I have been asked to provide a comment on the current ongoing case of the GMC v Dr H Webberley. The Tribunal hearing is being held at the Medical Practitioners Tribunal Service (MPTS).
Firstly, this blog is an opinion on matters as they proceed, and I have no part in the case. I am merely viewing aspects from the outside, like many others. I am preparing this in a non-professional capacity, but I do have some experience at giving expert evidence at tribunal over many years.
I am getting updates from ‘live Tweets’ from the hearing provided from the Tribunal service and will see if I can get a press update as well. I am also thankful to @truesolicitor and others for their updates on this case. We are aware of other live feeds but are also aware that these are not as accurate and the reporting is, let’s say, skewed. ‘live tweets’ are taken from them being in the room and hearing and seeing proceedings. Apart from being there, it’s the best we can get.
I am trying to remain faithful to the feeds and comments made, but to report the facts and give a background to the proceedings and how the trial system works.
In this case, and current tribunal hearing, Dr Webberley (Dr W) is accused of practising medicine outside the rules and regulations of the General Medical Council (GMC) during the period March -November 2016, A failure to hold a proper safeguarding policy, and (2018) a failure to be registered as a practice in Wales. But there is more to it than that.
This update is from day 26
Day 26 is brought to you by I agree with Dr Webberley
(Thursday) [week 7] of the public hearing.
Intended start at 10:30am.
The hearing finished, somewhat abruptly on Monday PM, ‘in private’.
The indication was then, we would be back today. Nothing was heard from the tribunal until this morning.
What happened Next?
From the well-known sport-based quiz show, the first tweet from @MPTS_Hearing (Live Tweets) was this:
Chair….all we can say is your concerns have been noted & if there is anything untoward that we will find out, we’ll address it, but we don’t have an explanation for it atm.
SJ : There’s nothing more for me to say atm.
So, we don’t know who’s concerns (presumably SJ’s) or what those are about.
Intriguing!! Is he trying to bring this down from the inside?
What’s on today?
Dr D is back today to finish his evidence as he is poorly. This is his second session and should finish today.
CW: it turned out to be a long day, with lots of issues covered. That said, these aspects, especially the panel questions may give a clue as to the direction of this hearing, at this stage.
If you are ready and comfortable, lets begin.
Dr D is settled and ready.
SJ continues his re-examination from the previous session.
It is presumed Dr D has no knowledge of these follow up questions. These lead on from Qs & As from both IS and the panel.
From the questions known, SJ establishes the following from Dr D:
1) Dr D gave a review of his experience from the US Callen Lorde Clinic treating GD. They dealt with a wide age range of patients, delivering care by GPs and a Nurse specialist, with external MDT and Endo provision.
2) MDTs don’t need to be in the same place as the clinic, and appointments can be made remotely, and notes recorded and shared.
3) Dr D suggested such a practice was commonplace in the UK, especially with electronic communication.
4) He only witnesses HT in adults (young people are outside his expertise)
5) There was an initial screening, an assessment, GP prescription and GP referral. All consistent with WPATHWPATH World Professional Association for Transgender Health https://www.wpath.org
6) HT needed 1 opinion with a GP with “relevant experience” and those with more complex needs were given additional practitioners. (15% might need more input)
7) Dr D says 15% is similar level to UK
8) SJ asked about medical history for Pt A. There was some discussion on this. This surrounded the matter of capacity and what information was (and should be) available to Dr W for shared care and how that may or may not have affected her position AND decision-making process. This that some aspects were covered by PTA’s mother and not Pt A. What we don’t have, is how much involvement PTA had in the process. Neither SJ nor Dr D allude to this. It is unlikely Pt A was side-lined.
9) The waters get a bit murky here. As PGB’s involvement is raised. There are key aspects that come from this. Dr D states that to be continually asked the same or similar questions by different practitioners can become stressful. Dr D says that shouldn’t happen with ‘cooperation’ between services.
10) Dr D “would take issue with PGB’s response and explanation as to why PT A may experience emotional liability.”
11) On the changeover and ‘handover’ between care establishments Dr D said “..you must share all relevant info involved with your patients care..”
