667) paints an unjustifiably gloomy picture interspersed with inaccuracies. Dr White has already addressed the question of British support for CAREC (April 27, p 1040) and we have just returned from a meeting of the Commonwealth Caribbean Medical Research Council at which, rather than the purported withdrawal of an annual £ 30 000 subvention, the UK Overseas Development Administration indicated a willingness to consider research support of up to [,160000 per annum for the next 3 years. However, it is the "failure of the British Medical Research Council unit [presumably the MRC laboratories in Jamaica] to train able local graduates" that I must address, as its director. This is a small unit with six medically qualified staff (currently three British, one American, one Jamaican, one Guyanese) working in sickle cell disease. From 1974 a special medical post was created, reserved for a graduate of the University of West Indies, to gain experience in clinical research, and this post has never been vacant. Traditionally aligned with the university department of child health, this post has trained twenty paediatricians for periods between 6 month and 2 years. The unit has also participated in research with members of the departments of medicine, surgery, obstetrics, radiology, genitourinary surgery, psychiatry, physiology, and anaesthetics, and the Tropical Metabolism Research Unit. None of these trained graduates had pursued a career in research-and here the problems are more complex, including lack of research tradition, the local standing of clinical research, and research career structures in the Caribbean. This unit offers elective opportunities to medical students yet, despite active local proselytising, attracts a West Indian student from the Caribbean only once in every 2-3 years. At the same time 30-40 students from other countries annually avail themselves of the opportunity, including West Indians in the UK, Canada, and the USA. The problem is perhaps buried in local attitudes to research which will take longer to address and for which there are no simple remedies. Undergraduates and postgraduates need exposure to the excitement of clinical research and such experience must be recognised and encouraged by the local medical authorities. Research career structures need development. In the meantime, the MRC will continue to do its utmost to promote the training of local research scientists. MRC Laboratories (Jamaica), University of the West Indies, Mona, Kingston 7, Jamaica
G. R. SERJEANT
Qualifications and quality of
care
SIR,- Professor Pereira Gray (April 27, p 1025) addresses the issue of doctors’ qualifications and the quality of patient care. His article seems to have been sparked off by the decision of a commercial medical negligence insurer, the Medical Insurance Agency, to offer a discount to fellows and members of the Royal College of General Practitioners on the grounds that they are believed to be at lower risk of claims of medical negligence than those who are not members. The Medical Protection Society-a non-profit-making mutual organisation of doctors and dentists-has no evidence to support the assertion that general practitioners differ in risk on the basis of postgraduate qualifications. It is the society’s view that qualifications per se do not prevent specific criticisms of professional conduct or competence. How defensible any complaint or claim is depends on the standard of care provided by the doctor on a particular occasion. The society has a policy of charging differential membership subscriptions on the basis of risk. Thus, private practitioner members in the high-risk surgical specialties pay higher subscriptions than general practitioners. It might become necessary to charge a higher subscription to general practitioners who do certain surgical procedures, but, as a member of the council of the Medical Protection Society and chairman of its general practice advisory board, I note that there are at present no plans or intention to do so. Pereira Gray’s comparison of the subscription charged by the medical defence organisations and the Medical Insurance Agency in
respect of annual indemnity arrangements is somewhat misleading since the provision of indemnity for acts of medical negligence is only one of the many benefits of membership of the Medical Protection Society. Most of the society’s work on behalf of members involves advice and assistance with a wide range of other professional matters such as disciplinary hearings, inquests and fatal accident inquiries, ethical matters, General Medical Council proceedings, libel, health service commissioner and public inquiries, insurance report writing, criminal matters arising from medical practice, and courts martial. The Medical Protection Society and the Medical Insurance Agency also differ in respect of the basis for the provision of indemnity. Members of the former who are in benefit at the time of an incident can seek the Society’s assistance in the defence of any claim that may follow. In retirement, neither the member nor his or her estate will need to pay further subscriptions. The Medical Insurance Agency, on the other hand, offers a contract of insurance that is based on the need to have a valid policy in force on the date on which the claim is made. Thus, doctors who wish to maintain cover for incidents that have occurred but are, as yet, unknown, can purchase "run off" cover for, as the agency states, "a premium... ultimately reducing to 20% of the rates then applicable". Unfortunately, "ultimately", insofar as medical negligence litigation is concerned, can often mean decades because of the sometimes very long interval between the clinical event and the initiation of legal proceedings. Membership of the Medical Protection Society avoids the need to pay subscriptions well into retirement and beyond. Additionally, the society sets no upper limit on the indemnity for any one claim. In times of claims inflation, fixed levels of indemnity may prove to be insufficient to meet the costs of a practitioner’s liability, especially if the limit of cover includes both the defendant’s and plaintiffs legal costs. General practitioners are not immune from high claims. Grove Health Centre, London W12 8EJ, UK
