I am grateful for Dr O'Hara's letter about the vignette in the College publication ‘Vulnerable patients, vulnerable doctors’ (CR101). I feel that I should reply to her, and through her to the North East London/East Anglia CME Group, as one of the authors of that publication.

The publication was ‘commissioned’ by the General Medical Council (GMC) after a series of high-profile cases involving psychiatrists. The College felt (under its then President, the late Dr Robert Kendell) that the GMC had ‘let us down’ in one particular case by not taking action against someone who had so crossed the boundaries of the doctor—patient relationship that it was beyond all acceptability. Much to our surprise, we were told that the GMC had no ‘vade-mecum’ to take off the shelf to judge psychiatric/therapeutic relationships against, even in what we would see as quite flagrant breaches of ethics. Slightly against our wishes, we agreed to write it for them.

In the event, it was a very worthwhile exercise, involving an initial working party of representatives from all Faculties and Sections of the College, important special interest groups (inside and outside the College) and lay bodies. This work was then distilled by the four main authors into a publication that again went through the College Committee structure until it was refined into the final Council Report (CR101). This was felt to be so important to practice that it was produced as one of the key ‘Good Psychiatric Practice’ series. It has received acclamation both within the College and outside; the GMC will use it as a template for many medical relationships, not just those in psychiatry.

Having said all that, the road to publication was not totally smooth. There were no vignettes in the original version, vignettes were later interspersed through the text, and we were finally persuaded to gather them together at the end to illustrate training points based on the main points within the text. All of the vignettes were controversial, but they were about controversial issues dealt with regularly by the GMC. None of them, I regret to say, was wholly fictional.

The vignette you talk about in your letter was discussed a great deal and was finally agreed for inclusion on the grounds that, if such appalling practice does come before the GMC, we had better tell them how totally unacceptable it is. There was no reflection cast on learning disability psychiatrists as a whole, any more than the other vignettes criticised the subspeciality involved in each one.

I hope that goes some way towards clarifying the process behind the publication at least. I only hope we might reach the day when it will be made unnecessary because such breaches of ethics do not occur. However, given the pressures that doctors work under, I doubt that will ever happen. This is why we were keen to talk about vulnerable patients and doctors all the way through.