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Independents' Day

'GMC processes may add to the distress and risk doctors face'

The GMC’s newly appointed independent mental health expert Professor Louis Appleby speaks to Pulse about what exactly the review will focus on 

Louis Appleby SUO

What specifically will the independent review be looking at? 

It will look at how the GMC works on fitness-to-practise and I will be looking at every aspect of how they do that. How they do that links into a broader system which includes how people get into difficulties with the GMC in the first place and what happens to them after they have gone through fitness-to-practise and what sort of support the system as a whole provides for doctors who have mental health problems. 

There’s a broader context to the specific question of fitness-to-practise and it will be my intention to look at all. Lots of people have told me about their experience with the GMC – delays in the system are one of the things that people find difficult. That’s one of several. People feel that they are treated as guilty from quite an early stage. They feel that the system is harsh in tone, it is quite protracted and they feel that the long term consequences are sometimes disproportionate, that they go beyond the immediate issue which is being dealt with.

Would you agree with those views?

I’m very sympathetic with that. It’s my intention to try and understand that better. I’m very sympathetic to the points people have made to me. My starting point is that we have to try to do the right thing by doctors even when their practice has been problematic and my starting sympathies are always with a doctor who is in difficulty.

28 doctors died by suicide while undergoing FTP investigations between 2005 and 2013, and the GMC recently said some of these doctors entered the procedures already having had very serious mental health problems…

People die by suicide for complex reasons, there is not single cause to suicide in most cases. It is usually that people face a number of problems which includes issues with their mental health.

This is why I said there was a broader context to this, it is how doctors with mental health problems are supported in general and how doctors work with employers, because a large number of referrals come from employers and about working out where the limits of public accountability lie.

So there is a broader context to this issue and to suicide prevention in general. My concern is that of all the difficulties that a doctor might be in, including their mental health, the GMC starts to get involved, and the concern is that the GMC process itself might add to the distress and the risk that doctors face – that seems to be something that should be avoided as much as possible.

Why might this be? It bound to be stressful for doctors to face investigation but there are about 2,500 and that investigations every year seems to me to be a lot given that there are 150,000 doctors in the country so one question is bound to be whether all those investigations are necessary because every investigation carries a degree of stress for the person that is being investigated.

It is a relatively small proportion, in 2014 it was 18%, that will face some kind of sanction including a warning. That’s a lot of people facing investigation who in the end have something done to them. The rest have no outcome or the outcome is consensual. My interest is looking at whether the GMC process can in the future be more consensual.

The issue of doctors coming in already with mental health issues is an important one. It is bound to be true but the question is what does the GMC do in those situations. The people who die by suicide don’t necessarily have mental health problems which are already known, so there are some people who come in who have mental health difficulties which are already explicit and they will need careful and sympathetic handling because they are already in difficulty and people can see that … but there are some people whose mental health difficulties haven’t been known and who might well deny mental health problems if ask directly but who nevertheless might be in distress and at risk, there has to be a similarly sympathetic way of handling those people.

Are there too many investigations?

I haven’t identified a number of investigations that shouldn’t have taken place – I am looking at the pure numbers. Of the 2,500 investigations concluded in 2014… 82% don’t lead to a sanction. That to me sounds like people are going through investigations increasing their risk and distress with no outcome imposed on them. It makes me think that there are too many and that a consensual process and outcome should be the aim for as many processes as possible. 

I do think that adds to the risk in people who are distressed and vulnerable – that’s the whole basis of my involvement.

Do you think the GMC has failed in its duty of care to those doctors who died by suicide while under investigation?

I understand why you might ask that, but I’m starting from now to see what the role of the GMC might be. There is an emotive language there which I won’t get caught up in. It’s about improving their process rather than levelling accusations at the GMC.

The GMC has said that wants to be more compassionate to the needs of vulnerable doctors. How can this be achieved?

There are some serious criticisms of the tone of communication with the GMC and the number of investigations that are carried out, and therefore the number of people who get caught up in a distressing situation, the protracted nature of these investigations and the long term impact on a doctor’s career – all those things need to be looked at.

Who is Professor Louis Appleby?

Last month, the GMC appointed Professor Appleby to review its fitness-to-practise (FTP) procedures to ensure that it is more ‘compassionate and sensitive’ to the needs of vulnerable doctors. The regulator said that he has been recruited to look at ‘every stage’ of its FTP investigation process and will examine how the GMC deals with doctors who may be vulnerable, following the publication of the GMC review in 2014 that found 28 doctors had died while under investigation.

Professor Appleby has already lead the development of the National Suicide Prevention Strategy for England, which focuses on support for families and prevention of suicide among at-risk groups and is a CQC board member.

He also leads group of more than 30 researchers at the Centre for Mental Health and Safety at the University of Manchester, where he is a Professor of Psychiatry.

Image credit: The University of Manchester 

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Readers' comments (20)

  • If democracy, justice, free speech and indeed Whistle Blowing are all hallmarks of our society, of which we are proud, this correspondence contains a large number of "anonymous" contributions. Discuss.

