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'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)

  • Like the administration of justice in the UK generally, GMC procedures take an inordinate length of time. That must be one of the most telling factors in compounding the stress of what is already an unpleasant process for any conscientious doctor who is in good mental health, and an unbearable burden for those who are not - which is perhaps what the data is telling us!

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  • "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."

    No. We live in a democratic country that is run by the rule of law. We cannot tolerate a situation where potential crimes are not investigated, that would be a perversion of the course of justice. These issues should be dealt with by the courts who have a duty to act fairly and not simply be covered up by half-baked reports. Recent widely reported scandals have shown us that unless there is a proper legal process, the problems never really go away.

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  • The big problem of the GMC and the MPTS is not only in the length of proceedings, but it does not make sense in its essence: many of these cases are initiated by false or trivial accusations. The GMC builds a castle of paper on anything, leading the verdict of "guilty" for the doctor investigated, no matter. There is not a single honest step in what is done.
    Certainly there must be supervision on doctors; but on what concerning the work it could be done by a disciplinary committee for the scientific part and by the normal Justice if any crime is committed.The MPTS exists only to support itself and those who are working in it, with the connivance of the GMC that increases its power through terror on doctors.
    It is a unique situation in the world and it is unacceptable.

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  • Here is a list
    1) ensure that doctors are not made to feel guilty until proven innocent
    2) change the inital letter completely removing the part that says "your revalidation is on hold until the investigation is comlete", again guitly until proven innocent.
    3) keep doctors informed every step of the way
    4) if there has been an internal review of the complaint at practice level, look at the outcomes and then put a stop to it
    5) write to the complainants and state that if you have made a vexatious or untruthful complaint, you are liable for the cost of the investigation if nothing is found
    6) ensure that only the complaint is looked at, the the poor doctors do not have to fill in piles and piles of other paperwork for NHS England, CQC etc and repeat himself
    7) there must be recourse for the doctor to take on the complainant for libel if nothing is found, otherwise there is nothing at all holding back people from complaining about not getting antibiotics or anything else they wanted.
    8) only the most serious 1% of cases should be handled by the GMC, everything should be done at local level
    9) start to look after doctors and treating them with respect and dignity they well deserve, we pay to keep the GMC going. Which other profession pays to be treated like criminals?

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  • What about investigation by the GMC just because of major depression, without even any complaint or concern at all ? This happened to me when I declared a mental health problem and the GMC investigated as if there had been a complaint when they knew I was already struggling with depression (and not working)! When two of their psychiatrists disagreed in their reports, my case was referred to the Fitness to Practise Panel. Of course this considerably added to my stress and a decline in my mental health. I was even advised by a doctor at the Doctors' Support Service that I needed legal representation? Why? I hadn't done anything! Prior to the FTP panel I withdrew my application to restore my name to the register ( I had taken voluntary erasure when I emigrated to Canada). But for the care of my doctors,psychiatrist, support services (not the Doctors' Support Service suggested by the GMC-they were unhelpful) and hospital admissions my name would probably have been added to the 28 doctors who sadly died by suicide.

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  • the GMC provides a golden opportunity for all the whingers and whiners and dopey NHS 'managers' to have a good 'pop' at doctors. The whole FTP system needs to be examined properly and then re-designed.

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  • I am currently under investigation by the GMC (hence this submission is anonymous, for fear of reprisals). I had no mental health issues, covert or otherwise, at the beginning of the GMC investigation, but have some symptoms now. These symptoms - not severe, but understandable guven the circumstances - have been caused entirely by the investigation, and the complaint which is vexatious. I can completely understand the need for a regulator to investigate concerns; but not why they take so long. During the whole investigation I have not been told when to expect an update. On occasion I have been told quite clearly that they are unable even to give an estimate as to when the next update will be. That is cruel, inhumane and unnecessary. The tone of GMC communications does make you feel guilty until proved innocent: the fact that your revalidation is put "on hold" is a classic case in point. What is annual appraisal for, if it does not give evidence of fitness to practice? But most of all, the thing which causes intense anxiety is the feeling that you are being investigated by an organisation which is incompetent. It was 11 months before I was told the allegation against me (the initial letter was wrong); I have been sent papers breaching confidentiality relating to another doctor's FTP investigation; I was told on April Fool's Day that my investigation would be concluding shortly, only to be e-mailed ten minutes later to say that there had been a 'human error', that the message referred to another doctor, and that my investigation would take 'several more months'. Now, at the complete mercy of the GMC, I await my FTP hearing and have no expectation that it will be fair or just.

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  • I have suggestion. Scrap the GMC

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  • Disgusting and immorall!
    Never so glad as when I took my name off the register 'voluntarily' when I could not get revalidated due to not being in the NHS. Initially I was really upset as being a doctor was my identity, now I am so glad I am out and that the GMC cannot get me.
    Fight the .... and keep posting everyone about your mal-treatment anonomously 6.45pm.
    If you had no health problems before and get some now, could you sue the GMC? Don't get mad, get even. Keep strong.

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  • I had one of the initial investigatons that took the maximum 6 months to the exact day before it was thrown out.The complaint was transparently ridiculous to anybody who spent five minutes studying the evidence. The whole process more or less destroyed me and has directly led to my going part time. This is a rogue organisation that needs to be entirely rebuilt and restaffed.

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