INVITED SUBMISSION
TO HOUSE OF
REPRESENTATIVES HEALTH SELECT COMMITTEE

ASSOCIATION OF SALARIED MEDICAL SPECIALISTS
5 December 2001
INQUIRY INTO THE ADVERSE EFFECTS ON WOMEN AS A RESULT OF TREATMENT BY DR GRAHAM PARRY

1. The Association welcomes the opportunity to address the Health Committee about this important matter.

2. The Association represents medical and dental specialists working in salaried positions. In New Zealand’s public health system, we represent more than 90% of salaried specialists and negotiate on their behalf concerning terms and conditions. We also advocate for a public health system in which the relationship between those who suffer and those who try to help them is optimally supported by the greater society.

3. It is in that advocacy role that we make this submission to the committee.

4. We have serious concerns that the nature of the Inquiry process could jeopardise the important relationship of trust between sufferers and helpers, between the responsible statutory bodies charged with giving substance to that trust and the House of Representatives and between professional practitioners and New Zealand’s society.

5. The Inquiry is being conducted in parallel with the deliberations of a judicial process in which natural justice and the rule of law are fully respected. However, the political weight and nature of solicited personal stories brought before the committee have far greater effect on those watching the proceedings than the necessarily dispassionate, factual and unbiased information presented, for instance, to the Medical Practitioner’s Disciplinary Tribunal or the Health and Disabilities Commissioner.

6. It is a very human characteristic for a sufferer to blame a person or group of people who may seem to be responsible for one’s misfortune. This is a very natural process and impossible to suppress from individuals’ emotions.

7. However, when it comes to assessing the level of responsibility, potential for punishment or censure, it is society’s responsibility, as a just culture to assure that that natural human characteristic, to blame, is balanced with natural justice, a fair hearing and an appropriate level of reparation to all victims. In the conduct of a professional practitioner, this also requires a high level of understanding the context in which mishap occurs and the differentiation of voluntary or wilful damage, performance beyond one’s capabilities or inadvertent bad luck.

8. In the case of surgical interventions and an estimation of competence, if you have collected 100 adverse outcomes do they arise from 200 or 20,0000 surgical procedures, were all matters of the context of the procedure and its pre- and post-operative management by the patient and practitioner taken into account? There is a major factor for both the patient and practitioner in relation to hindsight bias. Once the outcome of a process is known, it is well recognised that people often reinterpret their experiences before the fact in light of that outcome. This exposes doctors to the risk of guilt for outcomes over which they had no control and patients to unreasonable expectations of their care.

9. This is why virtually every responsible disciplinary system involves significant practitioner input to know what is reasonable to ask of a fallible human being, be they doctors or parliamentarians. Although the committee has involved an advisor with knowledge of Dr Parry’s field, without the extensive, and often exhaustive, analysis of every case brought before the committee, as occurs during the Tribunal’s assessment process or Commissioner’s investigation, that advisor will find explaining the full context of the various situations very difficult.

10. Because human beings carry out these investigations, they will not always be done perfectly with computer-like accuracy either. To err is indeed human and to blame humans for making errors is like blaming them for breathing. Where are the public attempts to help Dr Parry in the performance of his profession? Is he being supported by the hospital administration where he has worked so hard and selflessly?

11. One of our major concerns is that the process of a Parliamentary committee inquiry into the actions of an individual professional will further broach the tenuous trust between the medical profession and the society that it serves. Further, much of the media frenzy and pre-judging of the individual further precludes any opportunity for him to ever practice his vocation. Other professionals cannot help but identify with their colleague and anticipate being submitted to similar opprobrium.

12. A significant aspect influencing young New Zealand doctors’ thoughts about where they wish to practise medicine is the way senior doctors are treated. They have seen the systematic denigration of role models by a system more concerned with external controls, which often fail, than the recognition and encouragement of professional values, attitudes and practices that have far more capacity to improve outcomes for patients.

