Professionalism – All Doctors Have a Duty to Respect Colleagues

The purpose of this piece is not to educate any readers to buy into the professional values of doctors, or to enter into debate about specifics of professional behaviour. Rather it is to consider the behaviour of a group of doctors who have differing opinions on the future of cancer care and to remind us all of our duties of professional behaviour towards each other, and that this matters.  To this end we re-read a General Medical Council booklet entitled ‘Good medical practice: Professionalism in Action’ (henceforward shortened to GMP: PIA) and this blog will refer to this document frequently. 

The GMP: PIA document has 80 paragraphs which are principles of good professional behaviour, and the majority of these refer to how to treat patients with honesty, courtesy, respect and with good appropriate treatments.  We will not discuss these aspects but will instead focus on the professional behaviours that doctors have towards each other, and towards the circumstances in which they work.  We will not be making any allusions to the issue of the New Velindre Treatment Centre plans or the professional behaviour of the doctors at Velindre, but we will point the reader to draw some of their own conclusions if they wish to.

We start with Paragraph 25 which states: ‘You must promote and encourage a culture that allows all staff to raise concerns openly and safely’.  We have discussed in many previous blogs [see for instance ‘Is the New Velindre Team hopelessly out of touch?’, October 8th 2021; ‘Tuesday 26th – A Day in the Life’, October 27th 2021] our concerns that debate has been stifled.

Paragraph 36 states: ‘You must treat colleagues fairly and with respect’.  Within the Co-Locate team, and in the minds of the 163 Clinicians and others who have differing opinions this is an intriguing position…

Paragraph 37 states: ‘You must be aware of how your behaviour may influence others within and outside the team’.  Need we really say more…

Paragraph 59 states: ‘You must not unfairly discriminate against patients or colleagues by allowing your personal views to affect your professional relationships or the treatment you provide or arrange.  You should challenge colleagues if their behaviour does not comply with this guidance…’.  This paragraph justifies our dissent from the New Velindre position, and we are more than content to agree to differ from the Velindre position, but at least we respect their views but we note that they never deign to discuss the issues with us in Co-Locate…

Paragraph 65 states: ‘You must make sure that your conduct justifies your patients’ trust in you and the public’s trust in the profession’.  We have publicly acknowledged in a previous blog [‘Thank you Velindre staff!’, October 13th 2021] that we believe the Velindre team to provide exceptional care, and that patients being treated by the present Velindre team should truly respect their skills, dedication, talent and care: However, to maintain trust we would argue that the New Velindre team should respect divergent opinions and not dismiss them as unhelpful, irrelevant or unnecessary…

Paragraph 67 states: ‘You should act with honesty and integrity when designing, organising or carrying out research, and follow national research governance guidelines and our GMC guidance’.  Well, the Nuffield team and others have comments to make here we suspect…

This piece is not intended to accuse anybody of a lack of professionalism or that we or anybody else should involve the General Medical Council in this debate.  However, it is a call to lower the tone of any disrespect meted out (either intentionally or unintentionally) to the 163 clinicians who have signed the letter opposing New Velindre plans, the Nuffield Trust Report team, the team from Clatterbridge in Liverpool, ourselves in the Co-Locate team, and others who have honest concerns about the present direction of travel.

We all want the same thing surely, which is good cancer care for South East Wales into the future, and from our side, we would welcome an opportunity to discuss our concerns with any Professional member of the New Velindre team. Our continuing and sincerely held Professional views are that the proposed development of a stand-alone Cancer Treatment Centre is the wrong model, on the wrong site, and to be built at the wrong time – is to too much to ask that this is handled professionally?

‘Large-scale options appraisal’. Nuffield to Velindre.

Colocate Velindre recently contested a local politician’s claim about the Nuffield Trust’s Advice to Velindre in 2020: https://colocate-velindre.co.uk/nuffield-myths-always-look-twice/ It turned out the politician had not grasped Nuffield’s insistence on a large-scale options appraisal prior to everything else.

For Nuffield, transformation of cancer services should only ever begin this way. It comments (italics and bold added by us):

 ‘…we are not making any judgement about the decision to site the new VCC on the Northern Meadows. Such large-scale option appraisal exercise is not only well beyond our terms of reference but is fundamentally about values and the choices that need to be assessed and taken by all involved. It cannot be outsourced…’ (p.11)

The first surprise

The words ‘on the Northern Meadows’ pull the reader up short. For public information yields nothing about who concluded and sealed this refinement. Nor do reports disclose when it occurred. So nothing ‘large-scale’ there.

