Examination of Witnesses (Questions 270-291)
DR JOHN CANNING AND PROFESSOR VIVIENNE NATHANSON
16 NOVEMBER 2010
Q270 Chair: Thank you very
much for giving evidence. I am afraid that we are skipping on
because of time constraints, so I won't go into the background
as to why we are holding this inquiry, but the role of GPs is
obviously very important indeed as far as the granting of licences
is concerned. Do you think that this overstates the importance?
Is too much responsibility now being placed on a GP in respect
of the judgment as to whether or not somebody should own a firearm
or a shotgun?
Dr Canning: Yes, especially in
the way that you phrase that in terms of responsibility and judgment.
As a GP, I can give no judgment to someone's fitness to hold a
weapon, particularly forecasting the future. What I can do is
provide factual evidence about the past. It is impossible, and
I have spoken to other colleagues in specialities such as psychiatry
who say equally that it is impossible to predict the future.
Q271 Chair: You have heard
the catalogue of issues that have been raised by colleagues, Professor
Nathanson. My colleague, Mr Winnick, who is much wiser than I
am on these issues, has said that hindsight is a wonderful thing.
Looking back at somebody's record, you will say, "Why on
earth did they get the licence in the first place?" When
the applicant is asking for his or her GP to fill in the appropriate
reference, there is a view that GPs are actually prejudiced against
shooters. Do you think that that view is correct?
Professor Nathanson: I don't believe
that GPs are prejudiced against shooters. I think there are several
things going on. First, doctors see the health consequences of
the misuse of weapons and they recognise just how difficult it
is to treat gunshot wounds and so on. So there is a feeling that,
in terms of primary prevention, the world would be a better place
if there were fewer guns around. But that is not a prejudice against
people holding weapons and using them legitimately for hunting,
pest control or whatever the other purposes are.
The other side of this, though, is that GPs
will have very serious concerns about the nature of the certificate
that they are being asked to complete. If they are being asked,
as somebody who is a friend of the applicant and who knows them
socially or semi-socially, to talk about what they know about
them, then that is legitimate and that is easy. The problem is
when they are being asked as a doctor. They worry that if, as
a doctor, they say that they know of no reason not to give this
person a licence, then that will be read as, "This person
is not going to be dangerous in the future." Given that there
is no way that you can predict that—even the best forensic
psychiatrists in the world will tell you that you cannot predict
future dangerousness.
Chair: Yes.
Professor Nathanson: So, a GP
would certainly feel unable to.
Chair: We will probe a number of those
issues with colleagues.
Q272 Nicola Blackwood: Just
to pick up on exactly that point, obviously, you cannot accurately
predict the future, but GPs do make an assessment about the mental
health of a patient and whether they are likely to pose a danger
to themselves or others, because you recommend if a patient needs
to be sectioned. Do you think that that is analogous to this situation?
Does that role of GPs inform your judgment on this issue?
Dr Canning: The circumstances
of being involved in the detention and potential forcible treatment
of a patient are incredibly rare compared with the risk assessment
we are making day in, day out about people with mental illness
who may be at risk of self-harm. Self-harm is, unfortunately,
much more common that we would like. Those assessments are made
rarely whereas—20 to 25% of people will see their GP at
some stage in their life with a mental health problem. That is
an awful lot of people, and we are seeing an awful lot of people
and making a lot of judgments about risk. It is very rare—in
my experience, certainly less than once a year in my personal
practice—to be involved in sectioning someone. Those are
usually very major, often psychotic, illnesses.
Q273 Nicola Blackwood: But
it does fall within the role of a GP to deal with those kinds
of incidents and those kinds of assessments.
Dr Canning: Yes.
Q274 Mr Winnick: In your day-to-day
work as a GP, are you frequently asked about giving a reference
for the use of guns?
Dr Canning: I practise in inner-city
Middlesbrough where there may be guns, but they are not the sort
that we are talking about here. I have never personally been asked
to provide a reference or sign a certificate, nor have I been
asked by the police to provide any medical evidence. But, obviously,
I represent a larger group of people, whose practices include
rural areas where this is much more common. People are asked to
sign certificates and provide medical evidence—not very
often to provide medical evidence, but that happens from time
to time.
Q275 Mr Winnick: Generally,
would it be right to say that a doctor is not under a strict code
of confidentiality like priests? Perhaps Professor Nathanson would
answer the question: if a doctor—clearly not in the area
where your colleague practises, but in other areas—concludes
that it would not be desirable, indeed could be dangerous to the
public, for the person to have a shotgun or any firearm, would
that doctor feel obliged to tell the authorities?
Professor Nathanson: Indeed. The
obligation of confidentiality extends beyond the death of the
patient, but it is never absolute. The doctor has to judge whether
the individual poses a risk of serious harm to themselves or others.
In those circumstances, they would tell others to prevent that
harm, whether that is about a shotgun or something else.
