Firearms Control - Home Affairs Committee Contents


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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