But clearly for Nuffield a wide-open process is essential for setting the direction of a major service-change. And New Velindre agrees with this by presenting itself as a follower of Nuffield. To see Nuffield’s point proven beyond doubt see: https://colocate-velindre.co.uk/jaguar-electric-vs-rickshaw/

The second surprise

Velindre hasn’t even documented a large-scale appraisal for the change that underpins the whole decision process. Instead in 2014 some discreet group did its own options appraisal. It alone chose the option of an antique, ‘stand-alone’ clinical basis for the New Velindre (that is, a new building away from an acute hospital). More of that in another post soon.

The decision took many stakeholder clinicians by surprise in the Spring 2015 engagement. Some even felt pressured to accept the decision.

What it all means

Nuffield did not just cite its terms of reference and leave it at that. No, it also asserted the norm of a large-scale appraisal to inform and empower such major decisions as a new cancer building. This is the exact opposite of advising a go ahead with the ‘stand alone’ build as some claim. For Nuffield must have detected the absence of a proper appraisal in the main documents.

So even at a late stage, Nuffield found a way of propelling New Velindre towards a proper, large-scale options appraisal if none existed. But New Velindre’s leaders continue to defy this direction while loudly claiming to follow Nuffield’s advice.

No wonder the January 2021 letter from 163 senior clinicians (snubbed twice by Welsh Government) stated: “There must be a formal review, including an updated, full options appraisal…This can be done at pace.”

https://colocate-velindre.co.uk/letter-from-163-clinicians/

Action

A campaigner informed by the work of Colocate challenged one senior member of New Velindre in December 2021 with this question: ‘When was the Nuffield-style large-scale full options appraisal done?’ The response of the senior official was to pivot, walk away and accuse the questioner of rudeness.

It’s a reaction deeply worrying. The question just seeks safe and best cancer care in Wales. When did New Velindre carry out this obligatory, ground-laying, large scale, full options appraisal?

The Minister of Health should be sure on this by now, right? Can the Senedd Health Committee, shadow ministers and Senedd members reassure us? Not to mention health board managers and cancer clinical leads. For it matters to cancer care in all of Wales.

Anyone can write to these bodies and individuals for an answer, and we urge readers to do just that, urgently but very briefly. Let a link to this post do most of the talking but ask the question in italics above. It needs settling or best cancer care will soon be out of reach.

We predict that no satisfying answer to this question will emerge, in which case the safety and wellbeing of thousands of patients really can’t be assured by Welsh Government right now. It’s not too late to correct such a critical deficiency. Better late than never.

Co-locate is back

Co-locate is back. Slightly late, we wish you all the good things you need for navigating life in 2022. We are still in the fray this year, and still on the side of best cancer care. Our previous post depended on events as they broke and got posted just too near Christmas to have full impact. But it really brought vital information found only here so visit it anyway and do take a look at the brief YouTube clips. We work on to see truth out in the open and wise decisions on the rise. A new blog follows shortly.

Co-locate Velindre

New Velindre devalues stakeholders?

Can it really be that New Velindre devalues stakeholders and fellow professionals in cancer? We ask the question since a Velindre spokesperson has apparently devalued the following:

1: The 7 members of the External Advisory Board (EAB)

This body monitors the Wales Cancer Research Centre (WCRC). All its panel members are NHS professors with international reputations in cancer. It is the eminent panel of doctors that assures standards for cancer research in the whole of Wales.
See the Board’s letter at:
https://colocate-velindre.co.uk/eminent-clinical-reviewers-on-velindres-plans/
The letter warns that the New Velindre ‘stand-alone’ cancer centre is against patients’ interests. The current plan will damage Velindre’s recruitment, research, brand and reputation.

2: The 163 senior clinicians specialising in all aspects of cancer throughout S E Wales, their names known to successive Health Ministers.
See their letter at:
https://colocate-velindre.co.uk/letter-from-163-clinicians/

3: An award-winning NHS cancer centre critical for north Wales patients.

The New Velindre attitude on all three surfaced in October with a video clip showing its spokesperson publicly replying to questions.
See this and other brief clips at:
https://www.youtube.com/channel/UCsKXkeYLS68savA_m5nzi9g

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MEDICINE AND THE ENVIRONMENT – A VIEW FROM COLOCATE VELINDRE

One Month on from Cop 26

Co-Locate is not an environmentalist activist group and it is not in our remit to propose the co-location of the ‘New Velindre’ on environmental grounds; all readers of our work should be fully aware of our central and over-arching premise that co-location is the only safe future provision for cancer services.  However, this blog adds to the many reasons why the building of a new cancer centre on the Northern Meadows site is wrong by considering the green issues arising in the run up to, and since the COP 26 climate crisis talks in Glasgow last month.

