[R-G] Fw: UK NHS modernization: Suicide of an old-time GP

[Tim Murphy]

http://news.independent.co.uk/low_res/story.jsp?story=487199&host=3&dir=59

The suicide of Stephen Farley

This GP, with 25 years' experience, was loved by his patients and respected
by
his peers. So why did he die in despair?

By Malcolm MacAlister Hall

Independent (London)
03 February 2004

Late last week, the steel plate showing Dr Stephen Farley's name and
qualifications - "DR S.E. FARLEY MA, MB, B Chir" - was still fixed to
the wall of the village surgery in Leicestershire where he had worked
as a GP for 25 years. Here, in Ibstock, people say that he was the
village's favourite doctor, a kind, jovial man who was not just a GP,
but a friend.

Below the nameplate lay some flowers, wrapped in yellow paper. A note
pinned to them read: "For Doctor Farley, a wonderful doctor and a
much-loved gentleman. We will miss you very much."

Less than a week earlier, in a tragedy that shocked the village, Dr
Farley had been found hanged in an old barn behind his house, just a
few moments' walk from the surgery. He was 52. Colleagues claim that
he killed himself when depression set in after being hounded by NHS
managers for referring too many patients to hospital. In the new,
target-conscious, statistics-driven NHS, his referral rate was an
"anomaly". It was making above-average demands on the system, its
budget and its resources.

His death is the more poignant because patients describe him as an
old-fashioned village GP , whose door was never closed to them, day or
night. On the council estate on the edge of the village, mothers tell
of taking poorly children to his house at midnight, knocking on the
back door, and being warmly greeted by his wife Marion ("she always
gave you a nice cup of tea, with plenty of sugar"). They recount how
her husband would expertly examine these young patients, sometimes on
his kitchen table, oblivious to the lateness of the hour. "He and his
wife always made you welcome, whatever time it was," says Tina Lycett,
47. "He never turned you away, never."

As well as sadness and shock, there is an undercurrent of anger in the
village. Julie Clarke, 36, a former spokesperson for the tenants'
association on the Sunnyside estate, says: "I think [the NHS managers]
should have asked the patients for their views of Dr Farley before it
got to the point where he was driven to this. He would have had the
support of the whole village - I know that for a fact. And then it
wouldn't have got to this, would it? They should have given him more
of a chance, and everyone else more of a chance to speak up for him.
And they didn't. It's sick."

At the surgery in the High Street, where Dr Farley was one of five
GPs, grief is mixed with other emotions. "This is a terrible tragedy -
and one that I believe could have been avoided," says the practice
manager, Charles Jones. "Dr Farley was a brilliant GP, and he was
absolutely loved by all the patients and the team here. But the
Primary Care Trust believed he was referring too many patients for
hospital treatment.

"He had had nearly three years of this since it was first brought up,
and the finger was always pointing at him - there was this continuing
pressure. We felt they were hounding him, almost persecuting him.

"We were behind him in all his referrals, and even though I informed
the trust that we would deal with it as a practice, they homed in on
him. But he always had the patients' best interests at heart, and if
he thought they needed treatment he would refer them."

Jones adds that the patients have been "completely devastated" by his
sudden and unexpected death. "We've had them in here in floods of
tears, signing the book of condolence." The book had only been placed
in the surgery that morning, and by lunchtime there were 36 entries.
"The last of the true family GPs," Melanie Allsopp had written. "You
cared, and it cost you. Ibstock and the surgery will never be the
same." Another patient, Karl Hicklin, had written: "Steve, thank you
for saving my life 22 years ago. I will miss you greatly. God bless
you, doctor and friend."

Even though the British Medical Association says that the old-style,
open-all-hours village GP disappeared a decade ago, rendered extinct
by NHS modernisation, Ibstock is just the sort of place you might have
looked if you wanted to find one of the rare survivors.

Set in gently undulating Leicestershire farmland, its narrow main
street winds between brick-built Victorian houses and small village
shops. Down the lanes running off the High Street, you can see out
across the fields. This and the scattered villages round about, where
the practice's 9,500 patients live, was Dr Farley's world.

