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Independents' Day

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)

  • The simple fact that appraisal/revalidation is a poorly conceived and destructive process is lost in the whitewash of political spin enforced by the GMC and HMG.

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  • The whole revalidation thing comes at enormous opportunity cost to patients. Around once a year I spend literally weeks feeding the stuff I've done into the dreaded blank white boxes and clicking on endless clarity demands trying to get the damn thing to work. Whatever you do the appraisers are never happy and always find some nits to pick. No-one seems to realise you are also trying to keep a business afloat and provide safe care in the face of severe cuts. The whole thing is thoroughly dishonest and depressing TBH. There should be an investigation into how it came about and who made money from it.

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  • We should stop the knee jerk reaction for the media. Revalidation leads to more useless work and stress and is a PR stunt just because Shipman who is a drug addict and a criminal who has flipped. It is equivalent of giving a triple bypass for everyone who have or have not had chest pain. The profession is now over regulated and is unworkable.

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  • The widely share concern is the GMC says one thing and actually does something else.

    So for example they continue to maintain that and "punishment" of a doctor is so as to maintain public confidence in the profession, surely this standard can be applied to almost anything we do and will often stick, thus severely lowering the standard for attracting opprobrium.

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  • I'm surprised its only just over a half.

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  • what I have done is removed some reflections from my appraisal which could have been misconstrued 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.

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  • What is airline Industry standard ?
    Going to work like Dr BG to find 2 Registrars, 1 Consultant and 1 F2 missing, doing a double shift, and still expected to make no errors of omission or commision.
    Pilots do not fly 380s single handed without co-pilots, crew etc. Their rules and regulations are so strict and unequivocal.
    I find it amazing and am quite stunned when I constantly hear of airline standards in the grossly understaffed overworked NHS.
    I know I have done months singlehanded grade in hospitals.
    Airlines are one thing, the NHS is completely the opposite.
    In the airline Industry Dr BG would not happened, she would have just turned and walked away and shut the Dept.
    Now, if only we could behave like the airlines !!

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  • There have always been good reasons to reflect . ..and now many more bad reasons for any exposure of your honest reflections.
    I am leaving medicine soon and keep warning colleagues .
    There is little institution support. Thanks to all who tried to support what appears a sad accident . We don't ban drivers for accidents or maybe I missed evidence of more serious stuff

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  • David Banner

    We some how staggered through the 20th century without writing down endless reams of reflections on everything we did or learnt, and the world didn’t come to a catastrophic end. As professionals (and human beings) we all reflect on our negative experiences, but this zealous drive from Ivory Tower “educators” to slavishly record reflections for all the world (and its lawyers) to see was always a beaureaucratic car crash waiting to happen, and exasperated doctors are voting with their keyboards.

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  • Clever people always took care of such reflection in past. SEA May have medico-legal implication. Best option I think I is to discuss mistake with patient.

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