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Dr. Fox: Just so that the hon. Gentleman is not misinterpreted, let me say this. I hope he is not suggesting in any way that the pressures of any practice would cause people to murder their patients when he says that we must consider the causes. In my view, there are no "causes" when someone cold-bloodedly murders his own patients.

Dr. Brand: I am grateful for that intervention, because it allows me to clarify my view. As I have said earlier, Shipman dealt with his sense of infallibility--or, perhaps, insecurity; we do not know what motivated him--in a uniquely wicked, murderous way.

I hope that the inquiry will, in a sense, be in two parts: one part considering Shipman and how he managed to get away with his wicked and evil deeds; and the other considering the support and regulatory mechanisms that we need in order to assure the general public that the privileged relationship between doctor and patient is not abused, albeit in a lesser way, by other practitioners. Shipman is unique, but I do not believe that he is the only medical practitioner--or nurse, or indeed vicar--who, having found that he is professionally isolated, has started to behave oddly.

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Mr. Nicholas Winterton (Macclesfield): Notwithstanding his response to my hon. Friend the Member for Woodspring (Dr. Fox), is not the hon. Gentleman just a little concerned that his remarks may be seen as making an excuse for what has occurred? Does he not fear that the families of the 300 people who have been murdered might misunderstand what the hon. Gentleman--who is a respected doctor--is telling the House?

Dr. Brand: The hon. Gentleman ascribes to me a motivation that does not relate to what I said. There is no excuse for a Shipman: that was unique wickedness, on an enormous scale. The point I am trying to make is that the circumstances in which Shipman practised allowed him to put himself in a position in which he could commit multiple despicable murders. I suspect that if Shipman had been a member of a support group involving other GPs--a Balint group, a royal college group or a BMA group--and had discussed his cases, it would have become clear at an early stage that he was a very odd man with very odd values. That is one of the ways in which professional peer review works.

I welcome the Government's move towards clinical governance and audit and examination of professional practice, but that in itself will not pick up uniquely murderous wicked people. This returns me to the point made by the hon. Member for Macclesfield (Mr. Winterton). It will pick up the incompetent--but if we encourage people working in isolation to be part of a structure in which they share experiences, it may well be possible for it to pick up totally aberrant behaviour.

I do not want to be mistaken for one who thinks that the country is full of doctors who behave in the same way as Shipman. I think, however, that we are short of mechanisms to audit, and also to protect the community at large. I feel that, notwithstanding some of the Government's welcome measures, we have a great deal further to go.

The hon. Member for Woodspring (Dr. Fox) mentioned the discredited "ash cash" arrangement, whereby, basically, a doctor countersigns the reputation of a colleague without actually doing much in the way of work. It happens day in, day out. The fact that the coroner does not necessarily liaise with the registrar for births, marriages and deaths is nonsensical. Most cremations go through the registrar, and the coroner deals only with what is abnormal, suspicious or uncertain. It would obviously make sense if a single organisation dealt with all deaths: that would enable suspicious or uncertain deaths to be fed through the system to establish whether patterns emerged.

We must view the matter not just within tight local- authority boundaries. After all, not just the constituents of the right hon. Member for Stalybridge and Hyde (Mr. Pendry) were affected; my hon. Friend the Member for Hazel Grove (Mr. Stunell) has constituents who have been bereaved through Shipman's wicked actions. The technology is, I believe, available to enable us to link information so that we see abhorrent patterns of behaviour.

Mrs. Ann Winterton (Congleton): The hon. Gentleman says that closer liaisons could take place at the end of life to check that the number of deaths were not caused by, for instance, murder. As a practising doctor, can he tell me why Dr. Shipman was able to obtain so many prescriptions for diamorphine? Why was that never

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picked up throughout his practice, given the number of times we have been told that doctors must not over-prescribe, that their prescribing is checked, that there are limited lists, and so forth? In fact, there seemed to be no brake on the prescribing pattern of this particular GP.

Dr. Brand: I shall touch on that, but I wish to return to the point that I was making. Patterns of deaths are important, not only within general practice but within hospital practice. It is helpful for people who audit these issues to look at death patterns in long-stay wards or wards specialising in the care of elderly people to see whether a pattern emerges. I share the concerns of the hon. Member for Congleton (Mrs. Winterton) about some of the practices involving long-stay beds or the way in which some older people are treated, or not treated, in hospital. We should see whether we can pick up and learn from the patterns.