The commonest one is somebody continuing to
drive who should not be driving a motor vehicle—potentially
another dangerous weapon in the wrong hands. Frequently, doctors
will try to persuade the patient to stop driving, but the alternative
is that they will tell the DVLA so that the individual is immediately
stopped from driving. In that sense, a shotgun or other firearms
licence is the same, in that you're making a judgment that at
this moment the individual is a risk—and perhaps that is
the key; it is a little like the mental health consequences in
that the risk is at this moment.
You can say that with a little bit of confidence,
because the person is usually acutely depressed. It is the risk
of harm to themselves that is the commonest risk, and that is
when you would tell the appropriate authority. In most cases the
GP—
Q276 Mr Winnick: Thank you.
So from a professional point of view, it would be appropriate
for a doctor to notify the police, in what would obviously be
exceptional circumstances, and it would be professional to do
so.
Professor Nathanson: Absolutely,
yes.
Q277 Nicola Blackwood: My
experience is that doctors get nervous when what they're required
to assess widens beyond their normal sphere of experience. As
their representatives, what are your assessments of how GPs have
been responding to some of the proposals? Do they have concerns
about licensing officials coming to them automatically?
Dr Canning: I think the major
concern is that we may be considered to be the people who will
be responsible for making the decision. That is something that
we are not competent to do. It is not that we don't want to do
it, but we aren't able to do it and we are not the fit people
to do it—that's a society judgment.
Giving factual information is a day-to-day part
of practice—for example, information to life insurance companies
for people taking out insurance polices. There is a standard way
of doing that, and we provide facts. Providing facts is not a
problem; it is the interpretation of them that becomes the problem.
If we are, for example, in the very unusual circumstance of having
to breach confidentiality, we would be taking advice from colleagues
as well and would usually be talking to partners—the BMA
or our defence organisations.
Q278 Nicola Blackwood: Have
you done any survey or made any collation of the response to this
from your membership?
Dr Canning: Only through the contacts
that I have had with doctors nationally. I was speaking to a representative
of the doctors in Cumbria last week about their concern that this
becomes a situation for which doctors get the blame.
Q279 Dr Huppert: As I understand
it, the BMA, in discussion with ACPO, came up with the idea of
tagging medical records, so if somebody applied for a licence
or renewed a licence, that fact would be passed around.
What are your current thoughts on how that would
work? Do you think that it would be a sensible way forwards? Are
you concerned, first, about the fact that it might deter mentally
ill patients or people who are concerned from seeing their GP
at all, and, secondly, about the data issues of having a register
on the NHS of every gun owner?
Dr Canning: There are a number
of questions there. I'm not entirely sure that we came up with
it together, but it has been discussed by us and ACPO—in
fact, we're meeting tomorrow with Mr Whiting and people from the
Information Commissioner's Office to discuss the data issue. It
has been said to me that it will dissuade some people from seeing
their GP, if they believe that the consequence is that they will
lose their licence, and there seems to be a certain logic in that
just in the way people behave. There is a perception, I have been
told—though I have no evidence personally—that once
you have lost your licence or certificate, getting it back again
is much more difficult, even if there was a simple episode of
illness that may be related to that.
There are practical issues about tagging: not
everybody sees their GP, although many people do. There are now
in England many other ways of obtaining initial medical treatment,
not just at A and E and from GPs, as is the case in the other
three countries. There are walk-in centres and other centres where
people may choose to go and the record would not be available
there. There is the practical issue that our systems don't have
a means of doing that at the moment, not necessarily transferring
information on to the next GP as well.
Q280 Dr Huppert: Do you think
GPs would treat people differently if they had a tag?
Dr Canning: I think we should
treat people all in the same way.
Q281 Dr Huppert: We should,
indeed, but that is not the question I asked.
Dr Canning: No. I would hope that
they wouldn't. One has to be aware of the information, but be
able to deal with it. The relevance would be quite difficult to
interpret because of the prediction of the future.
Q282 Mr Burley: I have asked
this question of a number of witnesses and not got very far, but
now we have some doctors in the room, you might be able to help
me. I am interested in the actual type of medical conditions that
would cause a GP, such as you, to alert the authorities that the
person may not be suitable to hold a licence at the moment. The
examples we have been given include someone who might be depressed
because their wife had passed away, which is obviously a temporary
thing. You also might have someone to whom you are prescribing
Prozac, which is a strong drug.
Chair: We don't need all the medical
conditions.
Q283 Mr Burley: It could be
a recreational drug user. What sort of conditions would apply?
Dr Canning: That has to be based
on the individual person who is sitting in the consultation with
you. If someone has a florid psychotic illness, they are probably
going down the route for me to discuss it with a secondary colleague.
I would not be the only one involved in the sectioning; it would
also be a specialist doctor.
Moving down that route, if the person wanted
treatment, would be a worry. It is much more difficult with the
person who has had a bereavement—who has had something that
many of us cope with very well, but individuals don't. Predicting
who will and who won't is very difficult.
Q284 Chair: So, a florid psychotic?
Any advance on a florid psychotic?
