North by North West: The legacy of Shipman

Having been heavily encouraged last year to conduct more of their appointments remotely, GPs are now being upbraided for the reduction in face-to-face consultations.

A crescendo of criticism came earlier this month, after the lack of face-to-face appointments was mentioned in five inquests into patient deaths, leading to a predictable pile-on from the more alarmist press.

The strange detail that went unexplained, however, was that all five of these inquests were held by the same Greater Manchester South coroner’s office, which covers Tameside, Stockport and Trafford, with no evidence of other coroners raising these issues (the same office has since produced two more).

This raises the question as to whether these boroughs have been particularly gung-ho in moving to remote appointments. NHS Digital stats suggests, however, that they are in line with the national trend.

It is possible GPs in the three boroughs have not adapted as well to the shift as their peers in other parts of the country – perhaps meaning they missed things which others didn’t – but there seems to be a more significant variable in play.

Analysis of coroner stats in England suggests the GM South office is generally far more active than others.

In 2019, for example, GM South opened inquests into 26 per cent of the deaths reported to it, compared to the national average of 15 per cent.

Staggeringly, from the 2,575 deaths reported to it that year, GM South produced a total of 51 ‘prevention of future deaths’ reports.

This was more PFD reports than was produced by 17 coroners’ offices in the whole of Yorkshire, Humber and the North East combined, which had more than 33,000 deaths reported to them.

Mutch ado

So, what on earth is going on? Why is the GM South office so prolific?

NxNW was told by staff that senior coroner Alison Mutch (who in a previous role starred in a TV documentary about the Crown Prosecution Service) does not talk to the press, and was not interested in providing any sort of comment.

However, NHS sources in the area are certain the explanation goes back almost 20 years, to the Shipman inquiry, which severely criticised the coronial service.

Harold Shipman, the serial killer GP, practised in Tameside, and the inquiry pinpointed multiple failings by the GM South coroner’s office (then led by John Pollard) to probe the deaths of some of the victims.

According to the sources, those failings and the high-profile criticism that followed have spurred a far more active, meticulous and cautious approach from the local office, which has been led by Ms Mutch since 2016.

This has understandably led to frustrations within the local NHS, as the publicly available PFD reports result in a constant stream of negative headlines, giving the impression of services in disarray.

But more importantly, it raises the prospect that hundreds of deaths around the country are not being properly scrutinised by local coroners, which potentially means multiple public bodies are being allowed to continue making the same mistakes.

The chief coroner for England and Wales wasn’t interested in commenting either, and the Ministry of Justice did not respond.

Regression to trend

Asked whether they had investigated the impact of remote GP appointments, the Greater Manchester ICS issued a template response, saying they were “continuously reviewing and monitoring this way of working”.

However, NxNW has now seen a draft internal review which specifically examined the impact of reduced face-to-face GP appointments on emergency attendances.

The paper, produced in June by a unit within Health Innovation Manchester (the local academic health science network), notes how “system leaders and the media” had assumed the shift to remote appointments had led to a surge in accident and emergency attendances.

However, it found the supposed rise in A&E demand was in fact in line with what was forecast pre-pandemic. So, while it looked like a sharp increase compared to the low numbers during covid, the paper argued this was simply “regression to trend”.

Based on analysis of around 2,000 survey respondents, the paper added: “The reasons for attending A&E were more ordinary than the proposed theories by system leaders and the media.

“People came to A&E because they had been told to by a GP, other health care professional or 111. They believed their issue to be urgent and expected to find out what was wrong with them, to have a test or X-ray, to be treated today, or be seen by an A&E doctor.

“A significant proportion had seen a GP in the seven days prior to the attendance or had contacted services before attending A&E… the factors behind rising A&E attendances remain those underlying drivers that existed pre-covid, rather than the result of actions during to covid-19 ie fewer face-to-face GP appointments.”