WILLIAM MCN. STYLES
SIR,—Professor Pereira Gray indulges in the sport of navelgazing. As it has ever been since the beginning of the Royal College of General Practitioners, there are some excellent general practitioners who are not members and some awful ones who are. There are three criteria for avoiding litigation and disciplinary action: an ability to get on with people, conscientiousness, and luck. None are satisfactorily examined in the RCGP’s membership examination. My advice to the professor and the RCGP is: take the money and run, before the Medical Insurance Agency realises. "Vesey’s", Corpus Christi Lane, Godmanchester PE18 8HW, UK
Health
KEITH STEWART
professionals in NHS management
SIR,—The new business-style National Health Service health authorities represent a welcome return to consensus management but it is flawed by the lack of representation of the health professions. The authorities created by the NHS and Community Care Act have two features with profound implications for the way they will work and for the accountability of their members, especially the executive members. Furthermore, non-executive members are now paid; the concept of membership has thus changed from that of the more or less independent representative of some group or interest to that of an officer accountable to the health authority’s chairman. The only real difference between nonexecutive and executive members is the time they have available for health authority work. An equally profound change has befallen those senior officers (directors) who have become executive members. They have taken on corporate responsibility for the authority in its purchasing and, where applicable, direct management roles. They now have equal status with the general manager who thus reverts to the coordinator role that the administrator held in the old consensus management team. Nonetheless, the new-style health authority is not strictly a
British support for Caribbean research SIR,-Your Round the World correspondent (March 16, p 667) paints an unjustifiably gloomy picture interspersed with inaccuracies. Dr White has already addressed the question of British support for CAREC (April 27, p 1040) and we have just returned from a meeting of the Commonwealth Caribbean Medical Research Council at which, rather than the purported withdrawal of an annual £ 30 000 subvention, the UK Overseas Development Administration indicated a willingness to consider research support of up to [,160000 per annum for the next 3 years. However, it is the "failure of the British Medical Research Council unit [presumably the MRC laboratories in Jamaica] to train able local graduates" that I must address, as its director. This is a small unit with six medically qualified staff (currently three British, one American, one Jamaican, one Guyanese) working in sickle cell disease. From 1974 a special medical post was created, reserved for a graduate of the University of West Indies, to gain experience in clinical research, and this post has never been vacant. Traditionally aligned with the university department of child health, this post has trained twenty paediatricians for periods between 6 month and 2 years. The unit has also participated in research with members of the departments of medicine, surgery, obstetrics, radiology, genitourinary surgery, psychiatry, physiology, and anaesthetics, and the Tropical Metabolism Research Unit. None of these trained graduates had pursued a career in research-and here the problems are more complex, including lack of research tradition, the local standing of clinical research, and research career structures in the Caribbean. This unit offers elective opportunities to medical students yet, despite active local proselytising, attracts a West Indian student from the Caribbean only once in every 2-3 years. At the same time 30-40 students from other countries annually avail themselves of the opportunity, including West Indians in the UK, Canada, and the USA. The problem is perhaps buried in local attitudes to research which will take longer to address and for which there are no simple remedies. Undergraduates and postgraduates need exposure to the excitement of clinical research and such experience must be recognised and encouraged by the local medical authorities. Research career structures need development. In the meantime, the MRC will continue to do its utmost to promote the training of local research scientists. MRC Laboratories (Jamaica), University of the West Indies, Mona, Kingston 7, Jamaica
G. R. SERJEANT
Qualifications and quality of
care