12) He also said “In my opinion, it wasn’t in the Pt’s best interest to not share the info. I’d explain to the patient I’d be unable to provide the care they want.” Dr D is siding with Dr W on the lack of notes etc and info from PGB and UCLH on the one hand but saying he wouldn’t treat without it on the other. That’s a bit of halfway house and (arguably) breaches his later comments.
13) Dr D states that the responsibility to the patient lies with the prescriber. At the time of PBs PGB. And T Dr HW
14) However, Dr D Continues “It would be wholly inappropriate for care or treatment to be stopped by the first provider if the Pt sought alternative advice from another provider in the private sector.” Further saying “Suddenly withdrawing treatment confers a risk.” That is a direct inditement on the practice of PGB and his running of Tavi. (it gets worse)
15) Dr D States “The UCLH said the treatment would stop if it was sought elsewhere it would be incumbent on them (UCLH) that a safe treatment is put in place for the patient.” The UCLH/Tavi and PGB were NOT proposing to do this!
16) UCLH were proposing to delay HT until 16. Dr D said “PBs without HT can have risks.”
17) Dr D says he wouldn’t prescribe without communication to UCLH. He would have asked for consent from Pt A’s mother. I’m not aware that Dr HW didn’t try or want to do this. However, given what UCLH and PGB had said (see also later) is it any wonder Pt A’s mother didn’t want to communicate? This is pure coercion on behalf of PGB. That cannot be good for any patient whatever age. This is a continuance of Julia Grant and what she wanted to do. Its scandalous.
18) Dr D is taken through a letter he wrote to Dr Huckster that may have been to Dr HW (he later clarified it wasn’t directly to Dr HW directly). It related to GD learning and how matters could be improved between GPs and different providers.
19) There is then a chain of emails from Dr HW to Dr D about a request for minutes of a meeting regarding hormone treatment. Dr D was unsure if a meeting on that matter took place. However, it shows that Dr D and DR HW have communicated on issues on a number of occasions.
SJ finishes his re-examination questions.
What have we learned?
That Dr D has stuck to his guns at times. He isn’t totally in agreement with Dr HW in some areas but isn’t wholly against what she was trying to do either.
PGB has a lot to answer for, and it has to asked why he isn’t in the dock here. The practices and procedures that he has openly adopted, along with those of the KOI, have been called out by a number of experts.
It would seem PGB is hoping to hide in plain sight. By getting others in the frame, is he trying to cover up for his own inadequacies and coercive protocols? Are those of his own doing, or driven from higher up and/or from ministerial level?
After a short break, the hearing resumes only briefly to agree the next part of the timetable. Then there is a break until after lunch ready for Dr D to resume.
Dr D continues his responses, but this time to the panel.
These questions, as before are for the panel to understand various points that have been raised. Dr D has covered a lot of ground in his sessions.
1) The Tavi has a minimum age 16 for GA hormones (2016). Pt A was 11 at the time and had been prescribed PBs by the Tavi and a GD diagnosis. Is that an acceptable age? Dr D. Its outside my competency.
2) That Tanner stage 2 is needed for CSH, but prescription of CSH before 16 is not usual. (we have heard from other experts that it is rare but not unacceptable, in appropriate cases.
3) A clarification from Dr D, that CSH not usually before 16, but that he says being on PBs for more than two years before CSH can cause issues. So here is an important aspect. In this case PGB prescribed PBs to Pt at about age 11/x months. Thus CSH (in Dr D’s view no later than age 13/x months. Yet PGB complains that Dr HW gave too early.
4) Dr D says that for U16, he would need to seek Endo advice and see other results etc., but 2 years remains his maximum. That begins to align with what DR HW was trying to do but was stopped by PGB and this case.
5) Chair asks the same question. “Where was UCLH’s plan? They start PBs at age 11 if the position is you can’t be on PBs for more than two years? Dr D says he can’t say for sure (treats adults), but +2 yrs. is “undesirable”.
6) SJ intervenes and says PGB covered this in his evidence. We have established that PGB said other things that were disproved.
