It is likely that most GPs will be faced with a problem colleague at some time in their career. It is essential that prompt action is taken in the correct way so as to protect patient safety. Help is always at hand through your defence organisation, the BMA or dedicated whistleblowing organisations.
But raising concerns about your colleagues is never easy. More recently, at the independent inquiry into ‘shocking’ systematic failures of care at Mid-Staffordshire Foundation Trust, Robert Francis QC criticised hospital staff for not raising concerns when they knew patients were being put at risk.
The issue of other colleagues’ performance will not be far from GPs’ minds when they are asked to complete feedback form as part of their revalidation.
This article outlines key questions you may have when one of your partners at the practice is causing concern.
Dr Jones joined the practice a year ago with excellent references. However, in the last two months a number of patients have complained to reception staff about her rudeness during consultations and have asked not to see her again.
The local pharmacist has also contacted the practice to highlight a number of serious prescribing errors by Dr Jones. The practice manager approached Dr Jones to ask if everything was alright. Dr Jones remarked she was ‘just a bit tired.’
Can I leave the problem to resolve itself?
It may be all too easy to turn a blind eye to problems at your practice. You may feel that you do not have enough evidence to raise a concern or that it is none of your business. The colleague may be a personal friend, making it difficult to be objective about the situation. Your view may be in the minority, and you may be concerned that raising the issue might lead to professional isolation or possible scrutiny of your own practice. You may also worry about future employment or asking for a reference. If the problem is very serious, the GP partnership may be at risk, with consequent financial implications.
However, the General Medical Council (GMC) clearly states that doctors must put patient safety first and that this duty overrides all other professional obligations to colleagues:
“You must protect patients from risk of harm posed by another colleague’s conduct, performance or health. The safety of patients must come first at all times. If you have concerns that a colleague may not be fit to practise, you must take appropriate steps without delay, so that the concerns are investigated and patients protected where necessary.” (Good Medical Practice Paragraph 43).
Dr Jones’ erratic prescribing is compromising patient safety and must be addressed. Failure to raise genuine patient safety concerns may lead to professional sanctions.
Do I have enough evidence to raise a concern?
It is essential that concerns are dealt with quickly to prevent them from escalating and putting further patients at risk. Again the GMC provides definitive guidance:
“You do not need to wait for proof – you will be able to justify raising a concern if you do so honestly, on the basis of reasonable belief and through appropriate channels, even if you are mistaken.” (Raising and acting on concerns about patient safety (2012) Paragraph 10c)
Your role is not to conduct an investigation and you should avoid doing anything which may breach your own professional responsibilities. For instance, you should not access information about patients for whom you have no responsibility in order to confirm your suspicions.
Situations that GPs may typically be concerned about include:
- bullying or discrimination of patients
- inappropriate relationships
- allegations of inappropriate examinations or failure to use chaperones
- health concerns including alcohol or substance abuse
- prescription irregularities
- probity concerns (including retrospective additions or amendments to records).
Dr Jones and I don’t really get on. What if she takes my remarks personally?
It is vital to establish that the problem is a genuine patient safety concern rather than a personal grievance with a colleague. Inevitably there may be some overlap and this should be acknowledged. In whistleblowing cases, you are acting as a witness to highlight risk, malpractice or wrongdoing that may affect others. Grievances are complaints about an individual’s personal circumstances or employment situation. The GMC cautions against vexatious allegations:
“You must not make malicious and unfounded criticisms of colleagues that may undermine patients’ trust in the care or treatment they receive, or in the judgement of those treating them.” (Good Medical Practice Paragraph 47)
Making deliberately false allegations would be a disciplinary matter.
What protection do I have if I raise a concern?
Previous cases suggest that whistle blowers may be unfairly treated after making a disclosure. They may risk threats, redeployment or even constructive dismissal.1 However, the law is clear in that the Public Interest Disclosure Act (PIDA) 1998 provides legal protection for individuals who raise genuine concerns and expose malpractice in the workplace. The act applies to all NHS employees and includes all self-employed NHS professionals. This has been reinforced by a similar pledge in the recently amended NHS constitution.2 Any individual affected would have the right to take their case to an industrial tribunal to seek compensation. Victimisation of whistle blowers or any attempt to cover up wrongdoing should be dealt with as a disciplinary matter.
How should I raise my concerns? What support is available to me when I do so?
