The first NHS podiatric surgery
Part 3: The History of podiatry in the making
Mike Allard Williams, Shropshire
The first NHS podiatric surgery was performed by Mike Allard Williams in Shropshire. He was in the fortunate position of being the Chief Chiropodist of the district and simply booked an available operating theatre for his own use and started surgery. He asked no permission and was unchallenged for a while. It did not take long to conclude that jobs in the NHS, when we could get them, would not run to thousands, so surgery was not about 1000 members doing arthroplasties, but 100 teams doing thousands of procedures. From such posts recognition would flow and we would be properly established.
Essex and Podiatric surgery
If Allard-Williams formed the first NHS podiatric surgery unit, Ariori and I were the first recruited appointments in Essex in 1985. The chief chiropodist Tony Cotton (who I had known since my days at London Foot Hospital) booked a theatre and appointed us to perform one session of surgery per week. Clinics ran in the morning and we operated together in the afternoon. We were paid as sessional chiropodistsand this was a net loss for Ariori from his practice in Colchester.
After one year he resigned saying he could not afford the loss and held the belief that we would never get past the medical mafia to obtain proper NHS posts. I tried to persuade him to stay but without success. For the first time we had disagreed about prospects and the future. Of course he was right, or should have been. Neither of us could have foreseen the stance medicine and surgery would take in opposing us. If they had been rationale and methodical I think we would have lost the case for NHS podiatric surgery but they weren’t.They made pronouncements about the legal position which were wrong in law and as we exposed these errors their position became increasingly weakened. In Essex, Cotton was told by the local orthopaedic consultant that it was a criminal offence for anyone other than a registered medical practitioner to be in control of an operating theatre. ‘It was in the Medical Act,’ he said. It wasn’t and it isn’t. The RCS appeared to have misunderstood their Royal Charter
As others were appointed around the country similar claims were made. ‘Consent given for surgery, if you are not a doctor, has no status, and you are all liable for criminal assault’ -not so! These objections culminated in complaints to the General Medical Council (GMC) to prosecute us and the Royal College of Surgeons (RCS) to pronounce that they did not recognise us for performing surgery and to desist forthwith. They claimed that the RCS controlled surgery in England and Wales and if they said stop we had to stop. It took a letter from the Clerk to the Privy Council to explain that ‘the RCS appeared to have misunderstood their Royal Charter,’ it gave them control of surgical practice by their members and fellows, it did not give them control of anyone else.
Reflecting back in time
Borthwick interviewed Sir Norman Browse during his research when he had been President of the RCS. Sir Norman said, ‘You can imagine our shock and outrage when we discovered we had been entirely misinformed about our powers all this time, in fact the Charter is not worth all that much.’ The Royal College of Surgeons Council must have been pretty upset by this admission because when Graham tried to obtain an interview with the RCS a year later, no one would see her. During the early stages of negotiation with the RCS and the British Orthopaedic Association, we tried to co-operate by agreeing to inspections and visits for surgery. One of these resulted in a member of RCS council remarking to me, ‘…that it was all very well trying to straighten a bent fifth toe for 20 minutes and very pretty too, but you could amputate it in a minute or two with less effort.’
we were obliged to consider a better descriptive title for ourselves, hence podiatric surgeon
By the time wiser surgical heads started to question safety, antibiotic availability and patient understanding of who was providing the care, they had missed the boat. We were too established to be easily displaced. Do not take that to mean that the fights are over. Medicine and surgery will not make those mistakes again and if some crisis arises in the future you had better be prepared for a much more difficult fight.When our colleagues decided to change the name of the undergraduate degrees and produce podiatrists, we were obliged to consider a better descriptive title for ourselves, hence podiatric surgeon. Nothing has no consequences, even doing nothing. This resulted in another flurry of complaints to the GMC requesting prosecution for the use of the term surgeon.
Back to the Medical Act & the GMC
This is not what the Medical Act says.The offence is about misleading the public by the use of the term surgeon in that the public thinks you are medically qualified and registered with the GMC. The GMC have been consistent for more than 20 years in their response. ‘We see no prospect of a successful prosecution providing the term podiatric surgeon is used.’
The GMC gets requests to prosecute us several times a year and the response is the same. When I was Chairman of the unified Society in 2004[ix] this question was raised by the Department of Health. At a meeting with the Health Professions Officer and other officials they stated that they had legal advice that we were in breach of the law and would we advise members to stop using the term podiatric surgeon. I responded that we had legal advice that we were probably not in breach, but it was an open question since it had not (and has not) been tested in court. I offered myself as a test case and handed my personal card to them on which was printed Consultant Podiatric Surgeon. I also asked if they would provide us with a copy of the legal opinion. The response was they would consider the request. After that we asked under the Freedom of Information (FOI) for a copy of the legal advice.
International politics intervened. Tony Blair was fighting about the possible reveal of the infamous dossier of advice leading to the Iraq war in 2004. The word went out from the Cabinet Office that no government legal advice was to be released under any circumstance for fear of setting a precedent. An embargo that continues to this day. So our FOI request was denied and we have never seen their advice. I was never prosecuted and I have no reason to doubt that their advice was the same as the GMC position. Unlikely to succeed and not yet tested. Can we guarantee the outcome? No. Can the Department of Health? No. If they could they would have pushed the GMC to prosecute. For them the worst result would be failure in court which would endorse our position. Do not forget that it is always open to government to amend the Medical Act to specifically restrict the word surgeon to registered medical practitioners. The longer they wait, the more established our use. You will know, or should know, that currently there has recently been a consultation about new medical and health regulation. Reducing the number of regulators from 9 to 3 and re-writing the legislation are suggested. High risk for us and I hope that our Directorate and the SCP Council are fighting for us and our practice and that they responded to the consultation.
