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Independents' Day

Niall Dickson: 'The GMC accepts there is a lot more to do'

The chief executive of the GMC explains how the body is improving fitness-to-practise regulations

In their recent article in Pulse, Drs Lees and Williams highlighted the impact of GMC investigations on doctors, following research by Bourne et al published in BMJ Open last week. This is an important issue, and one which we are already addressing, but we accept it is an area where more can be done.

Bourne et al looked at the responses from nearly 8000 doctors who had been investigated by various organisations, the vast majority by local NHS bodies. Unsurprisingly it found that levels of stress were higher among the 374 doctors who had been referred to the GMC.

Being referred to a national regulator is bound to be stressful - it is hard to see how that can be avoided and it is right that doctors should be accountable for their actions. But we should do what we can to minimise the trauma - that is one reason why we are exploring consensual disposal and why we are doing everything we can to speed up our processes.

That is also why, over the last few years, we have been doing everything we can to show that the system is fair, to speed up the process at every stage and provide support for both doctors and patients who find themselves involved in our investigations.

Drs Lees and Williams are right to point out that a lot of the concerns raised with the GMC are closed without a doctor ever facing action. Many of the complaints we receive could and should be resolved at a local level, with the GMC handling just the most serious concerns. We have made changes to how we deal with less serious complaints, so that we can focus on those issues that might require us to take action on a doctor’s registration.  

But contrary to what was suggested, we do not ‘welcome’ the huge rise in complaints to the GMC - not least because there is nothing we can do about most of them. What we do welcome is a more transparent system and one where doctors and patients work in partnership. 

Likewise we are keen to do everything we can to encourage a culture in healthcare institutions that encourages and supports those who raise concerns. The fact that we have to take action in a few cases where doctors have seriously or persistently flouted our guidance is not incompatible with this stance.

No ‘punishment

Some of the concerns referred to us are very serious and we must act first to protect patients. That can include asking an independent panel of the Medical Practitioners Tribunal Service (MPTS) to impose conditions on a doctor’s practice, or suspend their licence, while we investigate.

This is not, as is suggested by Drs Lees and Williams, about punishing doctors before evidence has been found proven. It is a fundamental part of our role to protect patients. These panels have a duty to assess whether there is a prima facie case which, if proved, would put patients at risk. The decisions made by those panels have no bearing on the investigation or on the final outcome, which is not determined by the same panel.

So the claim that we want to punish and punish more is quite wrong. We have always accepted that the effect of the fitness-to-practise process created by Parliament can be punitive, the point we have sought to make is that the purpose is not to punish. It is to protect patients and the reputation of the profession.

The authors depict us as punitive and vindictive yet, as they point out, we dismiss most complaints because they do not reach our threshold. Sometimes we have to investigate to reach that conclusion but we are keen that as much as possible is managed and resolved locally. 

And our consultation on sanctions guidance has provoked the largest number of replies we can remember and while we will have to wait for the detailed analysis, the overwhelming response has been positive. 

We are reaching out to the profession and engaging with front line doctors as never before, and we have revolutionised the way we engage with employers through regular face-to-face meetings. Our Employer Liaison Service (ELS) has created strong links with employers and now supports Responsible Officers in managing concerns locally, helping to make sure that doctors are referred to us only when it is necessary. We are also making better use of our data to see what more we can do to support doctors at risk of receiving a complaint.

The fitness-to-practise work we do will always be controversial. The stakes are high and the circumstances are often disputed - it is unusual for both complainant and doctor to be satisfied. But it is important work and the actions we and the MPTS, do protect patients and do help to maintain the justifiable trust patients have in the profession. We have done a lot to improve a system under a lot of pressure, but we accept there is a lot more to do.

Niall Dickson is Chief Executive of the General Medical Council

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Readers' comments (43)

  • Following a Freedom of Information request to the GMC entitled:-

    ‘Number of suicides of doctors under investigation’ at

    https://www.whatdotheyknow.com/request/number_of_suicides_of_doctors_un

    The person asked the question:-

    1. Can you tell me how many doctors have died since 2012 under GMC investigation, at referral stage, prior or during a fitness to practice panel or within two years of an investigation being commenced including any formal warnings or any other action?

    The answer from the GMC on 18 December 2014:-

    I can confirm that the total number of such doctors who have died since 1 January 2012 is 49…

    Primary Medical Qualification Country # Doctors

    Greece 1
    Netherlands 2
    Poland 1
    India 1
    South Africa 1
    United Kingdom 22

    Total 28

    The further questions are:-

    Where did the other 21 doctors obtain their primary qualification from and is that also around 80% from the United Kingdom?