13. Indeed, a just culture that allows learning from the natural experiments that life brings to us all would clearly understand that humans should not be held to a standard of machine-like perfection. Indeed, a just culture would foster a society in which professional reliability is the behavioural norm promoted. Professional reliability was what alerted society to the failure of informed consent in Greenlane Hospital, the fact that managerial production-orientated priorities allowed patients to die in Christchurch Hospital and entire systems to breakdown in Gisborne. These are not stories promoted widely, perhaps because they suggest that, in fact, some aspects of the system are in fact working in a balanced manner some of the time. An imperfect system is not good press, a failing one is.

14. Of the Inquiry’s Terms of Reference, the Association is not in a position to comment with authority on the first two points, that is, Review the concerns of the women affected and Assess if there is a pattern to the adverse effects. We do, however, repeat our concern that the process be one which is fair and seen to be fair, that there be seen to be a balance between the various claimants. We also question the capacity of such a process to strike that balance. One thing that is often overlooked: doctors are bound by the values we profess, first, to strive to do no harm. When those we are trying to help, for whatever reason, decide to criticise and potentially harm us, we must turn the other cheek and depend on others to defend us. Doctors and other health professionals often receive criticism after a human loss even when they could not have changed the outcome. We accept that criticism because we know that blame is the first step in the grieving process. Unfortunately, the complaint process and multiple opportunities to pursue redress actually interfere with the progression through the grieving process. In New Zealand, this is exacerbated because the present level of compensation fails to provide an acceptable level of closure. Doctors perceive their level of vulnerability as very high and Graham Parry, known by many colleagues to be conscientious and hard working, has suffered the very plight that validates that perception.

15. The Term of Reference: Assess quality assurance processes at: a) individual level, b) institutional level, c) specialist college level and interfaces between each of these levels is a term upon which we can comment because it is central to the values we all profess. In fact, as Christopher Pollitt says, “The control of quality lies at the heart of the notion of professionalism.” The process by which quality is recognised and controlled has been a major issue at all levels and we would argue that the unremitting growth of highly hierarchical organisational structures in public hospitals has interfered with the ability of the professions— nursing, medical and allied groups, to foster an environment in which quality and patient safety can flourish. The process of maintaining a quality focus must start at the level of the individual practitioner who has the time and opportunity to fulfil his or her duties to patients, themselves and colleagues. A top-down, external control mode holds little promise to improve the provision of care. In fact, it is professional groups that have stood for maintenance of quality standards in the face of overwhelming pressure to increase commercial style “throughput” and “bottom-line” performance. This was one of the core findings in Christchurch and Gisborne and would be found in every other centre in New Zealand.

16. The Association is concerned that since the terms of reference concentrate on individual performance, it will interfere with the very important work of dealing with this core issue.

17. The final Term of Reference: Identify improvements that can be made in the clinical environment that will encourage an open and transparent clinical review process focussed on continuous improvement and prevention of harm could be, and is, the topic for a thesis. The first step is to recognise the central role of practitioners in the process of improving health care and to abandon the expectation that progressively more prescriptive external controls will significantly improve human behaviour. What is sought is a safety culture, which is a just culture, a reporting culture, a flexible and learning culture in New Zealand’s health system. This requires systematically shifting the focus from using information for preventing and controlling errors and violations by punitive actions to enhancing human performance through professional behaviour with emphasis on supported learning from experiences, seeking knowledge and demonstrating proficiency in a caring, respectful environment. This depends on the creation of a legal/regulatory environment (a just culture) in which information is used to promote improvement, not just monitor costs or to cover risky management decisions and allocate blame to individual practitioners. In the public hospitals the introduction of clinical democracy assisted by a flat management structure with facilitating management would provide a real impetus for the progression from a blame culture to a more healthy, productive and reasonable safety culture.

18. Whether or not the Health Committee Inquiry into the practice of an individual has the capacity to be the end or a blame culture or the beginning of a just culture is in your hands. The Association, drawing on all of its members’ wisdom, knowledge and integrity will work tirelessly to help in any and every way possible.

Peter R Roberts,
National President

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