Another aspect of development that is both critical and should not be forgotten is the importance behind grandparenting. This is the process where a new qualification or development occurs, but where dangers can inadvertently destroy or undermine progress previous made. We had our first issue back in 1977; the year of the first Podiatry Association membership examination. Those who were members already did not have to take it because they were grand parented to the qualification. The problem arose because one member believed that he would show solidarity with the examinees for the first time by taking the exam. ‘Don’t do it,’ his committee colleagues told him but he was determined. The potential problem is clear. What do you do if he failed? Does he lose membership? Do we keep it secret? This could lead to a serious dilemma?
First non-doctor Consultants
Fortunately we never had to solve this because he passed the examination. This principle is key to progress. Never dump the pioneers in a no win situation, lest you think this is obvious, too many professions fail to grasp the principle. Not medicine. They understand it only too well. We nearly lost our NHS title ‘Consultant’ in 1997.
Consultant title caused a further flurry of incorrect statements like, ‘the term is for the exclusive use of doctors, that is in the National Health Service Act.’ It wasn’t. We became the first non-doctor Consultants.
When meetings were held to extend this practice title to other Allied Health Professionals (AHP) and Nursing, the Royal College of Nursing wanted only those in possession of a second degree to be eligible for a Consultant post.
Several AHPs and myself argued most strongly that this was a clinical experience leadership role and existing Consultants and future consultants did not have to have a PhD or MSc as a pre-requisite. In the end agreement was reached that it was up to each profession to make the rules. As a result, it took nursing a further two years before the first Consultant was appointed as they made all their leading clinical people go back and get a second degree. You may also recall theatre nursing colleagues having to re-qualify to do assisting roles a few years back, often re-training with colleagues in education who had not worked in theatre for many years, a wholly avoidable paper chase. Beware the nursing approach.
We now see this same situation putting our leading practitioners at the same risk with annotation. Whilst I could not and would not criticise the creation of a route to annotation via gaining an MSc as a safety net route; it appears (to me) that existing post FCPodS should be grandfathered on to the annotation as a right. You have the same problem as posed previously. What happens to a Consultant who does not get the degree? Must he resign? And if you do have a panel of scrutineers as recently canvassed; who will approve the approvers? This poses a risk for existing podiatric surgeons by the HCPC. Is there more to be done? Of course. No professional development is ever finished and as you develop, so you get opposition. The undergraduate courses need improving. Now that the dead hand of manpower planning has been lifted from funding, when will we see an undergraduate course with independent prescribing, injection therapies and x-ray evaluation?
Where is the pressure for such a course, if not from the HCPC? It must come from the profession. How about improving the position of our NHS consultants and registrars? When we negotiated Agenda for Change we forced the creation of Band 9 but mainly for financial control as the extra score. We were not successful in getting proper recognition for teaching which in medicine is considered an additional responsibility. So we could get someone on to Industrial relations committee and get those on Band 8D properly remunerated. But the list is endless, there is always more to do.
The moral of the tale
“even if the occupant of number 10 says such and such, don’t assume they are right without checking again and carefully considering your response.”
You can read other articles in this SERIES: The Specialty of Podiatric Surgery Emerges by Ralph Graham and Continuing Professional Development in Podiatry by Ivan Bristow. Read about – what is a Podiatric Surgeon? on this site.
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[i] Council for the Professions Supplementary to Medicine 1960-2003. The organisation came onto legal statute to provide the public with what is now termed governance. It comprised several Boards of which the Chiropodists Board was one. Replaced by the Health Professions Council (HPC) and then retitled the Health Care Professions Council (HCPC)
[ii] Postgraduate Groups. (Editor’s note). The Society of Chiropodists formed Society Branches throughout the United Kingdom. Post-graduate groups sprang up to offer more than regular monthly meetings. In essence each group laid on courses that met the educational certificate of Podiatry which led to membership (MPodA) and entry toward hands-on Practice in podiatric surgery. The full award was fellowship FPodA. Until the advent of podiatry degrees, podiatry was a separate qualification to chiropody.
[iii] The Institute of Chiropodists The organisation originally adopted members from correspondent courses for chiropody and colleges. Today all podiatrists have to be registered through the regulator HCPC. Now re-branded the IOCP they form the second professional body for podiatrists in the UK.
[iv] Prince, R Known usually as ‘Bob’, drove many of the conferences with enthusiasm for new information and supported refresher courses for the primary examinations (MPodA). His name was linked to the ‘Bob Prince Memorial Lecture’ which still runs at the National Podiatry Conference as recognition for his contributions to UK podiatry
[v] Bell, David R was an early member and became a Chair and past President of the Podiatry Association offering tutorship within his independent practice in Maidenhead before NHS training was formally established.
[vi] Borthwick, A. A Study of the Professionalisation Strategies of British Podiatry 1960-1997. Institute for Health Research. University of Salford. PhD Thesis
[vii] Graham, M The Origins and Development of Podiatry in Britain 1969-1996. Department of History, University of Essex. PhD Thesis
[viii] Jardine, K. Was recorded as visual aids librarian in the Newsletter / Journal of the Podiatry Association 1980 p.6
[ix] Amalgamation of The Society of Chiropodists into The Society of Chiropodists and Podiatrists in 1998 with the cessation and absorption of the Podiatry Association. This was often referred to as the ‘Camden Accord’. The new surgical qualification FCPodS came under the College of Podiatry in lieu of FPodA, although still used by some together.
Thanks for reading the First NHS Podiatric Surgery by Ralph Graham written for Podiatric Reflective Practice and now part of a series on the history of podiatry in the making
Published by Busypencilcase Reflective Communications Est. 2015