    And what has happened to the person that made this request?

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  • Mr Dickson, I have a few suggestions for you and your fellow custodians of Public confidence to mull over
    1] You can do something about rising complaints- Stand up to public and media lynch mobs and do the right thing - Add a paragraph on your website to say that doctors are generally skilled and dedicated professionals- When things go wrong it is usually systems errors or matters beyond ones control [ie recognised complications of procedures or the natural progression /unpredictability of disease] and rarely the fault of individual doctors and to consider these factors before making a complaint ; Also add that vexatious / malicious or false allegations may lead to prosecution and amend the legislation accordingly [I’m sure that’s doable]
    2] As other colleagues have mentioned, Audit the effects of your procedures both retrospectively and prospectively ,particularly the effects on clinical services ie-
    • Establish to what extent are they responsible for the severe shortage / recruitment crises particularly in specialties such as A&E General Practice and psychiatry?
    • Apart from death what about other unfortunate outcomes of doctors who have been through your procedures and their families–ie how many suffer from anxiety or mental health issues as a result [as mentioned in Prof Bourne’s research] ; How many retire early or emigrate? how does one quantify the loss of skills and expertise to the NHS as a result?
    • As mentioned by Dr Lees,What about the devastating effects of suspension or ‘conditions’ regularly applied by your Interim order panels based on dubious , one sided logic and usually very little evidence.– What are the effects on the shop floor-ie how are hard pressed acute rotas covered when someone suddenly comes off it in less than 24 hours notice? How can senior colleagues be ‘supervised ‘ ? What about the added pressure / additional clinical and administrative workload and strained working relationships on already stretched colleagues? What about clinics / operating lists cancelled at short notice? What about the added enormous costs of locums or the effects of deskilling from prolonged restrictions or suspensions? Doesn’t this have the potential to seriously disrupt clinical services and ENDANGER patients rather than protect them?
    • What about the massive increase in aggression and intimidation faced by doctors from patients and relatives?

    3] Make yourselves more accountable – You have been curiously silent on the death investigation ; What about the non suicide deaths? To what extent did the GMC processes contribute to those – Or is that something you intend to wish away?

    4] Finally in the spirit of candour you are so keen to propagate, I humbly suggest that you and your colleagues do some honest soul searching and ask whether the stance you take is really about protecting patients or about justifying your existence –and your salaries

    Dr Patty Rao ; Consultant Paediatrician

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  • Having a complaint against you is stressful for Drs. We try to do our best and are genuinely hurt when we fail. This failure is mostly due to disease progression and diagnostic uncertainty. We feel professional and personal hurt when the patients decide it is our fault.
    It might be useful if the GMC had two separate procedures.
    1 you are a bad person (paedophile, arsonist, fraudster) and you are also a Dr.
    2 you are a Dr and you might not be up to scratch

    these assessments are very different and would have different impacts when being investigated.

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  • https://www.whatdotheyknow.com/request/information_concerning_numbers_o#incoming-609359

    23 January 2015

    Dear Dr Miller

    Reference: IAT/ME/F14/6735

    I am sorry for the delay in responding to your e-mail of 26 November 2014
    in which you ask about doctors who have died whilst there was an IOP case
    concerning them. The information which answers your first 2 questions is
    shown in the tables, below:

    1) How many IOP cases, where the doctor was suspended, were closed due to
    the death of the doctor concerned?

    Hearing Year Number of Doctors
    2009 1
    2010 2
    2011 3
    2012 2
    2013 3
    Grand Total 11

    2) How many IOP cases, not resulting in the suspension of the doctor, were
    closed due to the death of the doctor?

    Hearing Year Number of Doctors
    2009 1
    2012 8
    2013 5
    Grand Total 14

    The total number of doctors who died, whilst there was an open fitness to
    practise case concerning them in each of these years is as follows:

    2009 = 10
    2010 = 9
    2011 = 11
    2012 = 14
    2013 = 21

    I hope that this information is helpful to you.

