Transforming the culture of healthcare: sick doctors and the GMC

J Tomlinson

 

By Jonathon Tomlinson, 28 July 2014

 

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 websitePatients’ 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

 

Comments policy

We encourage you to comment on this blog. All viewpoints are welcome, but please be constructive and polite. We reserve the right to make editorial decisions regarding submitted comments, including but not limited to removal of comments.

 

Jonathon Tomlinson

About Jonathon Tomlinson

Jonathon Tomlinson is a full-time GP in Hackney, east London. He is a GP trainer and undergraduate tutor with special interests in 'Poverty Medicine', shame, trauma and education. He was recently voted the 49th most influential GP in the country by Pulse magazine because of his blog.
  • mark westwood

    Well observed…..good points raised

  • bioten

    Shame you don’t mention the worst type of bullying that goes on in the medical profession – that between doctors and their doctor colleagues.

    Some of the worst cases involving the GMC that I have seen have involved doctors who are professionally jealous making spurious complaints to the GMC about those doctors who actually set out to help patients and refuse to toe the line and follow the medical status quo.

    One such doctor, Dr Skinner was hounded with questionable complaints from the medical profession in the UK until his untimely death from a stroke (who know what impact the GMC stress had on his health?), yet he continued time and again to be exonerated by the GMC because the work he did with patients was effective in transforming their health problems.

    http://www.telegraph.co.uk/health/alternativemedicine/10985192/Could-a-renegade-doctor-save-your-life.html

    The nail that sticks out will get hammered down by the ignorant UK medical profession.

    What about encouraging diversity of approaches and treatment in the medical profession, based on the fact that the UK population is diverse and we don’t all conform to your simplistic, reductive tickbox models?

  • Socialisthealth

    As always powerful and compassionate. You dont discuss the stigma of mental illness. I suspect this is even more real among doctors than among patients.

  • chpichpi

    Further reading – an investigation into the way the GMC handles whistleblowing doctors http://www.hsj.co.uk/news/exclusive-former-judge-to-probe-gmc-treatment-of-whistleblowing-doctors/5073531.article#.U9vQXuNdU2Z

  • CHPI
  • Rita Pal

    Of course, what is written on paper does not transfer to reality. The problems with the GMC are entrenched and despite Dame Janet Smith’s damning indictment, it has never improved. The best way forward is to shut the place down and fire everyone in there. This will bring about accountability and a new start. Without it, doctors don’t have a hope at all. I think the UK’s medical profession spends too much time intellectualizing while their colleagues either have their careers prematurely terminated or their lives ended. It is time for action, not pontification by the same top dogs that are part of this systemic problem.

    Dr Rita Pal
    Rita Pal v GMC 2005. I still remain the only junior doctor to have sued them in libel and data protection breaches successfully.
    http://www.ritapal.info

  • Deenbondhu

    1.
    The UK
    General Medical Council (GMC-UK) is not independent of
    the UK Government

    2.
    GMC is not independent of the monopoly healthcare-employer
    NHS-UK

    3.
    GMC has
    been publicly found to have (operated) ‘fundamentally
    flawed procedures’ which were ‘not fit for (GMC’s
    statutory) purpose of protecting patients’ from bad,
    dangerous or dishonest doctors almost a decade ago (9/12/2004). The situation
    has worsened by the current Rules (effective 1/11/2004) as found on 15/5/2005.

    4.
    To date,
    GMC has failed to deliver its repeated public
    commitments on (a) declaring clear,
    objective, non-conflicting standards of
    professional conduct by doctors (b) open and accountable regulation, and developing procedures and
    processes that are fair, objective, and transparent and
    free from discrimination, (c) ‘Acting fairly to protect patients’ by “separation of functions within the fitness to practise
    (‘FtP’) procedures”, (d) adhering to the spirit and letter of the equality
    legislation (esp.
    Equality Act, 2010 Data Protection Act, 1998 & Human Rights Act, 1998)

    5.
    Consequently, GMC’s procedure rules are incompatible with Human Rights Act, 1998 & no responsible UK minister has made any statement
    under Section 19(1)(a) of the

    Human Rights Act, 1998 that, “the provisions of (GMC Fitness-to-Practise Rules)
    are compatible
    with the convention rights (European Convention on Human Rights, ECHR)”. GMC’s
    ‘closet’ adjudicating body MPTS has been operating illegally without any
    statutory backing since mid-2012, to date.

    6.
    GMC’s ‘permanent bureaucracy’ has publicly found to foster a ‘culture
    of mutual self-interest’ (pro-NHS agenda) of protecting dangerous and dishonest
    doctors within the UK NHS (Shipman, Neale, Kerr-Haslam, Barton, Chapman,
    et al, 100s)

    7.
    GMC’s
    ‘permanent bureaucracy’ anonymous staff unlawfully privately take all the regulatory decisions (that
    fall to be made by an independent Panel at the end of a public hearing) at the outset, by force of circular prejudice on the outcome against (the
    registration of) the practitioner(s) whom they target by way of discrimination on grounds of (their) alien [OQD]
    origin, BME, non-NHS or other demographics.

    8.
    The
    doctors targeted by the GMC have no logical or
    legitimate exit from the GMC’s endless circular
    procedures with pre-determined outcome, on which there is no time-limit, reprieve, costs-reimbursement, just remedy or redress.

    9.
    Since
    9/11/2001, GMC has been committing fraud by misrepresenting
    its status as a charity (by concealing its regulator-abuses) so as to avoid paying tax to HM Treasury (c. £20m /year), as
    well as making false declarations to the UK Charity Commission.

    10. GMC has also been committing fraud by misrepresenting (falsely exaggerating) its statutory
    powers on medical practice in the UK in breach of s47 of the Medical
    Act, 1983.

    11. GMC’s ‘permanent bureaucracy’ either
    controls the [104-35-24-now] 12-member Council & CEO as puppets; or they
    voluntarily collude in /and condone all the criminal
    activity of the GMC staff and agents (including but not limited to
    fraud, forgery, tax-evasion, fabrication & falsification of evidence, perjury, theft,
    harassment, intimidation, &c.)

    12. GMC is utterly irresponsible, criminal
    and totally unaccountable to any UK court, tribunal or
    the UK Parliament; the GMC Chair (head charity-trustee), CEO [Mr Niall
    Dickson] and Council employees routinely commit perjury
    to mislead the UK Parliamentary Health Select Committee (HSC) by making
    unfounded and untruthful statements that are unsupported by any facts or
    statistics at the annual ‘accountability’ hearings before the HSC (28/10/2010,
    14/6/2011, 26/7/2011, 4.9/2012 & 10/12/2013).