Transforming the culture of healthcare: sick doctors and the GMC

Two recent reports from Civitas and UK and international researchers about the treatment of doctors under investigation by the GMC raise very serious concerns. Their findings can be summarised in a quote from recent chair of the Royal College of GPs, Clare Gerada, in her capacity as a director of the Practitioner Health Programme - an organisation that provides confidential care for sick doctors:

'The GMC is "traumatising" unwell doctors and may be undermining patient safety.'

Doctors are traumatised by a lack of support and help with personal illnesses, intimidating communications, and excessively prolonged and poorly handled investigations.

Few doctors would seriously doubt that investigation by the GMC is extremely stressful. A powerful personal account from Dr Shibley Rahman illustrates the devastating consequences of a failure to provide support during an excessively prolonged investigation of an obviously sick and vulnerable doctor. Ninety six doctors died while under investigation by the GMC between 2004 and 2013. It is likely that some of these deaths were suicides but an investigation announced by the GMC last September has yet to be published. The Civitas report concludes that the GMC and NHS employers are failing in their duty of care to sick and vulnerable doctors and this is a risk to the safety and quality of patient care.

Nevertheless the report leaves out a lot of evidence that can strengthen their case for reform. Just culture and patient safety, kindness and compassion and patient-professional partnerships are vital components of a culture of care that includes both patients and professionals. Doctors’ health is threatened not only by the regulatory and disciplinary culture of the GMC but also a pernicious regulatory, target-driven NHS culture and the pressures of ever-increasing workloads in a climate of inadequate funding, under-staffing and increasing competition.

 Just culture

A just culture is one in which people are not afraid to admit mistakes because they are confident that they will be dealt with fairly. Recommendation 86 of the 2001 Bristol inquiry states:

'The culture of blame is a major barrier to the openness required if sentinel events are to be reported, lessons learned and safety improved.'

The Francis report 2013 quotes Liam Donaldson:

Honest failure is something that needs to be protected otherwise people will continue to live in fear, will not admit their mistakes and the knowledge to prevent serious harm will be buried with the patient.

The Berwick report into patient safety begins:

'Abandon blame as a tool, NHS staff are not to blame – in the vast majority of cases it is the systems, procedures, conditions, environment and constraints they face that lead to patient safety problems.'

When airline pilot Martin Bromiley’s wife died in 2005 during a routine operation he wanted to find out what happened:

'...he assumed that the next step would be an investigation – standard practice in the airline industry after every accident. “You get an independent team in. You investigate. You learn.” When he asked the head of the intensive-care unit about this, the doctor shook his head. “That’s not how we do things in the health service. Not unless somebody complains or sues.” '

This captures so much of what is wrong with how we deal with errors and complaints. Bromiley set up the Clinical Human Factors Group with just culture at its heart.

The ability of patients to speak up and share their concerns about care is also vital for safety and they need to be able to express their concerns, and complaints if necessary, without contributing to an adversarial culture. The GMC at present is contributing to an adversarial culture in which doctors are afraid to admit their mistakes.

Doctors as victims

The emphasis in the Civitas report is on doctors as victims, not only of the excessive and bungling efforts of the GMC, but also of vexatious patients or employers, an intrusive and salacious media, and unaccountable users of social media and feedback websites. We should be very wary of implicitly blaming patients. On page 11, they claim that the rhetoric of patient entitlement and choice has contributed to 'a massive escalation in cases dealt with by the GMC'.

A report from Plymouth University commissioned by the GMC showed that complaints are fuelled by traditional media's portrayal of 'bad doctors' and facilitated by social media. They describe the considerable public confusion about complaints procedures that is leading to complaints being made to the GMC that ought to have been dealt with locally without escalation. In common with the Civitas report, they found 'a general perception that the nature of the doctor-patient relationship has changed, with patients becoming less deferential, better informed and more willing to question the care they receive.'

The authors of the Civitas report appear to view this as a threat (page 33/34), rather than an opportunity. There are a considerable number of doctors like myself and patients who use social media to challenge one another and the wider goals of medicine and health policy in a spirit of enthusiastic curiosity. There are vigorous and encouraging debates challenging medical paternalism and the notion of doctors as victims. The Kings Fund and the BMJ are doing excellent work with patients as partners. Shared decision-making between patients and professionals is not only a philosophical/moral position that challenges medical paternalism, but has a rapidly growing evidence-base and an NHS website. Patients' preferences matter and so does good communication.

The rose-tinted view of the competent, skilful doctor who 'lacks empathy and wastes little time on social niceties' as the innocent victim of unreasonable complaints (page 33) doesn't stand up to the evidence above linking good communication with appropriate clinical decision making, nor the importance of kindness in care. Patients have every right to want to be treated kindly and involved in decisions about their care and doctors (even older, male surgeons) can do this.

Wider cultural issues

The extent to which the activities of the GMC are responsible for doctors' distress is important and under-appreciated. The authors of the Civitas report are absolutely right to draw our attention to the sad fact that the GMC is not providing support where is needed and is almost certainly contributing to the problem. Nevertheless there are many other important reasons for doctors' distress at present, some of which will increase the likelihood of a doctor being reported to the GMC.

Surgeons and physicians who make errors are badly affected even without being investigated. They tend to blame themselves and are more prone to burnout and future errors. Burnout is a serious issue among doctors, and recruitment to general practice has reached crisis point. The government policy of naming and shaming GPs who are below average in diagnosing cancer adds to our despair. Increasing competition at a time of austerity in hospitals leads to them being castigated for 'failing', leading to a spiral of decline, demoralisation, and cultural drift. Work pressures and poor management identified after Mid Staffs remain a serious cause of stress and illness for many NHS staff who are under increasing pressure to work when they feel unwell. All these factors are undermining the good health of professionals on whom patients depend.

Conclusions

It is essential that patients are protected from doctors whose behaviour puts them at risk, but we need better preventive as well as treatment measures and we need to minimise the harms when GMC involvement is necessary. Professional isolation and a lack of insight correlate well with under-performance and better support and teamworking, for example through coaching and mentoring can help.

This is a very important report with implications far wider than the treatment of individual doctors by the GMC. It is the interests of patients that doctors caring for them are cared for themselves. Added to evidence about just culture, patient safety, kindness in healthcare and doctor-patient relationships - this should prompt a significant cultural shift towards much more compassionate relationships between institutions, professionals and patients which will benefit us all.

Further reading

Ballatt J, Campling P. Intelligent Kindness: Reforming the Culture of Healthcare. RCPsych Publications 2012