7) Chair askes for a reminder. SJ has to find the transcript but recalls PGB said review at age 15. That is double the suggested period to Dr D. PGB is more experienced with childhood GD than Dr D, but his evidence has been found to be fallible. Also, his evidence is not ‘expert’ so will be what he feels justifies his case and not necessarily neutral.
8) Dr D reminds the panel that the “intent of PBs is to delay puberty and give the young person time to consider future changes, especially unwanted ones. A lot of this case and the whole Tavi-v-Bell decision is around that issue. Unfortunately, that decision and the institutional gatekeeping that has been laid bare in this case, does EXACTLY to opposite. That is potentially harmful and creates greater distress and anguish that it did before. This process is NEVER “rushed” as is often claimed. Just look at the waiting lists!!
9) Chair then asks, if high numbers of those on PBS (90%) go on to have CSH, what’s the point in delaying for so long if the outcome is high certainty of GA hormones? If they are only managing it, why not prescribe earlier? Is this to do with capacity to consent? The Chair is on it here. This is the whole issue. That question breaks through the barriers and barricades erected by the gatekeepers over time. It’s not about ‘rushing’ it’s about managing. No one seems to consider the child, only what THEY think the child thinks.
10) Dr D responds by saying its not a psychiatric disorder. Part of the waiting time is to gain stability for the patient and consistency in long term goals. Not to make an early decision they might later regret. Capacity is important, but stability is important, and adolescents are more stable in the decisions. That is entirely right, but how long is too long? If Drs understood what GD is like, they will know that patients “know” what inside. It’s often society and other pressures that hold them back.
11) Chair: It’s a matter of determination between the clinician or MDT and the Pt as to if that stability has been achieved. If he is stable and consistent, then the bar has been reached hasn’t it?
12) Before Dr D can answer, SJ jumps in. “There is a danger here”, he says Dr Klink addressed this issue. There is a danger (he says) is looking at this in isolation. He feels just because Pts mother and Pt decide that’s what they want, doesn’t mean the decision has to be made. (is SJ giving evidence now?)
13) Chair comes back: If an adolescent has arrived at a particular choice and has presented with stability and consistency, then the clinician will decide. It’s a conclusion the clinician is reaching based on the information in front of them.” (have they already decided this case?)
14) Dr D responds. A clinician would not be willing to endorse irreversible changes if there was concern but it’s a shared decision. (I’m not sure anyone is suggesting it isn’t. Its how and who to share with perhaps.)
15) Chair: “Pts A, B & C seem to be outside* of this environment . Pt A wanted assistance elsewhere as he was going to have to wait so long for GA hormones. Pt B was 16, didn’t want PBs but was being told to have PBs. Pt C was upset and distressed at the delays for 1st appointment.” The chair adds “I might say these Pts are outside* of the care you are extolling in Tavi and elsewhere.”
16) Chair: For people outside* the system is there not a need for a supplemental service to cater for these people who fell outside* or became dissatisfied with the system?
17) Dr D “Yes, as long as the care being offered is consistent with authoritative Guidelines” BOOM!
18) Dr D Its is undesirable that there is only one way of doing it. Within that there are guidelines provide a framework based on evidence. But if ppl work within the NHS or the private sector I see no reason why individuals shouldn’t be able to access..2 he tails off. He continues. “A cautious approach is needed based on clinical and professional judgement.” BOOM (again) This is A GMC witness don’t forget.
The Chair has cut through a lot of points here in this section of questions. A lot lead to a positive outcome for Dr HW on the basis of those questions AND responses. Dr D seems to be saying it’s OK. I know her, she’s fine, if she’s careful, methodical and takes advice and guidance. Also, he can’t understand the unnecessary delays and hold ups in any event.
The panel continue with questions.
19) A panel member talks about Bell – v-Tavi (which has no bearing on 2016) but relates it to decisions made then that could have an affect on the patient later on. Dr D doesn’t agree that Dr HW should rely on the Tavi consent basis.
20) Dr D adds that dual consent for PBs and CSH. They are separate assessments.