Many issues were hinted at in the early reports into the Shipman affair. The issuing of prescriptions to Shipman for controlled drugs was quite astonishing. Industrial quantities of diamorphine were dispensed for no good clinical reason. I am not sure what the drugs inspectorate or the policeman who is supposed to be in charge of drug registers was doing; someone comes to see us every year--or every two, three or four years, depending on how busy they are--to see what we are doing with the drugs we buy. Likewise, pharmacies should be inspected to see what is happening with their dangerous drugs registers.

Clearly, this case should have been picked up. Shipman was stupid; we keep hearing what a clever man he was, but he got vast quantities of drugs from a small number of pharmacies. It is extraordinary that that was not picked up. It is extraordinary also that the clever pharmacist who tried to blow the whistle was not listened to by the coroner because the coroner did not feel that it was his responsibility.

Dr. Fox: Does the hon. Gentleman accept that the problem was not with the prescription, but with the hoarding of heroin from dead patients, and that the disposal of controlled drugs should be a central element of the inquiry?

Dr. Brand: There were two problems: first, inappropriate quantities were given to Dr. Shipman; and, secondly, he neither destroyed the drugs--the proper thing to do--nor entered them in his own drug register as having been received. It is essential that drugs are trackable between the manufacturer and the patient. In this case, the system clearly failed.

I am sure that many issues will come out in the inquiry, which will be handled sensitively. We owe that to the large number of patients and relatives who were affected. However, I hope that in the broad remit that has been given to the inquiry, time will be taken not only to look at how we avoid a Shipman, but at the wider issues. We should look at how the statutory authorities can work together to avoid similar, if not as disastrous, occurrences of repeated incompetence and inappropriate behaviour that may well be dangerous. These patterns can be picked up and I hope that the inquiry will involve a wide range of organisations.

It is not good enough to say that this is a matter for the GMC and the employing authority. It is a matter for the different nations of the United Kingdom and for the

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international scene. There are lots of little strands floating around, following the reports on Neale, Leadbetter and other poor practitioners who got away with it for far too long. I hope that the inquiry will draw all of that together and that we will have an opportunity to discuss the recommendations in this House.

7.24 pm

Sir Nicholas Lyell (North-East Bedfordshire): I am glad that the Secretary of State has decided, on further reflection, to order a full public inquiry under the Tribunal of Inquiries (Evidence) Act. I am sure that that is the right decision. I am sure also that there will be great confidence in Dame Janet Smith, the High Court judge chosen to conduct the inquiry. She is highly respected and has a great deal of relevant experience.

When the Secretary of State came to the House earlier about the Shipman case, I was worried that the General Medical Council seemed to be being made something of a whipping boy. Although the GMC is undergoing changes, I find it difficult to appreciate how it would necessarily have been expected to spot a Shipman. The behaviour of Harold Shipman was extraordinary and far outside what, happily, we have expected during our lives. It was so utterly inconsistent with what we rightly expect, and get, from GPs that the ordinary disciplinary controls of the GMC would not have been appropriate. That is one of the issues that Dame Janet will consider. I should be surprised if the GMC--under almost any structure--would necessarily have found and stopped Harold Shipman. I should be interested to see what opinion the judge comes to on that.

I endorse what the Minister and my hon. Friend the Member for Woodspring (Dr. Fox) have said: Dr. Shipman was found guilty of these terrible multiple murders, not the medical profession. GPs generally provide an excellent service to the public and are having to do so under enormous pressure. I do not blame the present Government any more than previous Governments, but we know that greater numbers of hospital doctors and GPs are needed. We know that doctors work under great pressure and it is important that Governments of all complexions give them proper support.

The Minister referred to the NCAA. Although appraisal and audit may have some relevance to identifying a future Shipman, I would not want it to be thought that that was the NCAA's primary purpose. It is important that, while we should monitor GPs more closely than we have in the past, the monitoring should not become excessively burdensome. It should be constructive and designed, like most professional programmes these days, to enhance standards, rather than be overt policing of the activities of those concerned. The monitoring certainly should pick up aberrant behaviour and the personal appraisals should provide opportunities to spot possible danger, but they should always be constructive.

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