Some life experiences such as the death of a loved one or divorce are considered so traumatic that they can easily affect our mental health. But from our experience in supporting members going through investigative procedures, we know that many doctors would place the prospect of an investigation by the GMC near the top of their list of stressful episodes.
As well as the threat to their career and livelihood, doctors under investigation have often felt the fitness to practise (FTP) process itself was unnecessarily protracted, unfairly punitive and distressing. For a few, particularly those with existing health concerns, the pressure has tragically proved too much to bear.
To the GMC's credit, it has acknowledged the impact that an investigation can have and is trying to make the process more compassionate for doctors. As the GMC's assistant director of policy, business transformation and safeguarding, Anna Rowland is responsible for improving its fitness to practise process.
'One of the areas we have focused on since 2010 has been to try to minimise the impact of an investigation on doctors while maintaining robust patient protection,' she explains.' As part of my role, I speak to doctors who have been investigated and to patients who have been harmed and their families.
'Investigations place doctors and patients under a great deal of stress, and we keep them in mind when thinking about changes to the process. The teams I lead, and the GMC more widely, have been working on a number of projects to reduce the impact on doctors.'
Taken together, the projects and the reforms they are introducing are intended to ensure that the FTP process is used proportionately, investigations are completed as quickly as possible, and that more support is available to doctors during an investigation.
An early success has been the use of 'provisional enquiries' to gather additional information before the GMC decides whether a full investigation is necessary. 'While we are working hard to reduce the stress of investigations and speed them up, being investigated is still likely to cause stress so making sure we only open an investigation where necessary is one of the most important changes currently underway,' says Anna.
'The number of full investigations opened in 2016 was far fewer than in 2015 as a result of our use of provisional enquiries. We're now piloting the use of these where doctors are alleged to have made a one-off clinical mistake and we're also about to pilot their use where a concern has been raised about a doctor's health. We expect that this will reduce the number of investigations involving health, as well as making them much quicker.'
The GMC is also piloting requiring healthcare organisations and employers to use a new referral form when they raise concerns, to provide fuller information for the GMC to make an informed assessment at an early stage.
Anna emphasises that when making a referral, employers have to sign a declaration confirming they have taken steps to make sure it is accurate and fair, as well as tell the GMC if the doctor has ever raised patient safety concerns.
'Where a referred doctor has previously raised patient safety concerns locally we take steps to seek evidence that is independent of the views of the organisation about which the doctor raised concerns,' she says. 'These measures were put in place following an independent review by Sir Anthony Hooper, to ensure fitness to practise referrals are not used to victimise whistleblowers.'
And where possible, the GMC seeks to avoid the need for a hearing by the Medical Practitioners Tribunal Service. As Anna explains, 'At the end of some investigations - where we think a concern might be serious enough for a referral to a hearing but where the doctor may have information that could reduce our concern - we will meet with them before deciding if a hearing is necessary. In most cases where these meetings take place, providing there's no patient safety or wider public interest concerns, a tribunal is avoided.'
The number of full investigations opened in 2016 was far fewer than in 2015 as a result of our use of provisional enquiries.
Stress and support
As well as trying to reduce the number of full investigations and hearings, the GMC has been working to reduce the stress involved following the proposals developed last year with mental health expert Professor Louis Appleby.
Among the most vulnerable doctors are those with existing health concerns such as mental health problems or addiction. Measures to help this group include the creation of a trained and dedicated team to support cases which involve a doctor's health, while all teams have received training on how to spot the signs a doctor may need support. Anna says the GMC is improving the tone and content of letters sent to doctors who are known to be unwell, clearly setting out key steps of the process and the support available.
And there is now a single point of contact for doctors with health concerns, in relation to FTP matters, as well as an option to pause an investigation so they can seek health treatment without being regularly contacted by the GMC, provided any risk is being properly managed.
Anna believes this approach is helping to bring about real change. 'We get much more contact from this group of doctors since we introduced a single point of contact than previously, suggesting that having a dedicated, named person is allowing us to build trust.'
Of course, every doctor who goes through the fitness to practise process finds it a gruelling experience. The MDU's team of medico-legal experts are often the first port of call for members needing advice and support when going through the process, but what about those doctors not represented by a defence organisation like the MDU?
In recognition of this, the GMC funds a free Doctor Support Service which is independently run by the BMA and provides confidential emotional support from fellow doctors although not medical or legal advice. 'We know doctors find it beneficial to have someone to talk to who understands the profession and is not part of the process,' comments Anna.
'For any doctor that is now referred for investigation,' Anna continues, 'we have worked really hard on the tone of all our correspondence and we offer free support throughout the process.' She mentions the dedicated support now offered at the hearing centre, which is particularly important for unrepresented doctors who are unable to call on the expertise and support of a trained medico-legal adviser, and Anna reports 'very positive responses' from doctors who have used the service.
Inevitably, reforms to the fitness to practise process remain a work in progress and the GMC continues to evaluate the success of different initiatives. 'We're currently evaluating the impact of our pilot of early stage enquiries for cases involving an alleged one-off clinical mistake,' says Anna. 'We'll be providing further details on this as soon as we're able to in our 'GMC news for doctors' bulletin. And we publish the data we hold on complaints and investigations every year in our State of Medical Education and Practice in the UK report, so we can demonstrate how the changes we're making are having an impact.'
Legislation and limits
But there are also limits to what the GMC can do, as Anna explains. 'Currently, the Medical Act requires us to formally investigate any allegation of impaired fitness to practise. It also sets out the specific steps that must be carried out during an investigation. Even when there are no complications, completing the process required by the legislation takes at least six months.
'There are many cases we are currently required to investigate that could be managed locally, particularly where local restrictions are needed. We need a change to the law to allow more discretion and flexibility.'
In the meantime, the GMC is trying to engage more with all doctors and communicate more clearly about how it regulates the profession. 'We want all doctors to know the facts about fitness to practise rather than the rumours,' says Anna.
'Around 72 doctors are struck off the medical register per year - out of more than 270,000 doctors registered to practise in the UK. However, I get a sense from meeting doctors, from our liaison teams across the UK and from social media, that many doctors perceive this number to be much higher.
'I think that causes fear, when the reality is that the overwhelming majority of doctors are good doctors, and they have nothing to worry about. We know that a good doctor can make a mistake and, if a doctor has insight and takes steps to avoid recurrence, a one-off mistake is very unlikely to lead to GMC action.'
Doctors can find out more about the fitness to practise process on the GMC blog or share comments using #GMCexplained.
Interview by Susan Field
Assistant director of policy, business transformation and safeguarding, GMC
Anna Rowland joined the GMC in 2008 and is responsible for its fitness to practise reform and business transformation programme. Her background is in policy, regulation and business transformation. She previously worked in law after qualifying as a solicitor, and held legal policy and regulatory affairs roles at the Law Society.
See more by Anna Rowland