Turbulent times—the experiences of a college president

Election to president 

Somewhat to my surprise, I was elected President of The Royal College of Surgeons in April 1998. I had 3 months in which to reorganize my life before assuming office in July. At the time of my election the College had gone through a period of considerable change in the preceding 10 years, having moved on from being merely a College that was principally an examining institution for the FRCS and a repository for the world famous Hunterian Museum. (Perhaps in parenthesis I should add here that George and I share a close interest in the history of surgery, and in John Hunter, the founder of scientific surgery, in particular.) In the early 1990s it was realized that the College should be pursuing an active interest in the education of surgeons as well as examining their clinical and theoretical knowledge, and so a thriving Education Department was established, heavily influenced by the then President, Professor Sir Norman Browse. A Surgical Skills Centre was set up in which basic, intermediate and advanced craft skills could be taught, both on animal tissue and cadavers. I reasonably assumed that during the 3 years of my Presidency I would continue to have responsibility for these areas of surgical interest, and hopefully develop them whilst the College continued with its more traditional examinations and inspection of training posts. In the event this proved far from the case.

The first turbulence—media, public and political criticism 

Just 3 weeks before I assumed office, the British public were shattered by an event that came to be known in the United Kingdom and many other parts of the world as “the Bristol affair.” Surprisingly, this did not reach the publicity I might have imagined in the United States, and I therefore remind you that it comprised two surgeons, both highly respected, being found guilty by the General Medical Council of underperformance in the field of pediatric cardiac surgery.

Their combined mortality rate had been very considerably greater than in other institutions around the country, a fact which had been recognized for several years but no action taken. A junior anesthetist had blown the whistle and the findings as presented to the public were damning. One surgeon was erased from the Medical Register, and the other banned from operating on children for 3 years.

There then occurred what I can only describe as a media frenzy, exacerbated by adverse political comment, with the public taking sides both for and against the convicted surgeons, and the College being right in the middle! Although my immediate predecessor had to withstand the initial 2 weeks of barrage, I found myself picking up the pieces of intense criticism of the College, its training methods, and its seeming failure to act in the light of underperformance. This event became a catalyst for a concerted attack in succeeding months on the surgical profession generally sadly stimulated further by two additional high profile cases of surgical underperformance (both gynecological) which hit the headlines in a major way. I had the unenviable task of restoring the public image of surgeons, the profession of surgery, and the College. At one time it seemed as if every week would bring yet another damning headline, not only in the tabloid newspapers, but also in the broadsheets. Let me give you a flavor: “Doctors in the dock—one in 10 of our surgeons is providing substandard care alleges a book out this week.” “110 women maimed by surgeons’ mistakes.” “Stop the butcher surgeons says MP.” “Greater accountability will bring the surgeon gods back to earth.”

These four headlines were each from well-respected broadsheet newspapers. The leader column writers and the feature writers then gave grist to the mill. In summary, it might be said that criticisms of doctors were of poor communication, secrecy, arrogance, a patronising attitude, unwillingness to admit error, inaccessibility when things went wrong, and, in some cases, a lack of knowledge or skill. Criticisms of medical Royal Colleges generally, and the surgeons’ College in particular, were that they were inward looking, self-interested, unaccountable, ineffective, and at odds with public interest. Damning words indeed. In short, the College and its head, the President, faced a massive crisis of image.

What to do? 

The first decision taken by the Council of the College was to reverse the policy of former years, and instead of being low profile and keeping the media at arms’ distance, to become high profile by using the media, newspapers, radio and television alike, to promote the image of surgery and especially that of the College.

Together with our sister surgical colleges from Scotland and Ireland we rapidly prepared a formal response to the Bristol affair and the questions that arose from it, and published a document, widely circulated, acknowledging that a different culture needed to be established among surgeons where there could be universal explicit quality assurance of surgical practice, improved communication, recognition of accountability to the patient and to society, and the avoidance of isolationism. Team-working was the way forward. A press conference was called to launch this response at which a large number of television cameras, radio commentators and newspaper reporters were present, to say nothing of a number of parents whose children had died in Bristol. It was a difficult but very worthwhile exercise and, despite great hostility from some of the parents, the response by the media was extremely positive and the feedback was that the College had done well.

We followed this up with another document titled “Team working in surgical practice” amplifying some of the views previously expressed and, a little later, a booklet was widely circulated titled “Good surgical practice,” laying down explicit standards which the College expected surgeons to practice. Under the chapter heading “Good clinical care” there were 14 headings stressing the importance of lack of discrimination, technical competence, compassion, communication with patients and relatives, appropriate consent, and willingness to involve the skills and knowledge of other clinicians if ones own expertise is limited. Other chapters included teaching and training responsibilities, working with colleagues (team working again!), record keeping, and the dealing with complaints.

Each of these documents received wide support and involved me with numerous press interviews, radio interviews, and television appearances. Over and above this we continued to labour the importance of our skills laboratory and the tuition that occurred, as there appeared to be a public perception that in some instances surgeons’ skills were not kept up to date. Something I might say for which there was very little, if any, evidence.

All this activity came to the attention of the civil servants in the Department of Health, and also to the Secretary of State for Health, who I invited to come and see the facilities within the College for himself. I wanted to explain first hand to an extremely critical and sceptical politician that, far from being all bad, things were actually very good indeed. I was delighted when he accepted the invitation, and to my intense surprise, 24 hours before he was due, there was a message from No. 10 Downing Street to say that the Prime Minister, Tony Blair, would like to accompany him and meet me for a private chat.