21) Dr D states he doesn’t agree with some of the basis of assessment of capacity and how this sits with multiple assessments, particularly from third parties. He feels that capacity or otherwise should be fully documented. The suggestion is thar Dr HW only partially documented aspects of capacity and may have relied too heavily of other assessments. This is a moot point, given he said that too many assessments is an issue also.
22) On the issue of dual prescribing and where there may not be autonomy, Dr D states that “doing no harm” is the issue and it’s not “uncommon” for two different Dr’s to be prescribing for the same patient. Especially in the field of Sexual health prescriptions where clinics are confidential.
23) A panel member states “Pt A was under the care of Dr Young and PGB, Dr HW has provided evidence that these two Dr’s were NOT willing to work collaboratively with her. An email to Dr HW in June 2016 in which the mother of PT A says Dr Young is against getting treatment.” He continues “ Re PGB, she (Dr HW) met with PGB at a conference and (her quotes) “he made it clear that we could not be friends or colleagues”, so felt she could not work collaboratively with them.” That just seems wholly vindictive and is the entire reason why we are here. He has an axe to grind!
24) The panel member the asks? “ Does that change your opinion in any way as to what Dr HW should have done when she decided to prescribe to PT A?
25) Dr D Responds, after a looong pause. No, it doesn’t change my opinion, but ethical issues like this don’t have a right answer,” He continues. Medical practitioners must form their judgement based on guidelines. He would not have prescribed T. (that is based on him not having all the fact. He has said that no treatment is harmful, and that harm reduction prescription is appropriate “within guidelines”.) The long pause suggests he is tied by that answer.
26) Panel Member: If GD is not a MH disorder, where does dysphoria arrive from? Is the distress not a consequence of denying the Pt the very thing they need? GA therapy? BOOM (yet again)
27) Dr D responds, That is a very empathetic response.” He continues. Some patients find life intolerable, experiencing extreme levels of distress. He carries on to say that there is a wide range of stress and anxiety in patients. All options need to be considered in each case. In the past, to move along the “conveyor” like system, a patient HAD to pass through all the stages , needed or not. Its not like that now. (the KOI don’t think so)
28) Patients goals may change, he says, but it’s not about holding people back. ( nice theory.)
29) Panel member : “in your opinion, Dr HW was not able to justify that decision?”
30) Dr D responds: “There’s a number of decisions involved. I think where Dr HW fell below the standard there was information available I was not party to.
31) The panel ask questions on the same vein, and Dr D suggests referral to the “ethics committee”. The panel seem to think this isn’t justified. It seems Dr D is hedging his bets here as he’s no U16 GD expert as he says “sorry to sound like a stuck record”
That ends the panel session of questions.
Outside* see the section below “handbags at dusk”
What have we learnt?
Much the same as before. Dr D is mainly siding with Dr HW but does have some issues in places. However, he suggests that as he doesn’t have ALL the information he can’t go the whole distance and say categorically, she was wrong.
We have also seen that the panel seem to have cut through the rhetoric and are asking very important and cutting questions. They seem to have seen things as they are and not as glossed over by the GMC. That could be important later. We will have to see, how that line of questions sits when the get to as Dr HW herself in the coming days.
Will they ask questions in a way the answers are what they want to hear, or in a way that is more negative and require a greater level of clarification in response?
For the final part of the session, and its been a long one for Dr Dean, IS gets to re cross examine Dr D. Again, he is just seeking to clarify responses, in a hope to bring the panel back in line with his way of thinking, should they not be doing so. SJ, of course, is trying to do the same.
IS takes the stand ( or his video screen)
1) He asks Dr D how he is basing his responses on the treatment of U17’s given he has NO experience of treating such patients (and that is entirely what this case is about). “how are we going to assess the evidence you are giving?” he says.
2) Dr D states its based on “authoritative guidelines and discussions with others along with his own experience and knowledge. He has worked with other GPs who have prescribed for GD but only in adults.
3) Dr D acknowledges there are long delays in children getting treatment, that adults “may not have to jump through the hoops that children do”
4) He acknowledges also, that “there are a lot of very cross people out there.” In the time it takes to access the services needed and “justifiably so”.
