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Appraisal guidance needs 'immediate update' after Bawa-Garba case

Prominent GPs have reacted to a controversial High Court ruling concerning a junior doctor by saying it raises serious questions about how doctor's reflections are used and recorded, and that new guidance is now needed urgently.

The call comes after judges yesterday ruled in favour of the GMC and said Dr Hadiza Bawa-Garba should be struck off the medical register - against the ruling of the GMC's own Medical Practitioner Tribunal Service.

Dr Bawa-Garba was convicted of manslaughter on the grounds of gross negligence by Nottingham Crown Court in November, according to reports this was partly on the basis of evidence used from her own e-portfolio.

But the case has attracted considerable attention as many doctors have warned that it penalises the doctor for systemic trust failures and criminalises clinical error. 

Health secretary Jeremy Hunt said yesterday that he was 'deeply concerned' about the unintended consequences regarding doctors' ability to learn from their mistakes.

Today, the BMA has said it 'will be arranging meetings with the GMC and government in the coming weeks to discuss this case and the wider implications that flow from it'.

BMA sessional GP subcommittee lead Dr Zoe Norris, who is a GP appraiser, went further, telling Pulse: 'It’s impossible for this case not to affect patient safety. We have all been trained to be open, honest, and reflecting on the care we provide our patients.

'How can I ask colleagues to do this, knowing it can be used against them? Knowing that no matter the number of patients they have seen, how understaffed and over stretched they are, it won’t protect them from criminal charges and the GMC.'

She went onto call for an update to guidance which doctors must adhere to complete their appraisals.

She said: 'We can no longer reflect openly and honestly, so the chances to learn from our mistakes is gone. There must be an immediate change in guidance for appraisers, and doctors, to protect us all.'

The RCGP, which is responsible for appraisal guidance, said it would not comment on whether it would review this, stating only that it supported a statement the Academy of Royal Colleges put out regarding the case.

The Academy statement said: 'All staff must be encouraged and be able to reflect honestly, openly and safely, and without the fear of recrimination as part of the vital learning process. The threat of this being used in a potentially negative way may potentially promote a lack of candour as well as loss of learning opportunities.'

It added that it recognised 'that medical Royal Colleges and faculties have a role to play in helping to ensure that all doctors in training are fully supported by both clinical and educational supervisors, that there are mechanisms for safe reflective learning and standards are set that include all parts of the system'.

BMA chair Dr Chaand Nagpaul said the case had raised 'questions and concerns about how doctors' reflections, which are an important tool for learning and professional development, are used'.

He said: 'It is important that patient safety is not undermined through clinicians being deterred from engaging with reflective practices about patient care for fear of reprisal. It is vital that we promote a culture of support and openness in the NHS that addresses the root causes of the pressures undermining doctors' ability to do their best for patients.

'The BMA will be arranging meetings with the GMC and government in the coming weeks to discuss this case and the wider implications that flow from it. The goal must be to build an environment where doctors and all healthcare staff have the resources, facilities and support to provide patients with the quality of care they deserve, as well as empowering them to raise concerns if they believe they are working in unsafe conditions.'

House of Commons Health Committee chair and former GP Dr Sarah Wollaston also said she was concerned about the ruling, in response to the health secretary's comments: 'I agree there are unintended consequences from this case and whilst ministers cannot intervene in judicial process for this case there will need to be a review not only of system pressures but to make sure clinicians can learn from errors rather than fearful of discussing them.'

The GMC said on Twitter that it would soon be clarifying its own guidance on how doctors should reflect. The tweet said: 'Doctors' reflections are made for the purpose of learning and development. We don't ask doctors to provide their reflective statements if we are investigating a concern about them.

'A doctor may provide these to demonstrate they have shown insight - but this is very much up to them. We'll soon publish more detailed guidance on reflection, making clear that for education, training and revalidation purposes, reflective notes - which are potentially disclosable in court/tribunal proceedings - should normally be anonymised because the focus should be on learning.'


Readers' comments (32)

  • GMC doesnt care about patient safety. These royal colleges are just interested in saving their institutions.If these organisations cared about doctors,they wouldnt have seen the decline of the NHS.Allied health professionals are doing the job of a doctor.I ask GMc where are your standards.what about the trust in the profession.Double Standards!!

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  • We have to react to the system and no fool will not defend their interests. It is called risk management. Do not take on high risk cases or operate on them. Do more investigations and refer more. Be extremely careful discussing your mistakes if at all. It looks like the GMC has not learnt from all the previous suicide cases it promised but have become worse and it shows the RCGP is weak and only the BMA stands up for us. Please BMA, set up a more reasonable alternative to the GMC. I do not want to pay such an organisation. I believe in regulation but this is ridiculous. Making a mistake in this rubbish system is equivalent to stabbing someone intentionally. Unacceptable.

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  • Manslaughter should not be used against health professionals unless there is evidence of intent.
    If we are to be held to such a severe degree of accountability then we will have to have private medicine. We are not paid enough justify the risk.

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  • I'm not sure how the law works but it seems to me we are now guilty by being open before being proven innocent Unfortunately to practice medicine in the UK we have to register with the GMC. Are they fit for purpose? I also thought appraisal was similar to patient doctor confidentiality. Obviously not. Beware!
    I believe we should all now boycott appraisal if we no longer have faith and confidentially in a system meant to make doctors better.
    Disclaimer- I have nothing to hide.

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  • GMC: Not fit for practice.
    Get crowdfunding folks.

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  • All career officers in schools should warn students considering medicine of this Manslaughter risk. It frightens me that a mistake or not even a mistake can lead to this horror

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  • Agree with Oz @ 3:29pm.
    Appraisal can now be seen as not just a feckless and wasteful process but now in it's true colours, a system for self incrimination.

    Time for appraisal to cease or be reformed. At the very least, it should be immediately suspended until it is independently investigated. Appraisees cannot walk away without losing license for non engagement. Time for appraisers to 'reflect' and disengage. You can 'throw in the towel' for any reason. There are lots of other activities that would benefit more from your skills.

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  • How can reflection be done honestly when that can be used against you
    Reflection is done to find something to learn and this might be taken as a guilt.I am scared.
    Are we asked to be dishonest ?

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  • Crowdfunding is already a success and I hope that we are able to fight the GMC ruling and bring to book those responsible for systemic failures. Managers and other Accountable people in NHSE/CCGS and Trusts all need to be stripped naked in this case and analysed and brought to book for first mismanagement, then scapegoating this junior colleague. Unfortunately, these are the people who have no accountability at all and that is the tragedy of today's NHS. So much for boosting morale and plans to recruit new Doctors.

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  • Appraisal does not need tinkering with, but scrapping with immediate effect. It is yet another example of the utter uselessness of the BMA that our supposed Union has not called for the farce to be abandoned. Perhaps in the future an evidence based replacement might appear, when appropriately trialled and shown to work.

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