My meeting with Tony Blair went well. He was notably impressed with the Education Department and the Surgical Skills Laboratory, spending nearly an hour touring the College, accompanied by the Secretary of State and a number of civil servants. I had the opportunity of a private 15-minute discussion with them in regard to their growing concern for the state of the National Health Service as a whole, quite apart from any specific surgical concerns. This led to my involvement in the second major turbulence.

The second turbulence—the NHS crisis 

About a month after the Prime Minister’s visit to the College, I found myself summoned to No. 10 Downing Street in the company of my opposite numbers at the Royal College of Physicians and the Royal College of Nursing, the Chairman of the British Medical Association, a senior general practitioner, and a senior trades’ union worker, to be asked by Mr Blair and the Chancellor of the Exchequer if the professions would work with Government actively to try and restore the former glory of the National Health Service provided the necessary funding was given to rectify the continued shortfall over many years by former administrations. Of course, we all said “yes” as we were all dedicated to the principles of the National Health Service.

In the Budget a few days later the additional funding was promised and I and others embarked on a massive process of meetings, consultations, and workshops which culminated in the production of a large document titled “The NHS Plan”. This detailed a 10-year program of change in methods of working within the National Health Service, and aimed to rectify the many deficiencies and problems that had arisen, the most high profile of which was the long waiting times for surgical operations. A Modernisation Board was set up, chaired by the Secretary of State for Health, to oversee the implementation of the Plan and I was invited to be a member. I then found myself regularly in both the Department of Health and in the Secretary of State’s office, discussing the many points of detail that arose and feeding back to the politicians the varying responses of those at the coal face.

Needless to say, this led to another burst of intense media interest, and instead of finding myself on television or radio talking about the alleged underperformance of surgeons, I was talking about the problems of the National Health Service and whether or not I thought the Government proposals would succeed in achieving the desired aim. There were some who believed, as a consequence of my cooperation with Government, that I was a political pawn but in fact this was not the case and I was completely free to speak critically, both in private and in public, when I thought it appropriate. Indeed, just before the recent General Election, there was a front-page headline in a respected Sunday newspaper: “Top surgeon attacks unethical NHS pledge” and it was explicitly stated in the article that my remarks “weeks before an expected General Election will infuriate Health Ministers.” In fact, this was far from the case as Ministers accepted that my remarks were entirely legitimate!

Press relations 

My relations with journalists, whether they were newspaper reporters, feature writers, radio commentators, or television interviewers, were at all times extremely cordial. I made a point of getting to know them all individually, and regularly invited them into my office to give briefings and updates, something which they had never previously experienced. This led to mutual trust. During the 3 years I was only let down twice, once by a freelance newspaper journalist who put an unjustified wrong slant on a lengthy interview I gave her, and once by a television program, the producer of which had a particular bias he wished to put across. My contribution was subtly edited to fit that bias.

One needed to have fairly thick skin, however, as the caricaturists had a field day on more than one occasion—if you are in the public eye you can’t expect an airbrushed photographic image on all occasions!

The third turbulence–professional woes 

As if all this wasn’t enough to keep me busy and on my toes, it was during my Presidency that the problems relating to decreased hours of work for surgical trainees particularly and health workers generally began to take effect, something which I know the United States is just beginning to face. Under European law the long hours that trainee surgeons were putting in were deemed to be unacceptable and employing authorities had to reduce the working week to its current 56 hours, shortly to be 48. This led to enormous strain on the teaching programme, and on the provision of adequate cover, bearing in mind that the medical and surgical workforce at consultant level of the Health Service had failed to expand to meet the additional need. Service pressures began to dominate as a result of political imperative at the expense of training opportunity. Morale among consultants, already considerably dented, became lower still, with an increasing trend toward early retirement from the Health Service at the age of 60, rather than the conventional 65. How different from the United States!

Sadly, despite my best efforts, this was a turbulence I was unable to quell and the problems here remain.

Envoi 

These Presidential experiences may sound depressing but in fact they were far from that. Indeed, I found the 3 years to be exceedingly stimulating, causing me to grapple with problems previously unexperienced, and meeting a large number of people that I would not otherwise have met. It was immensely satisfying to be able to influence in a small way many areas of College policy, the public perception of the College, and the workings of the National Health Service for the good. I certainly did not achieve everything that I would have wished but at the conclusion of my term of office the adverse media comment had stopped, the College seemed high in the public esteem, and there were signs, albeit not many, that the National Health Service was beginning to find its feet once again. The fact that all surgeons are human and that errors will inevitably occur from time to time became accepted by the public and politicians alike. One of my last acts was to be a joint signatory with other senior clinicians and with politicians to a document explicitly criticizing a “blame culture” and stressing the importance of learning from errors, rather than punishing those who unfortunately have committed them.

My final act as President was to comment publicly on the recommendations of the Governmental Inquiry that had been established after the Bristol affair at the beginning of my Presidency 3 years earlier. This Inquiry very largely formalized all the things that the College had been promoting, and far from apportioning blame, was constructive and forward looking to a new climate of culture within the medical profession. I felt happy to endorse it without reservation.

George—as one Past President to another, both of whom have worked toward similar ends for the good of patients and of the profession—let me say once again how honored I am to have been invited to speak at this very special occasion. I wish you every happiness in future years.