The British Medical Journal has devoted a whole issue to the issues of climate, environment and health1.  The NHS in Wales has issued a document published on 22/11/2021 entitled ‘How NHS Wales is responding to the climate emergency’2.  Velindre University Trust has contributed to the latter, and we select the following excerpts from Velindre’s series of ‘ambitions for the greenest hospital (sic) in Britain’ to discuss further below.

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Nuffield Myths. Always look twice.

What’s more disconcerting than misinformation?

Especially misinformation about major medical issues as serious as cancer.

A constituent recently emailed Senedd MS Julie Morgan calling for an independent external clinical review of New Velindre’s stand-alone model before the proposed building works go forward. This was her reply, received by email on 3rd December, 2021:

‘The Nuffield Report was quite clear that the build should go ahead.’

This is very serious misinformation. It illustrates why we should always look twice at claims to be following the Nuffield advice. For Nuffield made no such recommendation.

What the Nuffield advice rather said was that ….

‘….we are not making any judgement about the decision to site the new VCC on the Northern Meadows. Such a large scale option appraisal exercise is not only well beyond our terms of reference but is fundamentally about values and the choices that need to be assessed and taken by all involved.’ https://www.nuffieldtrust.org.uk/project/independent-advice-to-velindre-nhs-university-trust pg 11.

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What did our survey find?

Staff are being given a whitewashed version of the process with absolutely no information to allow them to provide critical clinical feedback on the project. Velindre are being in no way transparent with their own staff, many of whom totally lack a basic understanding of the realities of this centres proposed service provision as a result.‘ (respondent 6)

Regular readers will know that we’ve been running a survey asking people about their awareness of the New Velindre plans, and what they think of them. The survey is still open, and can be found here: https://www.surveymonkey.com/r/Q6TM7FR

What have we learned so far?

We knew when we started it that the survey was not going to give us statistically accurate results. People answering it are likely to have been interested on the subject (one way or another) already. Also, we don’t know what proportion of people who looked at it chose not to answer. So we’re not going to be saying ‘95% of respondents agreed…’ for example.

We can say, though, that we received many more responses than we’d expected, much more quickly than we’d expected. Not everyone who responded agreed with our views, but the vast majority were polite in the way they disagreed.

Many of the people responding are Health Care Professionals, and many of them currently work, or have worked at Velindre. We’ve no way of identifying any individuals.

Two key themes emerged: concerns for staff and patient safety with the stand-alone model, and the lack of consultation by Velindre with their own Staff and more widely.

We’ve already highlighted some comments on Twitter (@colvelindre) You can find out more about what Health Care Professionals think of the plans below:

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Iolo Williams on Co-Location

On a recent visit to the Northern Meadows Iolo spoke about how a cancer centre cannot any longer be built away from a main hospital, rather they should be “side by side.”


Iolo said that although he has been a massive supporter of Velindre, for example walking up Kilimanjaro to help them, he is now asking Velindre to think again and find a more suitable site so that the new cancer centre is not set apart from a main hospital.


Here is a short video of Iolo at the Northern Meadows.

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This is what a colocated cancer centre looks like

Guy’s Cancer Centre: colocated and amazing

Take a look at this video describing the colocated cancer centre at Guy’s Hospital in London.

The planners at Guy’s recognised that patients were receiving their care from many different locations over two sites, ‘and it was exhausting’.

New Velindre Leadership say that there’s just no room to build a colocated centre on the UHW site. They say the build in Whitchurch will provide a better patient experience, despite the risks and stress of patient transfers.

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What did the Nuffield Trust say about the stand alone New Velindre Cancer Centre?

Independent Review?

Regular readers of these blogs will know that we have repeatedly called for an independent clinical  review of the stand-alone model for the new Velindre Cancer Centre. 

As an example, we’ve described the process undertaken in the independent review of the Mount Vernon Cancer in this blog: https://colocate-velindre.co.uk/jaguar-electric-vs-rickshaw/.

Many people think that the Nuffield Trust carried out an independent review of the model in late 2020, so therefore all is well.  Velindre and Welsh Government are very happy for people to believe this, but sadly it isn’t true.

 The Nuffield published advice to Velindre on 1.12.20. It can be found here: https://www.nuffieldtrust.org.uk/files/1606833630_advice-on-cancer-services-in-se-wales-velindre.pdf)

We’ve touched on the Nuffield advice briefly in a previous blog https://colocate-velindre.co.uk/what-about-the-nuffield-trust-advice/. This blog looks further at the Nuffield advice, what it covers and what it doesn’t.  You can read a more detailed synopsis of the entire report here: https://colocate-velindre.co.uk/nuffield-synopsis/

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Jaguar Electric v Rickshaw?

