How the threat of a letter is making GPs practise more defensively

A major report from Pulse’s publishers Cogora is looking at how an increase in the number of complaints is affecting general practice, which is being serialised in three parts in Pulse. In the second part, Jaimie Kaffash and Sophie Borland look at how GPs are practising defensively due to fears around the GMC and litigation

This is the second part of the serialisation of our new white paper, supported by Medical Protection, on improving the complaints and regulation processes

For many GPs, a complaint is the first step in what could be an arduous road that culminates in local commissioner involvement, the CQC or the Ombudsman. But, at its worst, it comes in the form of a letter from the GMC or a law firm.  

The number of complaints is on the increase, and in a distorted version of the ‘prevention being better than the cure’ mantra, GPs say they are getting ahead of the danger by practising defensive medicine.

A new Pulse survey of around 836 GPs reveals that 78% agree with the statement that the threat of complaints is making them practise more defensive medicine than they believe is best for patients. More than a third strongly agree.

In practice, this includes referring patients more readily than they otherwise would, ordering tests earlier, spending significantly longer writing consultation notes and providing extensive safety-netting advice primarily to protect themselves against future criticism.

This comes at a time when the GMC is opening more cases than ever – but fewer are ending in any kind of censure.

Defensive medicine

Dr Sarah Townley, deputy medical director at Medical Protection, says: ‘We know our members feel a growing sense of pressure. They’re worried about all sorts of medicolegal issues – complaints, claims, even police investigations – it’s definitely at the back of their minds.’

As a result, Medical Protection, through its research arm the MPS Foundation, is looking into the concept of defensive medicine and its impact on doctors in a study alongside Trinity College Dublin and University College Cork. Dr Townley says: ‘The study is only halfway through, but my understanding is that there are multiple factors that can lead to defensive medicine.’ This could be around the fear of a patient being unhappy or the ‘wider culture where doctors feel they’re being publicly criticised a lot’. However, she adds, ‘it might be fear of the regulator’.

Respondents back up Dr Townley’s point. GPs tell us they were more inclined to prescribe certain medications, refer, or spend a longer time writing notes. As one GP put it: ‘I have found myself practising more defensive medicine at times, perhaps investigating or referring where previously I might have watched and waited. Despite time constraints, I find myself writing essays in patient notes to make sure I’ve covered my own back, safety-netted clearly. This, combined with patient attitudes, has made working in the NHS almost untenable in the current climate.’

Another one said that general practice is a ‘very high risk environment’ and, as such, ‘the only way to navigate this is to act and practice defensively and have a low threshold of risk. Otherwise, almost certainly something will come back to bite you’. However, they added: ‘It will almost certainly happen even when you are practicing defensive medicine but you hope the risk is reduced.’

One respondent told us they ‘certainly practise more defensively than I believe is ideal’, which has been a result of direct experience. ‘For example, where patients who have had a stroke have subsequently complained that opportunities to manage their cardiovascular risk factors were missed at routine reviews or even administration events in their medical record. This creates a pressure to pursue aggressive primary prevention even in patient groups in whom the evidence for these types of intervention is minimal, such as in elderly patients.’

Many GPs raised the point that there is an impact on patients in being over-diagnosed, over-medicalised and being made needlessly anxious – which also have implications for the NHS on both costs and waiting times.

But there are also huge impacts on doctors themselves. Research published in the British Medical Journal in 2019 involving over 3,100 obstetricians and gynaecologists in the UK found a strong link between defensive medicine and burnout.

The GMC says its way of combatting defensive medicine is through promoting good practice, with treatments based on doctors’ clinical judgement and the patient’s needs, and decision-making to be based on the exchange of relevant information between doctor and patient including clear, accurate and up-to-date information. It adds that its outreach teams have delivered training on its standards to nearly 35,000 doctors in 2024.

GMC queries increasing

What is perhaps exacerbating these problems with defensive medicine is that the number of complaints about GPs to the GMC is increasing.

Outcome of initial triage decisions for GPs from 2020-2024

But a far higher percentage is being closed at the initial stage and far fewer are leading to investigation. The GMC, for its part, has made moves to improve their processes for doctors in recent years, including the introduction of provisional enquiries, which are early-stage enquiries to decide whether to investigate or close the case, as well as measures to try and mitigate the harms of its investigations through initial phone calls and pausing them for six months when the doctor is unwell.

It is also currently undergoing its biggest reform in 40 years. A Department of Health and Social Care consultation, launched in March 2026, said that the current process was ‘out of date’, and ‘over recent years, the need for a more flexible approach to regulation has become clear’.

The new consultation brings physician associates and anaesthesia associates within the scope of the fitness-to-practise regulations. But the headline-grabbing aspect was providing the GMC with the right to appeal medical tribunal decisions – which the Government had previously promised wouldn’t happen.

This brought criticism from, among others, the BMA and Medical Protection medical director Dr Pallavi Bradshaw, who pointed out that GMC is the only UK health regulator with a statutory right to appeal its own tribunal’s decisions, duplicating the powers of the Professional Standards Authority: ‘The proposed changes mean that a doctor would be subject to potential appeals from both bodies following either a substantive or interim sanction which is likely to lead to more delay, uncertainty and cost. This anomaly contributes to the increasing distrust between doctors and the regulator, and this is a disappointing development for the profession.’

However, there are more welcome aspects of the reforms, including allowing the doctor to avoid a full fitness-to-practise hearing if they agree with a sanction. However, Dr Townley says that there will need to be safeguards in place: ‘For example, that doctors who aren’t represented aren’t disadvantaged, and that people still have enough time to deal with all the documents, data and paperwork that a GMC investigation produces.’

Despite all the reforms the GMC has introduced, the process certainly does need to be streamlined; recent figures from the Professional Standards Authority – which oversees the GMC – show fitness-to-practise hearings are taking an average of two years to process.

Litigation

Equally concerning is the threat of litigation. In April 2019, the Government launched a state-backed indemnity scheme for GPs meaning they no longer had to arrange and fund their own clinical negligence cover after medical defence organisations were having to increase fees exponentially due to the threat of big payouts. Although the move was broadly welcomed by the profession due to the rising costs, the scheme doesn’t cover GMC cases, criminal proceedings and any private work and as such, GPs are still encouraged to be members of a medical defence organisation.

Figures from NHS Resolution – which runs the indemnity scheme – found that there are around 3,000 new cases brought every year for the Clinical Negligence Scheme for General Practice (CNSGP) and Existing Liabilities Scheme for General Practice, which is for historic cases for members of Medical Protection or the Medical and Dental Defence Union of Scotland (MDDUS) – covering cases with varying degrees of damages (see table).

NHS Resolution cases

But for GPs, this isn’t a financial issue. One GP tells us: ‘I received a letter about a patient I hadn’t even seen alleging that the practice hadn’t called their client in for a screening test. I devoted full days to this, taking time out of my practice to see lawyers. The whole process lasted two years and the patient and their lawyers withdrew the claim a week before the court case.

‘When you receive the letter from the lawyers, it is utterly terrifying. It is the emotional aspect – it completely shakes your confidence, makes you question everything you do.’

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