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GPs may fall foul of rules on waste

What is the best course

of action if you feel a colleague is falling down on the job? Dr Anahita Kirkpatrick of the MDU gives advice

It's never easy to raise concerns about the competence of a colleague, especially if that colleague is senior and well-respected. But what if a GP is obviously not functioning properly and yet refuses to admit there is a problem? What if you fear he or she is a serious danger to patients?

Depending on the nature of the concerns and your relationship with this doctor, you may consider discussing the matter with him or her. You may receive a perfectly reasonable explanation.

However you decide to act, it is always advisable to contact your medical defence organisation for advice about the best way to proceed if you have concerns about a colleague's performance or conduct.

It may also be useful to approach another colleague to discuss your concerns, particularly if you are daunted by the prospect of challenging a respected senior partner directly.

You should not allow your personal opinion of your colleague to affect your professional opinion of their abilities and appropriate action thereafter. You may be regarded as partially culpable and perhaps asked to give an explanation to the GMC yourself if you choose to turn a blind eye to poor performance which resulted in harm to a patient.

While many GPs in this position are understandably reluctant to take action, the GMC makes it clear in Good Medical Practice that as a doctor, your first duty is to your patients: 'Where there are serious concerns about a colleague's performance, health or conduct, it is essential that steps are taken without delay to investigate the concerns, to establish whether they are well-founded and to protect patients.

'If you have grounds to believe that a doctor or other health care professional may be putting patients at risk, you must give an honest explanation of your concerns to an appropriate person from the employing authority.'

In such circumstances GPs are advised to discuss their concerns with the PCO, following the existing procedures.

The Health Service Circular on Clinical Governance (HSC 99/065) makes it clear that all PCOs require 'routes for other clinicians to voice concerns about colleagues' and many now have written policies on how doctors can report concerns about poor performance.

The PCO may decide to refer the matter to the GMC or the National Clinical Assessment Service (NCAS) which can advise NHS bodies on handling concerns about professional performance of individual doctors and about local systems for handling poor performance.

The NCAS can also carry out assessments of GPs where there are concerns about poor performance, but patient safety is not considered a serious risk. In these cases it can suggest medical help, retraining and/or a period of supervision.

If you are subsequently dissatisfied or worried at the action taken under local procedures, or for any reason you do not feel you can use them, then the GMC stresses you should get in direct contact.

The GMC has produced a guide1 for GPs, practice managers, medical directors and clinical governance managers that says you should inform it straightaway 'if you believe a doctor's behaviour is, for whatever reason, putting patients or anyone else at risk of serious harm'.

If it decides to investigate, the GMC will contact the doctor's employers to find out whether there are wider concerns about his or her fitness to practise. The guidance also gives examples of where the GMC has taken action, including where the doctor has:

·Made serious or repeated mistakes in diagnosing or treating a patient's condition

·Not examined patients properly or responded to reasonable requests for treatment

·Misused information about patients

·Treated patients without properly obtaining their consent

·Behaved dishonestly in financial matters, or in dealing with patients or research

·Made sexual advances towards patients

·Misused drugs or alcohol.

If you believe your colleague's actions pose an immediate risk to patient safety and the GMC needs to be informed, you will be expected to provide enough information to help begin an investigation. This includes the doctor's full name or surname, initials and GMC registration number if possible, and the doctor's home address or address of the practice.

You will be required to give a full account of events or incidents that concern you, with dates and details of your concern, if possible. Supply copies of any relevant papers and/or other evidence you have and provide a detailed note of any action you have already taken ­ for example if you have already spoken to the doctor, or another senior colleague, or made a complaint to the doctor's employer. Where possible you should also supply details of anyone else who will support your complaint.

If your report includes identifiable information about a patient, you should seek consent from the patient. If that is not practicable, or if the patient refuses consent, paragraph 21 of the GMC confidentiality booklet says: 'You should contact the GMC, or other appropriate body, which will advise you on whether the disclosure of identifiable patient information would be justified in the public interest or for the protection of other patients.'

The GMC makes it clear that should it decide to act on your concerns, it may ask permission to show the GP in question your letter or statement. If the case proceeds to a formal hearing, you might also be asked to attend as a witness.

Some GPs who have called the MDU advice line have asked whether they could make an anonymous complaint to the chief executive of their PCO. This is a possibility but don't expect much to come of it as anonymous complaints can be easily dismissed as gossip or innuendo.

Of course, reporting concerns about a colleague is never easy and at worst can result in emotional stress, but GPs should not be deterred from acting in good faith if they believe a colleague represents a danger to patient safety.

Case history: partners' swift actions may have saved depressed doctor from ruin

Everyone had become increasingly concerned about the senior partner. His appearance had become gradually more dishevelled; he was turning up late to practice meetings and seemed irritated by the smallest issues.

However, it wasn't until he was off sick for several days and the other GPs were seeing some of his patients that alarm bells really started to ring.

His medical judgment, usually reliable and considered, seemed questionable and the practice nurse commented that she found a blood sample in his room, which should have been sent off to the lab. When confronted by another partner on his return to work, he denied anything was wrong, but the colleague noticed there was a strong smell of alcohol on his breath. Shocked by this, the other doctors in the practice decided to contact the GMC and told the doctor what they were planning.

He was initially angry but then broke down and admitted he was depressed that his marriage was under strain and he had been drinking heavily to cope with depression.

With his partners' support, he subsequently co-operated with the GMC's health assessment and readily accepted the written undertakings suggested in their report, agreeing not to consume alcohol while on duty and to seek counselling for his depression and heavy drinking.

Six months later, the doctor had reduced his hours and was still seeing a counsellor, but the partners were delighted that his performance had returned to its previous high standards.

For his part, the doctor admitted that his colleagues' actions may have saved him from making a serious error.


1 Referring a doctor to the GMC: a guide for individual doctors, medical directors and clinical governance managers,

GMC, June 2005

Anahita Kirkpatrick is an MDU medicolegal adviser

The cases mentioned are fictitious, but based on cases from MDU files ­ doctors with specific concerns are advised to contact their medical defence organisation for advice

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