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  • Carthago (GMC & MPTS) delenda est!!!! Simply you must get rid of such a garbage! They are shameful expressions of an even but low level democracy. Nowhere in the world there is a faint similarity in the medical governance. The comments I read are giving great suggestions to deaf ears and arrogant minds.

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  • The GMC is so draconian = I have been there due to a mentally ill person [ a severely ill unfortunate held in hospitals for months] complaining constantly about something that I never did. [ it is called delusion] .
    But the GMC went through years and years of complaints, till one day the letters stopped coming.
    I was never, ever even told the outcome after years of harassment.
    When I see suicides etc, to me, it is the horrible, terrible attitude of the GMC that is the reason. They have no idea of compassion, justice, fairness, even handedness or even listening to the defendant, even when the complaint is so absurd as to be beyond daft.
    I, for one, personally would say to any young person, think long and hard before you become a doctor to work in the UK.
    That is why so many people are anonymous. You are dealing with an absolute MONSTER

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  • I never went back to work after my investigation. I developed severe depression and suicidal ideation. No mental health problems of any kind before. This was entirely due to the loss of power and feelings of total helplessness due to my career and reputation being ruined, when my (I believe sociopathic)nurse reported me to the GMC after I had sacked her due to repeated lying. Finally when she was confronted, she threatened me that she was " well going to bring me down with her". Well she did, with a lot of help from the GMC. No clinical complaint or error at any time and yet they just felt they had to investigate. She was never examined psychiatrically at any point. The whole thing was utterly unfair and ridiculous, but they destroyed my life. Twelve years later I am still not working and wouldn't go back because of my terror at the possibility of it happening again.

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  • You pay to defend yourself (Mps) you pay to investigate yourself (gmc) and you pay to sue yourself (tax which pays for legal aid)!
    Being a doctor in the uk is bad for your health
    Anonymous as GMC still alive well and active

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  • I retired four and a half years ago.I requested my name be removed from the register as I did not wish to practice medicine any further. I was refused!!! because a local complaint was pending( not GMC) that might lead to a GMC complaint!!!! After further review of the complaint( not GMC), by the GMC,I was allowed to have my name removed with my good name intact. That made me feel like being released from slavery (guilty if innocent and guilty if guilty.

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  • I hope that Prof. Appleby will be taking evidence from those doctors, including those who have posted here, who were either being "investigated" for depression, or had no pre-existing history of mental illness but developed mental health problems in the course of the process -the latter then goes quite a long way towards suggesting that the process in its present form is so distressing as to be causative. They also need to stop using quasi-medical terms such as "investigate" and "refer", which I suspect sometimes leads NHS employers to think that you "refer" to the GMC as you would to a hospital, for an opinion or treatment. They may see it as a way of "diagnosing" a problem doctor but it doesn't feel like that to the individual, given the absence of any form of consent or volition on their part.

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  • Retired early because of mindlessness of revalidation. On advice of MPS asked for voluntary erasure. Took months and was made to feel like a criminal who was getting away. After 40 years of work glad to be out of their b*st*rd clutches, no thanks of course for all my years of service. This is a dreadful and unaccountable lot of unqualified people. Did they failed the med school viva? So glad to be free, but we need to get rid of the GMC which we are forced to pay for, like tipping the hangman...

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  • Whilst being investigated for several years, the FTP panel failed to provide evidence (and cross examination of their alleged medical expert) of my guilt: Such conviction cannot be safe and leaves me, already brutally scarred by the ‘unexplained personality disorder’, defamed and alienated for life when I should not be deprived of my defence and fulfilling my vocation yet pooled in a group under a lethal risk. as showed by Ms S Horsfall’s Audit of Dec- 2014. Due to the effect of GMC’ conduct and investigations I operated under loss of: employment, credit lines, family life, self-esteem and contributing grief and mental health problems and financial hardship; it has not be possible for me to initiate a timely Appeal: herewith am I treated as a persona non grata and is Art 6 violated. Considering the case as a whole, suspension of doctors’ licence has amounted to a criminal measure, which requires that FTP’ proof for an erase has to be beyond doubt

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  • nobody disputes that a GMC investigation is the most stressful and difficult event that can occur in a doctor's career. much of this stress is related to the prolonged nature of GMC investigations, in turn related to the volume of complaints received by the GMC.
    it is high time for the GMC to streamline procedures -
    1 all health issues to be directed immediatly into a health track with properly resourced support and assistance for doctors to regain function and return to work if possible.
    2 other than in exceptional circumstances, the GMC should only consider a pattern or group of incidents, not one-off incidents. far too many cases referred to the GMC could be properly handled by quality local resolution.
    3 other than in exceptional circumstances, any matter referred to the GMC must contain a prima facie case of serious impaired fitness to practice. far too many cases are referred which will never meet this criterion but are investigated at length and cause doctors massive stress.
    4 other than in exceptional circumstances, any case referred to the GMC should have the facts established by a proper investigation eg police, coroner/civil/
    criminal court, NCAS, NHS internal investigation, Ombudsman.
    adopting these principles will reduce the number of cases the GMC needs to consider and allow full, proper and speedy investigation of the very very small number of cases where a doctor's performance poses a real threat to patient safety.

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