Professor Nathanson: That is absolutely
one example. The other one, of course, is an acute and severe
depression, where you do have somebody who is talking about suicide,
and where you believe that there is a chance that they will pursue
that action. Obviously, access to a weapon is a very effective
way of committing suicide. People who are depressed are far more
likely to hurt themselves than others.
Chair: Mr Burley, are you satisfied?
Q285 Mr Burley: I don't understand
what "florid" is; I shall look it up when I go away.
Apart from those two conditions, people who are alcoholics could
go home and get the gun out. It is a very difficult line to draw,
isn't it?
Professor Nathanson: In terms
of things like alcohol or other drug abuse—
Q286 Mr Burley: A cannabis
user?
Professor Nathanson: It is about
the way in which that impacts on people's behaviour and mental
state. For example, some cannabis users are pushed into a frank
schizophrenia from the level of cannabis use, or there is a relationship.
It would be their behaviour, in other words—their psychosis
or schizophrenia—that led you to the concern. The fact that
it was caused by or made worse by cannabis is incidental.
It is the same with a person who is an alcohol
or other drug abuser; it is their behaviour and their mental state.
It is not the cause of it. Whether it is organic or drug induced,
is in a sense slightly irrelevant to the doctor. It is that this
person is a danger to themselves or others, and we need to remove
them from society.
Chair: It would be helpful if we wrote
to the BMA, and some of these other issues were explored. I think
Mr Burley has raised a very important point. Are you satisfied
with that, Mr Mackey? Thank you. Bridget Phillipson.
Q287 Bridget Phillipson: To
return to the analogy around driving licences, do you think that
someone is less likely to come to you if they are suffering from
mental ill health, and they think that their licence or certificate
will be removed, than someone who has a medical or physical condition
that would render them unfit to drive?
Professor Nathanson: There is
no evidence that they would not come forward. The evidence is
actually clearer that men—middle-aged men in particular—are
relatively unlikely to see their GP. Most people see a doctor
within a three-year period, but the group who are least likely
to are middle-aged men, who, as I understand it, tend to be the
people involved in these cases. So GPs are less likely to see
them.
Why don't they come? We don't really know, but
they present late. They present late even when they are suffering
pain, including mental pain. There is no evidence—and it
would be very difficult to gather any—on whether a worry
about a licence would stop them, but worrying about the impact
on your driving licence does not stop people from seeing their
GP. So that should give us some degree of comfort.
Q288 Bridget Phillipson: In
terms of tagging medical records, how would you respond to concerns
about protecting those data within the NHS more broadly?
Professor Nathanson: There is
the meeting tomorrow—it will include the Information Commissioner—and
it needs to bottom that out in detail, but of course we do need
to make sure that that is protected.
I note that in a few of the submissions, people
are concerned that the data could be leaked—it seems that
it is almost as if data could be leaked to become part of conspiracies
in which people burgle houses where there were known to be guns.
That is certainly not something that we have thought about in
terms of medical records. The approach to confidentiality is all
about the fact that the information gathered for health purposes
is sensitive—not always, but it may be sensitive for the
individual, and they have a right to privacy. We would need to
ensure that that privacy applied.
Q289 Alun
Michael: You were both quite clear about knowing where the
line is drawn on confidentiality and when you would have a public
duty to share information despite confidentiality rules. Do you
think GPs are sufficiently aware of those guidelines? Perhaps
a better way to put it is whether you think that all GPs are sufficiently
aware of those guidelines, particularly where the background might
not give an understanding of the culture of certain areas.
Dr Canning: There are two
words that we never use in medicine. One is "always"
and the other is "never", because there are always exceptions.
I cannot say that for all GPs, but—
Q290 Alun
Michael: With respect, Professor Nathanson said that a doctor
would, which rather implied universality among the profession.
Professor Nathanson: There
are pretty good levels of understanding, certainly around things
such as driving; obviously, doctors do understand driving rules.
Having said that, we have, with the Department for Transport,
just produced a new version of "Fitness to Drive", so
that all doctors can look and check the latest information on
different drugs or medical conditions. Certainly, there is always
an ongoing need to keep refreshing people.
We get a great number of phone calls from GPs
on a regular basis who ring us up and say, "I have a patient
with x. Can I just talk it through with you and check that I am
right to do the following?" That suggests to us—and,
okay, maybe a select group ring us—that the majority of
GPs know there is an issue and they also know that it is just
a good idea to check with someone that this is the right person
to be phoning.
Whether it is the police or another agency,
they are just checking that through. Again, any change in the
regulations would enable us to push out more advice to GPs to
make sure that they are more aware of how the new rules affect
them.
Q291 Chair: But GPs, of course,
watch television as well, despite being very busy. They would
have seen what happened in Northumbria and Cumbria, so this kind
of event would have an effect on their decisions.
Professor Nathanson: Absolutely.
Chair: Dr Canning and Professor Nathanson,
thank you very much for coming in. We will write to you, because
we have some further questions around what Mr Burley has raised.
We would be grateful for a quick response.
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