Mar 8, 1986 - right to make it plain that a doctor who decides that he needs to seek help forthe girl by consulting her parents is properly exercising his clinical.
BRITISH MEDICAL JOURNAL -VOLUME 292
8 MARCH 1986
secrecy to a minor than would have been the case where an adult had consulted him for any other reason. Confidentiality cannot be absolute, as is clear from the two and a half pages of possible exceptions in the GMC handbook. The doctor might, of course, conclude that it was the family as a whole, not only the girl, who needed help, and he might be able to provide it without breaking confidence. But the General Medical Council is right to make it plain that a doctor who decides that he needs to seek help for the girl by consulting her parents is properly exercising his clinical
that to break confidentiality is an exception to the general duty to observe the rule of professional secrecy and it-also mentions that "whatever the circunstances, a doctor must always be prepared to justify his action if he has disclosed confidential information," seeking advice from a medical defence society when necessary. This document is not a charter to allow doctors to disclose confidential information about under 16 year olds to their parents. It is therefore particularly unfortunate that it has been presented in this way to the press and therefore to the few teenagers who may most needssupport. No matter what our attitudes towards sexually active teenagers, the medical profession is left to deal with some of the consequences. In 1984 there were 1328 births and 4158 abortions among under 16 year olds (Office of Population Censuses and Surveys). It is therefore unfortunate that the reporting of the GMC guidelines has been allowed to- confuse not only the general public about the ability of an under 16 year old toconsult a doctor in confidence but also the doctors. Should the doctor follow the present Family Planning Service Memorandum of Guidance Revised Section G-The Young (Appendix (HN (81) 5 (LASSL (81) 2)? This discusses the provision of family planning for under 16s. It states not only that "special care is needed not to undermine parental responsibility and family stability" but. also that it is ''widely accepted that consultations between doctors and patients are confidential" and supports this principle. These guidelines were supported by a large majority of medical representatives at the last BMA annual representative meeting as well as being backed by the strength of the law. Should the doctor ever consider using the GMC's new guidance "to disclose the information learned from the consultation"? This statement does not even specify to whom this information could be disclosed-for example, police, parents, etc-and may deter many patients from obtaining the help they need. This matter needs urgent clarification if we are to serve our patients well. I hope that the GMC will reconsider its guidance, bearing in mind the support expressed at the BMA conference for the current D-HSS guidelines. If it feels unable to do this it would be helpful if it requested the press to improve the reporting on its current guidelines to emphasise that it would take -a most exceptional circumstance for a doctor to break the rule of
judgment. As a guild we do not consider the provision of contraceptives to minors to be medically wise or morally right, but we do believe that a minor has rights to confidentiality in consultation. Following the House of Lords ruling it is now legally recognised that a child of under 16 may have valid powers of consent to treatment but that this depends on her maturity. We hold that the right to claim secrecy from one's parents must run in parallel with this and hence also depend on maturity. There may, therefore, be occasions when the doctor will consider that the girl is in danger as a consequence of her own immaturity and that he must therefore override her claim to secrecy. In suggesting that the new guidelines represent a change in the position of the GMC, Dr J D J Havard (22 February, p 508) states that the GMC in 1971 strongly criticised a doctor for notifying the parents of an under age girl that she had attended a family planning clinic. In fact the report to which he refers states that the girl was "just over 16"-and that the GMC disciplinary committee did "not regard [the doctor's] action in disclosing the information referred to in the charge as improper. I share Dr Havard's concern about the statement of the Brook Advisory Centre that its clinics will not inform parents, not only because it may make girls less likely to consult their family doctors but because there is no mention of a lower limit of age or maturity below which their sense of duty to the girl would require them to seek proper help for her.
If, in the words of Lord Fraser, "The medical profession have in modern times come to be entrusted with* very wide discretionary powers going beyond the strict limits of clinical judgment and, in my opinion, there is nothing strange about entrusting them with this further responsibility which they alone are in a position to discharge confidentiality. satisfactorily," then it remains for us to reassure parents (as well as minors) that doctors can still be Family Planning Association, trusted to do what is best for them in all circum- London WIN 7RJ
697
ANGELA MILLS
stances.