SIR,- Professor Pereira Gray (April 27, p 1025) addresses the issue of doctors’ qualifications and the quality of patient care. His article seems to have been sparked off by the decision of a commercial medical negligence insurer, the Medical Insurance Agency, to offer a discount to fellows and members of the Royal College of General Practitioners on the grounds that they are believed to be at lower risk of claims of medical negligence than those who are not members. The Medical Protection Society-a non-profit-making mutual organisation of doctors and dentists-has no evidence to support the assertion that general practitioners differ in risk on the basis of postgraduate qualifications. It is the society’s view that qualifications per se do not prevent specific criticisms of professional conduct or competence. How defensible any complaint or claim is depends on the standard of care provided by the doctor on a particular occasion. The society has a policy of charging differential membership subscriptions on the basis of risk. Thus, private practitioner members in the high-risk surgical specialties pay higher subscriptions than general practitioners. It might become necessary to charge a higher subscription to general practitioners who do certain surgical procedures, but, as a member of the council of the Medical Protection Society and chairman of its general practice advisory board, I note that there are at present no plans or intention to do so. Pereira Gray’s comparison of the subscription charged by the medical defence organisations and the Medical Insurance Agency in
respect of annual indemnity arrangements is somewhat misleading since the provision of indemnity for acts of medical negligence is only one of the many benefits of membership of the Medical Protection Society. Most of the society’s work on behalf of members involves advice and assistance with a wide range of other professional matters such as disciplinary hearings, inquests and fatal accident inquiries, ethical matters, General Medical Council proceedings, libel, health service commissioner and public inquiries, insurance report writing, criminal matters arising from medical practice, and courts martial. The Medical Protection Society and the Medical Insurance Agency also differ in respect of the basis for the provision of indemnity. Members of the former who are in benefit at the time of an incident can seek the Society’s assistance in the defence of any claim that may follow. In retirement, neither the member nor his or her estate will need to pay further subscriptions. The Medical Insurance Agency, on the other hand, offers a contract of insurance that is based on the need to have a valid policy in force on the date on which the claim is made. Thus, doctors who wish to maintain cover for incidents that have occurred but are, as yet, unknown, can purchase "run off" cover for, as the agency states, "a premium... ultimately reducing to 20% of the rates then applicable". Unfortunately, "ultimately", insofar as medical negligence litigation is concerned, can often mean decades because of the sometimes very long interval between the clinical event and the initiation of legal proceedings. Membership of the Medical Protection Society avoids the need to pay subscriptions well into retirement and beyond. Additionally, the society sets no upper limit on the indemnity for any one claim. In times of claims inflation, fixed levels of indemnity may prove to be insufficient to meet the costs of a practitioner’s liability, especially if the limit of cover includes both the defendant’s and plaintiffs legal costs. General practitioners are not immune from high claims. Grove Health Centre, London W12 8EJ, UK
WILLIAM MCN. STYLES
SIR,—Professor Pereira Gray indulges in the sport of navelgazing. As it has ever been since the beginning of the Royal College of General Practitioners, there are some excellent general practitioners who are not members and some awful ones who are. There are three criteria for avoiding litigation and disciplinary action: an ability to get on with people, conscientiousness, and luck. None are satisfactorily examined in the RCGP’s membership examination. My advice to the professor and the RCGP is: take the money and run, before the Medical Insurance Agency realises. "Vesey’s", Corpus Christi Lane, Godmanchester PE18 8HW, UK
Health
KEITH STEWART
professionals in NHS management
SIR,—The new business-style National Health Service health authorities represent a welcome return to consensus management but it is flawed by the lack of representation of the health professions. The authorities created by the NHS and Community Care Act have two features with profound implications for the way they will work and for the accountability of their members, especially the executive members. Furthermore, non-executive members are now paid; the concept of membership has thus changed from that of the more or less independent representative of some group or interest to that of an officer accountable to the health authority’s chairman. The only real difference between nonexecutive and executive members is the time they have available for health authority work. An equally profound change has befallen those senior officers (directors) who have become executive members. They have taken on corporate responsibility for the authority in its purchasing and, where applicable, direct management roles. They now have equal status with the general manager who thus reverts to the coordinator role that the administrator held in the old consensus management team. Nonetheless, the new-style health authority is not strictly a