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Over half of GPs change or stop reflections following Bawa-Garba case

Exclusive Over half of GPs say they have changed their reflection practices following the case of Dr Hadiza Bawa-Garba case, which experts say has huge implications for patient safety and the learning culture in the NHS.

Of 682 GPs responding to a Pulse survey this month, 52% said they had 'stopped or adapted' their appraisal reflections in the wake of the case, which has sparked wideranging fear among health professionals.

Some 42% said they had not changed reflection practices, with the remainder saying they did not know.

Earlier this year, the GMC was successful in overturning a decision by its own tribunal to let Dr Hadiza Bawa-Garba continue practising despite a manslaughter conviction.

The case of Dr Bawa-Garba was especially controversial because experts giving evidence at her gross negligence manslaughter (GNM) trial - heard by a Crown Court in 2015 - had been informed by her personal reflections.

What GPs are saying about changing appraisal reflection practices

Dr Mark Howell, a GP partner in Somerset: ‘I am now much more vague in the details I put into my appraisal to make sure there is absolutely no way the case discussion can be referred to an identified case.

'I now write things such as “child admitted to hospital after I saw them in surgery and discharge stated UTI; when I had assessed them I concluded they had a viral infection”, "I reflected that I would consider urine dipstick testing next time".

'I would omit any date of the event or age or particular time frame/reference to details that could be associated in court.’

Dr Ben Burrows, a GP registrar in Gloucester: ‘I think whilst there is clearly some misunderstanding over the extent of the use of the reflective summaries, it remains true that elements were utilised in the case, albeit indirectly. In the current climate I consider it wise to limit expression, and instead focus more now on the process of how I reflect upon events.

'This, I feel, meets the GMC requirement and also my own personal ethic on this process. Until there is a situation more akin to the airline industry process, I do not think many doctors, perhaps juniors in particular, will reflect with the breadth and depth that they would like to.’

Dr Pippa Vincent, a GP partner in Enfield: ‘From now on any reflection areas (other than relating to reading etc) will say: "I am happy to reflect on this case one-to-one with my appraiser. However following the Bawa-Garba case and the unjust treatment of a UK doctor by the GMC on 25 January 2018 I am not prepared to reflect in writing." I have not had an appraisal yet since then so I have no idea how this will be taken by an appraiser.’

Dr Joe McGilligan, a GP partner in Surrey: ‘I have removed some reflections from my appraisal which could have been misconstrued and in future will only put in positive reflections to prevent anyone using them against me in a court.

'We were supposed to be moving to the airline industry standard of no blame reflections so others could learn from near misses or actual events but clearly the lawyers only see the opportunity to use the information to either sue or defame.’

An anonymous GP principal said: ‘I feel the GMC has lost touch with the medical profession. I have lost all trust in them. We are hamstrung as we need to be registered with them to work. I have therefore chosen not to reflect at all.

'I am nearing retirement and will happily walk away and retire if this is an issue. The profession will lose a doctor they might have otherwise kept on for a bit longer at a time when there is an increasing shortage of GPs.'

Following the case, the GMC has said it would never use personal reflections in fitness-to-practise investigatons but that it could not stop them being used by courts.

But responding to the Government's review into GNM in medicine, the GMC urged UK governments to consider changing legislation to grant doctors' reflections protection against being used by courts because they are 'so fundamental to their professionalism'.

Also in light of the case, the BMA and GP defence organisations have called for the GMC to lose its right to appeal Medical Practitioner Tribunal Service (MPTS) decisions.

And BMA chair Dr Chaand Nagpaul said the Pulse survey results served to 'reinforce' the BMA's fears that patient safety is being undermined by the actions taken in the Bawa-Garba case.

He said: 'This survey reinforces the BMA view that the GMC’s decision to appeal has had a counterproductive effect, meaning doctors are less likely to be open with reflection and which will undermine rather than improve patient safety.