5) That “guidelines say we have to” look at all reports from others in assessments referring to the actions taken by Dr HW. (accepting what she did was right)
6) That clinical judgement is important, and she is entitled to look at all the available information.
7) That it is important good records are kept “for good practice” especially in difficult cases.
8) That Dr D agrees all practitioners should be using WPATH guidelines.
9) Dr D has heard of the KOI, but not familiar with them. IS then explains that ALL patients HAVE to come through CAMHS even though WPATH states GD is NOT a MH disorder. Dr D responds “That’s a very interesting point”. There is a conflict of protocols here and the KOI are in breach of one or both.
10) Dr D accepts the WPATH guidance is interpreted differently in different centres and different countries.
11) Dr D clarifies that the US clinic he saw was a GP run practice. And states “it’s not entirely different to a UK practice.” He adds, “there are similar places in Soho as an example of LGBT affirmative care.” He’s not exactly deflecting punches for the red team here; he seems to be soaking up punches for the blue team.
12) IS clarifies the point of Bell-v -Tavi that was for 2019/20 and relates to the number of cases. In relation to consent, and capacity, Dr D states that all factors need to be considered from clinicians to family and friends. Fertility issues are “routinely explored” and form an important part of the decision-making process.
SJ returns to ask some more questions.
13) SJ asks Dr D what he meant by patients “being entitled to make the wrong decisions?” Dr D says that, in life, we all make the wrong decisions occasionally. However, what is wrong, is “in the eye of the beholder”. This relates to discussions with GD patients about fertility, contraception and how this is affected by Gillick competence, that is being challenged by Bell -v- Tavi.
14) Dr D, having not worked with GD children then states he has prescribed contraception for a 13-year-old, and that was a “balanced view” decision. Has he just accepted that everything in the garden is rosy?
Handbags at dusk
SJ states he is unhappy with the “language” used by the panel when referring to the patients as “outsider(ers)” He says none of those patients are “outside” but notes Dr D says they are frustrated at the delays in obtaining care and treatment.
SJ sates he also unhappy about patients “falling foul of the system”. He says Pt A was “re assimilated back to the Tavi, the GMC didn’t call Professors Hindmarsh or Butler as ‘experts’ as they do not “pose the Tavi or UCLH as the only legitimate way, that is not the GMCs position.”
SJ then affirms that the GMCS case is based on “independent expert evidence.”
SJ (panicking perhaps) states “ I’m concerned I’ve Failed to get evidence of addressing these issues” when referring to the backgrounds of why patients A & B needed and/or were denied treatment.
SJ also states he is concerned the panel are “forming the view” of how the patients were treated or categorised. ( I think they are, but not the one he wants. There is perhaps a degree of desperation here)
The chair responds by saying if its wrongly interpreted, then the ‘outsider’ tag is withdrawn. He has not said what replaces it.
IS then makes his points.
He states he disagrees with SJ, and the points made, and understanding is “perfectly clear”.
IS says that there was apparent reliance of Dr KS (evidence) in relation to Pt B. Dr KS has not seen any other documents in the case apart from the evidence of Dr Bouman.
IS continues to state that Dr KS has said “I have not been asked by the GMC to review my comments are based on Dr B’s report only. I am not sure what the GCs position is, what is the system that the GMC says should be relied on? Are they suggesting the KOI or multi-faceted?” IS is pointing out that even one of the GMC’s own witnesses hasn’t been provided with all the necessary information
SJ responds that he has made it clear the GMCs case is based on expert evidence on an MDT approach. The GMC made it clear its not against private practice, it’s about care provided and meeting a good standard.
The sessions ends with the Chair saying the “will reflect and consider”.
Most of the GMC experts except Dr Klink (who loves MDT’s) seem to think a flexible approach is acceptable. The re is no agreement as to what an MDT actually is and what a minimum number of practitioners make up an MDT. That could be a vital point moving forward on this.
What next?
Back Friday at 09:30 (day 27).
Dr Klink has to return, along with Dr Kierans (KOI).
The GMC case is nearly completed.
To be continued…../
Nicola
