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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)

  • Anonymous Locum GP

    usual BS

    usual interest groups looking after themselves first

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  • If 'reflection' etc in annual appraisal has finally been recognised as being in all practicality a form of self implication in criminal activity (formerly known as adverse medical outcomes), then appraisal should be suspended forthwith. See Art 14 ICPPR, ('taking the Fifth' concept, basic to all Western legal systems).

    Is annual appraisal in its present form a breach of Human Rights law and so illegal?

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  • " 'The BMA will be arranging meetings ....."

    GMC, NHS England and the Department of Health will be quaking in their little leather jack-boots at the thought. Perhaps a strongly worded letter to follow. That will fix it.

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  • Anybody who admits to any clinical mistake in reflection of significant events is a fool.Personally I have spent 30 years in medicine in clinical practice and never made a mistake. I know it might not be true my appraiser might know but the lawyers/GMC won't have something to hang me by.
    Personally blame the RCGP with the stupid naive focus on reflection

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  • Just had my appraisal - basically told to put nothing controversial down - do not reflect on anything if it’s negative

    A waste of time

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  • Damned if you do (reflect...then used in evidence against you)....damned if you don't (not enough reflection....appraisal won't be signed off). Any Dr/trainees now should just fill their appraisal documents/e-portfolios with minimal, bland, non specific comments. Nice one GMC! This case just encapsulates the rampant blame culture that continues to exist in the NHS.

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  • we need to ensure the whole profession is aware they must only reflect the mistakes/failings of the system. nothing about them personally. any appraiser who asks for personal reflection to be struck off immediately

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  • The GMC have got us into this appalling Catch 22 and the GMC can get us out of it. And Weasel words won't cut any ice. There needs to be a clear legal understanding that reflection is privileged.

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  • So glad I left the country..... my nephew was thinking of applying for medicine, he's got the grades and being doing the interviews recently.... I showed him this case.... after 'reflection' he's now considering chemical engineering instead.

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  • GMC double speak: 'We are supporting you when under pressure' (not so from this case). and more relevant to this article: 'You only provide your reflection if you wish' (Tribunal guidance: If reflection is witheld insight cannot be demonstrated and penalties will be a the higher end of the range).

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