Graduating with distinction from Cambridge, he trained in the Hastings
area, and moved to Ibstock 25 years ago, to a substantial Georgian
house at one end of the High Street. At first, the surgery was in a
colleague's house just across the road. By 1985, he and his fellow GPs
had moved to a new surgery in the High Street, a couple of minutes'
walk from his house.

Villagers recall a happy, jovial family man with two children, a
regular church-goer, and a participant in almost every village event.
With his mutton-chop whiskers, his country clothes and a big grin on
his face, people say he looked more like a cheery Farmer Giles than a
doctor. Apart from his job, his other passion was making home-brewed
beers and wines. He was often out gathering nettles and berries for
some new vintage. A generous man, he would usually give most of it
away.

He was generous with his time, too - perhaps to a fault, as far as the
modernised NHS was concerned. "He was never happier than when he was
out there in the community doing his job. It was his life," Charles
Jones says. "In modern practices nowadays, in line with national
guidelines, we all have out-of-hours cover, and we pay for it. But
there were instances when we'd say to Stephen, "What were you doing
seeing patients at home at 1am?' And he'd say, 'Well, they couldn't
get through to the on-call people...' That's the kind of man he was.
The patients knew that he would never turn them away. And Marion was
the same; she was a country GP's wife, and she expected that. It was
as much her vocation as his."

It was almost three years ago that the local Primary Care Group first
raised questions about the number and type of cases Dr Farley was
referring for urgent admission to hospital. The issue dragged on. When
the group became the Primary Care Trust (PCT) under further NHS
reorganisation, moves to monitor Dr Farley's work began in earnest at
the beginning of last year. It was proposed that Leicester
University's Post-Graduate Deanery - an independent GP training
organisation - should carry this out.

"They call it 'mentoring', and it was a topic that came up at a
meeting with the PCT's clinical governance team in July," Jones says.
"When a team from the Deanery came in November, they offered it again.
The practice said, 'Fine, we don't have a problem with it, but if you
do it for one you do it for all. We run a very efficient practice
here, but if you're questioning how we're doing things, then question
everybody.' We said that all five doctors would agree to mentoring,
and if there was a problem we'd be more than happy to learn from it.
But then the Deanery came back again, with, 'We have offered Dr Farley
mentoring.'"

Jones says that this would have meant someone sitting with him in his
surgery, overseeing his work. At 52, and with some 25 years'
experience, Dr Farley found this prospect humiliating. Demoralised by
nearly three years of his professional competence being called into
question, he became increasingly depressed. With hindsight, Jones
remembers that in the run-up to Christmas, Dr Farley was subdued. "He
seemed quiet, which was not Stephen. So, yes, there was a change. But
I suppose we're the last to see it among ourselves. And nobody," he
adds, "saw this coming."

On 15 December, a Monday, Dr Farley didn't come to work. Instead he
went to see his own GP, and was referred for help with his depression.
After about five weeks off, he was advised to make a gentle return to
duty by coming in each day just to do some paperwork. His first day
back at the surgery was two weeks ago. At the end of that first week -
Friday 23 January - he came in as usual at around 9am.

No one saw him leave. But at 1pm that day, Jones took a desperate
phone call from one of Dr Farley's neighbours, who had found him
hanging in the roof space of the barn behind his house. A former
paramedic, Jones raced down the road with a nurse and a resuscitation
kit. They found there was no point in using it; Dr Farley had been
dead for more than an hour.

Among the tributes that flowed into the surgery last week, one was
especially significant. It was from a consultant to whom Dr Farley had
referred many patients over the years. The consultant told Charles
Jones that in all the patients Dr Farley had ever sent to him, he had
never once found the GP to have made an incorrect diagnosis. "He had
never known Stephen to be wrong," Jones says. "Coming from a
consultant, that's quite a statement."