'The BMA’s submission to the Norman Williams review of GNM has called to remove the GMC’s powers to appeal MPTS decisions.'

In March, LMCs passed a no confidence vote in the GMC and demanded advice for GPs to stop written reflections and Pulse has reported that the BMA is in talks with the GMC about updated guidance for doctors, expected to complete in the summer.

Medical Protection Society medicolegal adviser Dr Ewen Ross said: 'Our advice is and remains that reflection is an important part of a doctor’s professional development, and furthermore, not documenting an incident or reflection during appraisal may lead to a greater risk of allegations of probity and referral to the GMC.'

GMC chief executive Charlie Massey said: ‘Reflection is central to professionalism and it is vital doctors feel supported to practise openly. And if a doctor faces a complaint, being able to provide evidence of their openness and insight will help them demonstrate that they are fit to practise.

‘Because doctors’ reflections are so fundamental to their professionalism we have concluded that UK and devolved governments should protect them in law. We are also working with other organisations to provide clear guidance for all doctors on how to approach reflective practice. We have also begun conversations with other regulators on how we can better support team-based reflection, and the scope for joint guidance.’  

Have you personally stopped or adapted appraisal reflections in the wake of the Bawa-Garba case?

Yes - 51.47% (351)

No - 41.64% (284)

Don’t know - 6.89% (47)

The survey was launched on 12 April 2018, collating responses using the SurveyMonkey tool. The 28 questions asked covered a wide range of GP topics, to avoid selection bias on one issue. The survey was advertised to our readers via our website and email newsletter, with a prize draw for a Ninja Coffee Bar as an incentive to complete the survey. A total of 682 GPs answered this question.

Readers' comments (23)

  • even any comments i make on THIS forum are now only things I would be happy to have read out in court one daytbh

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  • the whole thing needs an injection of common sense. The front line seems powerless. Some evidence of reflection of say a complaint or SEA at the time of appraisal should be sufficient. The educationalist have succeeded in turning learning into a chore/hassle.

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    I shall put this article in my appraisal and
    me an my appraiser can reflect on it .....

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    reminds me of the joke
    A man is being arrested by a female police officer, who informs him,
    "Anything you say
    can and will be held against you."

    The man replies,

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    Anything i say can be read out in court in the future...
    I love lawyers and judges they are the most wonderful productive people in the world ... we need more in the GMC ...
    They don't know what they are talking about
    Why would anyone possibly show contempt of court...

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  • I agree with Truth finder.
    Doctors have always reflected internally and verbally. Medicine has an oral tradition. Appraisal turns that into a written profession as with the profession of law. Generally we aren’t that good at the written version. It’s in writing so it can be used against doctors although I know the educationalists believe that putting thoughts into writing helps with the thinking and articulation.
    Drawing would also do that!!

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  • And the other half - they stopped before the case. Medicine is doomed in this country. Bawa-Garba case again highlights the opinion the general public have of doctors.

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  • As all for one says,the contrast with airlines is stark;

    Imagine the departure lounge,Leicester acute paediatrics is ready for boarding;

    Please be aware we have not had the resources to adequately fuel this service,it does not have enough petrol for the flight

    The co -pilot is away doing something else.

    The pilot is too busy to check the aircraft

    The ground crew are overworked, underpaid, and really not in control of the situation.

    This plane is obviously going to crash

    However the General Pilots Council say it is important to maintain confidence in free flights.

    The pilots union are too pissed, and brain dead ,to understand the situation,.

    If you die the pilots defence union will definitely give you an apology

    Please proceed to the most envied flight in the world,

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  • Why would any overseas doctor want to work in the UK ? Facing torturous Revalidation and all the other litigation complaints culture . Doctors wanting to work here must be deluded .

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  • On Panorama last night was some pretty disturbing stuff on people convicted after only half their social media conversations were brought into evidence by the police. Obviously this completely changed the context since remaining data proved the case had no merit and one innocent man actually went to prison! We need to be extremely careful how these reflections used and disclosed.

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