    Kind regards

    Mark Ellen
    Information Access Team
    General Medical Council
    3 Hardman Street
    Manchester M3 3AW
    Direct Line: 0161 923 6347

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  • What is going on?

    https://www.whatdotheyknow.com/body/gmc

    [name removed] (Account suspended) made this Freedom of Information request to General Medical Council

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  • Dear Mr Dickson,
    There are many ways that that stress associated with a GMC referral might be minimized for the vast majority besides seeking to curtail the experience through consensual disposal. The most basic of these is ensuring that there is an appropriately high standard of analysis of cases from the outset by professionals with relevant expertise and experience. We are aware of many cases where this clearly hasn’t happened and it is also borne out by comments from doctors surveyed in the GMC’s own research (Community Research Exploring the experience of doctors who have been through the GMC’s complaints procedures: Final Research Report General Medical Council March 2013). I was pleased that you told the Health Select Committee that you are taking steps to try to ensure the most serious cases are assigned to the more senior and experienced decision makers but that may still leave others where it takes far too long before basic common sense intervenes.

    I am also pleased that you do not welcome the huge rise in complaints to the GMC although this is the impression we have gleaned from past statements (page 5 On the State of Medical Education and Practice in the UK 2013; GMC Statement in response to ‘Factors associated with variability in the assessment of UK doctors’ professionalism’ 28 October 2011).
    It was not our intention to portray the GMC as vindictive so I must apologise if you felt that. On the other hand we would stand by comments about GMC processes being punitive because – whatever may be said to the contrary – that is how they are perceived. It is not just doctors who may regard the GMC’s sanctions as a punishment: we cited the view of academic lawyer Paula Case (someone whom the GMC itself cites as an authority in the 2014 State of Medical Education and Practice Report) “the rationales for sanctions and punishments share much common ground”. It was also Case who suggested that ‘the process is the punishment” in relation to interim orders. I suspect it is also the perception of parts of the media and general public - how else can one explain news items such as this http://blogs.channel4.com/victoria-macdonald-on-health-and-social-care/calls-change-doctors-avoid-justice/2045
    But I really don’t want our key concern to be buried in a battle of semantics. They are that some aspects of current regulatory systems (including the GMC but not confined to it) may now be working against patients’ interests through distorting practice and encouraging doctors to reduce hours, retire or leave the UK. You refer to taking action “in a few cases where doctors have seriously or persistently flouted our guidance”. Our point is that in order to deal with them, a vast number of doctors are having their wellbeing put at serious risk for lengthy periods and at substantial costs to ‘the system’. This is not proportionate and is not likely to benefit patients. Surely, there has to be a better way of safeguarding patients (including ourselves and our families) while enabling doctors to get on with their practice free from fear?

    Hilarie Williams (co-author of original article)

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  • In this fascinating and revealing interview, Professor Brian Edwards asks some very important questions and gets definitive answers from international expert Professor Brian Jarman

    Professor Edwards:- What advice would you give a Chief Executive of a Trust with a posted high mortality score?

    Professor Jarman:- “A high HSMR is a trigger to ask hard questions. Good hospitals monitor their HSMRs actively and seek to understand where performance may be falling short and action should not stop until the clinical leaders and the Board at the hospital are satisfied that the issues have been effectively dealt with.”

    http://www.nhsmanagers.net/guest-editorials/slaying-the-myths-a-laymans-guide-to-mortality-rates/

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  • @ Hilarie Williams also @ Niall Dickson (if you're reading this article)

    Apologies for posting anonymously but I fear reprisals and have little confidence in this regulator to act appropriately.

    In the small number of cases to which Mr Dickson refers, "...in a few cases where doctors have seriously or persistently flouted our guidance" the police and courts to deal with law breaking where needed. Local procedures to deal with other issues in the vast majority of cases. Unwell doctors to be managed by occupational health. Doctors to be subject to a fit and proper judicial process as any other member of the public would expect to be. The GMC's activities to be scaled back in line with other modern western health systems.

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  • Regarding these on-going discussions about medical regulation, one word keeps coming up again and again. That word is "fear".

    A culture of fear is unlikely to do anybody any good.

    I do hope the GMC will seriously consider the thoughts of Christoph Lees and Hilarie Williams. Otherwise the risk is that any potential culture of fear may heighten further. In my view any such culture of fear will not be helped through military approaches (GMC senior officials recently suggested this at a parliamentary hearing). In my opinion regulation is necessary but disproportionate fear is not. The heightening of fear amongst healthcare professionals risks working against patients interests.

    Dr Peter J. Gordon

    "We are being regulated to death" http://wp.me/p3fTIB-NX

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  • The document from the expert witness who looked at my case for the GMC which was dismissed after 8+ months was titled

    Dr XXXX vs. The GMC

    this was a document to see if the case should go to the fitness to practice committee (it never did).
    So before I had ever had to defend myself the GMC which I pay for had put up an adversarial front. So much for being supportive.......

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