What’s all this about?

A simple comparison reveals a shocking contrast between the New Velindre Project and the parallel Mount Vernon one, at Northwood, Middlesex. Very similar challenges, but utterly opposite responses. This blog is only a taster for the full, shocking contrast between the two. You can read a more detailed comparison (‘Which way was Wrong’) here https://colocate-velindre.co.uk/which-way-was-wrong/.

So what’s at the heart of it?

Which Way was Wrong‘ reveals the New Velindre team autonomously deciding in 2015 to eliminate the prevalent model for new cancer centres: co-location with an acute hospital, from their thinking. Moreover, in contrast to Mount Vernon, Velindre’s documents show no evidence of peer consultation with partners and stakeholders before this far-reaching decision.

What happened in the two settings before the full options appraisal?

Mount Vernon, before making any decision affecting options, underwent an extensive independent external review. The review included interviewees well beyond Mount Vernon’s own staff (see ‘Which Way was Wrong‘ for detail).

Velindre doesn’t even make mention of such formal independent consultation before getting down to impacting the options.

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Sliding Doors

The following highlights how an extremely common scenario unfolds in a stand-alone centre versus a co-located site. The hypothetical patients could be any of us or our loved ones. The details used are fictitious but standard and will be only too familiar to every medical professional who reads this

Patient S

Patient S is currently attending an oncology clinic in a stand-alone cancer centre. She is 52, a librarian and lifelong smoker who enjoys walking her dog. She is going to be admitted for the management of pain and feeding problems following her radiotherapy for laryngeal cancer.

S’s husband has been trying to feed her soup and mashed potato to keep her energy up but notices that she has been coughing when she eats. The team explain that she may have been inhaling some of the food because of her abnormal swallow. 

S’s prognosis is excellent and her treatment should be curative.  She currently can’t cope at home because she struggles to swallow her pain killers. She is becoming dehydrated and is in severe pain. Her team have decided that she should have a tube placed for nasogastric feeding and pain relief with supportive nursing for a few days whilst they regain control of her symptoms. S is admitted to a stand-alone cancer centre, about three miles from the nearest acute hospital.

Several hours later

S is much more comfortable. She has a nasogastric tube in place so she can be fed and receive pain killers. Unfortunately, later that night, S starts to develop temperatures and a cough. The nurses notice she is becoming confused and sounds breathless. A chest x-ray shows pneumonia with the nasogastric tube in the correct location.

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Survey still open

It’s fun, it’s easy to fill in, and it seems to be pretty popular. We’re keeping it open for a while longer so there’s still time to complete it if you haven’t already. it usually takes less than two minutes, so why not give it a go!

Here at co-locate Velindre we are keen to hear your thoughts and views. on the location and structure of cancer services in South East Wales. 

To make this easier, we’ve devised a quick survey which is completely anonymous. 

The survey is for anybody, not just those who agree with us, although we would ask for civility in responses. 

you can find the survey here:

 https://www.surveymonkey.com/r/Q6TM7FR

Thanks for all your feedback!

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More Clinical Letters

Many people know that senior cancer clinicians wrote twice to Welsh Government about the plans for the new Velindre Cancer Centre. They asked for an independent clinical review.

https://colocate-velindre.co.uk/clinical-letter-to-ministers-7/

Those clinicians (57 signed the first letter, 163 the second) worked in the Health Boards whose patients travel to Velindre for radiotherapy and chemotherapy.

Velindre clinicians also wrote

There are other, less well known letters. This time from clinicians in Velindre themselves, spelling out their concerns about the Velindre plans. Again, asking for an independent external review. They wrote to Welsh Government Ministers and Officials, as well as their own Chief Executive and Medical Director. You can read the letters in full on Welsh Government’s own website: https://gov.wales/sites/default/files/publications/2020-12/atisn14500doc2.pdf

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The Birth of New Velindre. Mystery solved

This conversation is fictitious. But free of alternative facts.

‘North Cardiff doesn’t know it. Cancer patients don’t know it. Many cancer clinicians throughout Wales don’t know it. Even you, a rookie reporter, don’t know it. ‘

Uh? Know what’?

‘How the New Velindre Cancer Centre became destined for the wrong location. We should run the story at the weekend. People just don’t know that the Minister of Health, around 2015, instructed the Velindre Board to build its new Cancer Centre on a ‘stand-alone’ site. You know, not at a big hospital (1).’

‘So who exactly did that, and do they-‘

‘He’s First Minister now. He’s the one who did it. That’s where it all started.’

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