I M JESSIMAN Guild of Catholic Doctors,
Cbisleburst, Kent BR7 SES 1 BMA comments on Gilhick judgment. BrMedJ 1985j291: 1209. 2 British Medical Association. Handbook ofmedical ethics. London: BMA, 1984. 3 Anonymous. Proceedings of the GMC Disciplinary Committee. BrMedj 1971;i (suppl):79-80.
SIR,-I would like to support Dr J D J Havard's leading article. A few members of the medical profession may hope to escape any professional responsibility towards the small proportion of under 16 year olds who are sexually active-by threatening to use the General Medical Council's guidance on this topic to break the confidentiality which exists in any doctor-patient relationship. It is perhaps worth advising any practitioners with this attitude to read the entire section relating to confidentiality in the- GMC's document ProfessionalCondu1ctandDiscipline. This points out
Allocation of resources SIR,-Dr G I M Swyer's account of his illness and experiences in the Royal Free and Middlesex hospitals (1 February, p 337) is a marvellous and moving example of how high- technology medicine and surgery, at efficiently run centres of excellence, can save lives. It should be read by doctors, civil servants, and politicians responsible for the allocation of resources both to and within the National Health Service. I fear, however, that his concluding paragraph, in which he inveighs against the threat to centres of excellence by a reallocation of resources to cottage and district hospitals, misses the mark. The underlying problem is that the resources allocated to the NHS are now insufficient for the efficient functioning of all its parts. As a general practitioner serving a rural area I use the services of a local cottage hospital, a district general hospital, and a centre of excellence. It has become in-
creasingly obvious that, as demand for-resources outstrips supply, standards at all levels are threatened. The right to be partisan and fight for one's own corner must always be respected, and arguments about resource allocation will continue indefinitely. As a profession, however, we will cease to be effective as proponents for any part of the National Health Service if we do not also point out that this government allocates- less as a percentage of gross national product for the health provision of its inhabitants than any other" in Western Europe. If we fail to do this, we may find ourselves without efficient centres of excellence or efficient cottage hospitals. Neither can be maintained at the expense of the other. JoHN C M GILLIES Glenluce,
Wigtownshire DG8 OPU
SIR,-I write, I suppose, from Dr G I M Swyer's Much Binding in the Mud, where our cottage hospital is shortly to be "upgraded" (1 February, p
337).
It was sad to see his interesting Personal View with its decent air of gratitude ignite into angry flames as he presented the false dichotomy between centres of excellence (sic) and cottage hospitals. We in Much Binding in the Mud are the first to salute the technical achievements, dedication, and, indeed, overwhelming necessity of the type of unit Dr Swyer was so successfully treated in, but from our grass (or should I say muddy?) roots we also feel that the NHS can be seen at its very best in its cottage hospitals. Perhaps Dr Swyer, who lives in London and is acquainted with centres of excellence, has not had the happy experience of seeing for himself the kind of work that goes on in cottage hospitals and the efficient use they make of their resources? Certainly that would be one explanation, for -his dismissive, unfunny, and unoriginal use of fictitious place names. It would also account for his foolish statement: "To upgrade the cottage hospital at Much Binding in the Mud to dubious district general hospital status," which is as insulting to the district general hospital as it is to the cottage hospital. I wish Dr Swyer the fullest and fastest recovery and would be delighted .to acquaint him with the centre of excellence here in Much Binding in the Mud when he is better. R H WESTCOTr South Molton, N Devon, EX36 3BU
Cobalt on the way out'
SIR,,-All that Dr Roger Buchanan (1 February, p 290) says about why linear accelerators now tend to be preferred to cobalt units for megavoltage radiotherapy is true, but it is not the whole picture. As he rightly says, modern linear accelerators are much more complicated and need much more technical support than cobalt units. This support is generally given by NHS technicians, employed on medical physics technician (MPT) scales, with mechanical workshop skills or skill in electronics. Such staff are difficult to recruit and retain owing' to competitive salaries offered by industry or by other public services. Experience has to be gained in post, since there is negligible opportunity to gain it elsewhere. Numbers are small and 'one man's departure knocks a large hole in a team of two or three. It is uncommon to find such staffemployed higher than the MPT II scale, currently £8073 to £10 070, and many are on MPT III or IV (£6703£8664 and £5653-£7431 respectively). In south east Scotland electronics technicians in the NHS can increase their salaries by 3'0% to 50Gb