To receive the legal protection provided by the PIDA, you must carefully follow your employers’ protocol for raising concerns (the PCT’s, if you’re a partner), and carefully document your actions. If the concerns about an individual are relatively minor, it may be appropriate to deal with the matter locally within the practice.
In our case scenario it would be reasonable for a senior partner or trusted colleague to approach Dr Jones and explore the concerns in a supportive, non-confrontational way. A heavy-handed approach at this stage may lead to intransigence on both sides.
Dr Jones explains that she is having a difficult time at home and this is impacting on her performance and concentration at work. She recognises that her prescribing errors are unacceptable and that the practice needs to take action. It is agreed that she will take some time off work to seek professional support for her problems. On her phased return to work, Dr Jones agrees to regular feedback meetings with a senior mentor and an audit of her prescribing. She also offers to write letters of apology to the patients she has offended.
You should encourage your partner to seek advice and assistance through their GP. For more serious health concerns, an occupational health assessment may be helpful. Specific services for doctors with mental health or addiction problems may be available in the area and should be accessed for specialist input (www.support4doctors.org). If your partner is refusing to communicate with you about the issues, you should first seek advice from your defence organisation or your Local Medical Committee (LMC).
In more serious cases it will not usually be appropriate to approach the individual doctor directly. Serious concerns about a doctor should be raised with the PCT medical director or clinical governance lead. Particular care is required if yours is a minority view within the practice. GP trainees should discuss their concerns with their trainer or director of postgraduate general practice education before acting, unless the matter requires immediate attention. Your concerns should be treated confidentially and discussed only with individuals with proper authority.
Doctors concerned about patient safety issues at work can discuss the matter confidentially and receive advice from their medical defence organisation, the BMA and charities such as Public Concern at Work (www.pcaw.org.uk). Local support should be available from trusted colleagues and the LMC. You can also call the NHS Whistleblowing Helpline (08000 724 725).
If your concern is about the wider delivery of healthcare or serious system failings rather than an individual practitioner, the matter should be raised with the PCT. From April 2013 public interest disclosures will be made to the NHS Commissioning Board. If you feel that the responsible person is part of the problem then you should approach the GMC or the Care Quality Commission (CQC), which has strong enforcement powers to deal with organisations which fail to deliver acceptable standards of care.
You should resist any temptation to take the matter to your MP or the media, unless your organisation has a well-documented record of failing to deal with patient safety concerns. This step should never be taken without first taking professional advice.
Will the doctor be suspended?
Health issues should usually be dealt with locally, with appropriate support provided for the doctor. For more serious concerns the PCT has the option to place restrictions on the individual doctor’s practice.
For very serious or urgent matters they may choose to suspend the doctor from the performers list whilst investigations are carried out. Sometimes, the PCT medical director may have no choice but to refer the matter to the GMC who may then restrict the doctor’s practice or suspend them at an interim orders panel hearing. Following an investigation a PCT may impose conditions on a doctor’s continued inclusion on the performer’s list, or even remove them from the list altogether. The GMC also has wide powers to impose conditions on a doctor’s practice, suspend them, or even erase them from the register.
How can the practice protect itself?
The effects of a problem partner on the practice can be wide ranging and serious. They include a potentially challenging and unpleasant working environment and loss of morale amongst practice staff. Excluding a GP will inevitably lead to an increased workload for the remaining doctors and may be costly financially. Whilst these considerations are important, they are not valid reasons for failing to act when genuine patient safety concerns arise.
It is vital to have systems in place to allow staff to confidently raise concerns promptly in the first place. Each practice should have a whistleblowing policy that is easily accessible and updated on a regular basis. Staff should receive training on an annual basis to ensure that they are familiar with the necessary procedures.
Dr John Adams is an associate medicolegal adviser for MPS.
1 Calkin S. Whistleblower nurses faced daily personal insults. Nursing Times. 1 November 2011. http://www.nursingtimes.net/nursing-practice/clinical-zones/management/whistleblower-nurses-faced-daily-personal-insults/5037238.article; Silverman R. Whistleblowing nurse ‘forced out’ after airing concerns. The Daily Telegraph. 15 August 2012. http://www.telegraph.co.uk/health/healthnews/9477645/Whistleblowing-nurse-forced-out-after-airing-concerns.html
2 Department of Health. NHS Constitution updated. 8 March 2012. http://www.dh.gov.uk/health/2012/03/nhs-constitution-updated/