There are many stories of Dr Farley repeatedly referring patients back
to hospital until his diagnoses - which had been dismissed - were
eventually proved correct. One patient he referred three times, sure
that something was seriously wrong. Only on the third visit was cancer
diagnosed. A local councillor told Jones that Dr Farley had saved his
life twice last year by insisting that he be re-admitted to hospital.
Life-threatening blood clots were found. All around Ibstock, villagers
tell of his dedication in treating their ailments, great and small.

Former school dinner-lady Barbara Hicklin, 81, recalls how Dr Farley
once gave her ointment for an infection on her leg. "A few days later
he came to the house to see if it was improving," she says. "I didn't
ask him to come. He came because he cared. He was a lovely man, and I
feel terribly sad about what's happened. If he'd known how much we all
cared about him, I wonder whether he might have changed his mind about
doing what he did. But it's too late now, isn't it?"

In Julie Clarke's living room on the Sunnyside estate, friends and
relatives drift in and out, offering their own tributes. Her partner
Jonathan Lycett, 19, tells how Dr Farley had once examined him on his
kitchen table after a football injury, and sent him to hospital. He
was discharged with "bruising". Dr Farley referred him again. It was a
broken collarbone.

Clarke's brother Ian tells how the GP diagnosed his 15-year-old
daughter Emma as having meningitis, merely from the fact that she was
being sick and had a headache. "The symptoms hadn't fully appeared,
but he knew," Ian says. "Emma loved him because he probably saved her
life."

Clarke's sister-in-law Sarah Hines recalls the doctor's kindness to
her two-year-old son Tommy-Lee, born with a cleft palate and prone to
repeated infections. "Every time I took Tommy down he'd say, 'How's my
little lad?' He were brilliant with him," says Hines. "If it was late
and Tommy was poorly, I used to take him down his house, going on
midnight sometimes. And he was always there, and ever so nice to you."

The Charnwood & North West Leicestershire Primary Care Trust issued a
statement saying that it was duty bound to take action in cases of
high referral rates. Offering his deepest sympathies to Dr Farley's
family, friends and colleagues, the trust's chief executive, Andrew
Clarke, said: "I can confirm that the PCT had identified significantly
higher emergency referrals and admissions from this practice compared
to all other practices in the area. This was so extreme that we felt
it was important to carry out one of our key NHS responsibilities: to
review and understand any GP activity that appears to be extreme in
nature."

He said that the PCT had asked the Post-Graduate Deanery to carry out
a "review based on their access to best clinical practice". He
insisted that this was "neither a disciplinary process nor a
cost-saving exercise". The doctors were not "under investigation". At
Andrew Clarke's request, the area's Strategic Health Authority has
agreed to launch an independent, external review - in effect an
inquiry - into the dealings between the practice, the PCT and the
Deanery.

It probably won't make much difference to Karl Hicklin. It was he who
wrote in the condolence book about Dr Farley saving his life 22 years
ago. The incident was a motorcycle accident, after a driver had pulled
out in front of Hicklin's bike at a junction in Ibstock. Hicklin, then
19, was trapped under the car with a smashed leg and ruptured kidney,
spleen and liver. Telephoned by a passer-by, Dr Farley was first on
the scene. Typically, it was his day off.

"He injected me and kept me alive, kept me talking, and he came in the
ambulance to hospital with me. And he looked after me ever since,"
says Hicklin, now 41. In later years, the GP was the first to realise
that Hicklin had developed a mild form of schizophrenia, and later
angina - which he had been told by another doctor was just
indigestion.

"On his days off, if he was passing he'd nip in to see how I was. I
think he was hounded to do what he did - and why they were hounding
him I don't know, because he was only doing his job and putting his
patients first. He was an absolutely brilliant man - and I'll miss him
terribly," Hicklin says. "He had more time for his patients than he
had for himself."

In the days after Dr Farley's death, the secretary of the local
medical committee, which represents GPs, was reported as saying that
Dr Farley was "an old-style doctor who was operating in the new-style,
Blairite system. Nowadays," he added, "they run a few computer
programmes and decide what's wrong, which is completely at odds with
the old-style, holistic approach."

Perhaps Dr Farley's problem was that he was just too conscientious.
Perhaps he cared about his patients too much. It's hard to measure
such things on a spreadsheet.

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