For many years the relative informality of approach to governance has been one of the attractions of pilgrimage medicine, with clinicians feeling they can concentrate more on quality of care rather than red tape. Nevertheless transparent clinical governance is a modern day reality, and our sick pilgrims deserve to receive the same or better standard of care during a pilgrimage than they would receive at home. The future viability of pilgrimages including sick pilgrims is therefore interconnected with good clinical governance.
The seven pillars of clinical governance are—clinical effectiveness, risk management, patient experience and involvement, communication, resource effectiveness, strategic effectiveness, and learning effectiveness.
This is best provided by having good pilgrimage structures in place to ensure that excellent clinical practice is applied to the care of pilgrims, that the pilgrimage as an organisation has robust processes and procedures in place to identify and learn from clinical issues, and that they can demonstrate that learning. All of this is within the ability of any pilgrimage assisted by up to date clinical leadership, whether doctor, nurse or both. There is more information about what is recommended in "Guidance for arranging Pilgrimages involving children, young people and adults at risk" published in 2018 by NCSC and CSAS.
The clinical team is made up largely of nurses and doctors, as well as some allied health professionals such as physiotherapists, occupational therapists, etc. It is important that clinical staff are in good professional standing with their relevant professional organisations, and that their activities are covered by insurance. Nursing insurance is generally provided through the pilgrimages insurance, however, this does not cover the activities of doctors, who need to make contact with their individual indemnity organisations. Several years ago, there was a concern about this cover, arising from the decision (later reversed) by one medical indemnity firm to discontinue cover for doctors accompanying pilgrims to Lourdes. The background to this decision was that EU law stated doctors had to have insurance, and all UK medical indemnity firms provide assurance (not unlimited resources) rather than insurance. Currently all large indemnity organisations will provide cover for “humanitarian work” in Lourdes.
However, pilgrimages may wish to consider separate insurance to provide cover to the pilgrimage for overarching activities undertaken by doctors, such as assessment, training, etc., as this is not covered in the Catholic Insurance Services policy, which many pilgrimages use. This form of insurance was originally developed in conjunction with Seirbhis for use by Irish pilgrimages, but it is now more widely used in mainland Britain.
It is important to stress that the role of a doctor in Lourdes is very different from their professional role at home. They cannot practice medicine in the normal way in France without being registered and accredited there, an undertaking which is not practical for all pilgrimage doctors. However, the view of the British Lourdes Medical Association, after seeking legal advice, is that the normal practice of medicine has a different definition to that of the role undertaken by doctors in Lourdes. A doctor practising medicine in a normal professional manner would take on new patients, make diagnoses, initiate treatment plans, and refer as required. (Interestingly the definition of medicine is becoming blurred by the roles of nurse practitioners, who diagnose, manage caseloads and initiate treatment in their own right. However, nurse practitioners do this within narrow prescribed limits, which is in fact analogous to the work of British doctors in Lourdes.)
For the sick on a pilgrimage, they present with existing diagnoses and treatment plans prior to travel, and the role of the doctor is to help replicate these. Changes in a pilgrim's conditione are normally either predictable within the context of their disease and of the pilgrimage, and therefore can be viewed as a predictable aspect of the existing treatment plan, or are completely unexpected, where the role of the doctor would be to signpost the pilgrim appropriately, as a “Good Samaritan”.
The BLMA and Seirbhis ( the Irish Pilgrimages' Medical Organisation) have jointly consulted with a barrister who is a specialist in medical negligence, and whose view is that a pilgrimage doctor is not practising medicine in France, because:
This interpretation is completely analogous with the position of a team doctor travelling with a sport or other team, so there are robust precedents to call on if ever needed.
Not all pilgrimages have been able to take doctors, so it is clearly possible to travel without them, but there are significant disadvantages.
Clinical decision-making: This is extremely important for the more complex pilgrim, and not having doctors means that it may not be wise to take some of the more unwell pilgrims, if there is no-one with the skills to lead their on-going care.
Leadership: Many nurses now do have good leadership skills, but lone nurses may well need to refer more frequently to French clinical services in the absence of senior colleagues with whom to discuss issues. Doctors have credibility as authority figures so can more easily provide clinical leadership where there is differing views about the best course of action within the pilgrimage. They may find interaction easier than nurse colleagues with French health services, where the clinical hierarchy is based on physician leadership.
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