Fear is a natural reaction for any doctor notified of a GMC investigation. When an MDU member first contacts the MDU for assistance with a GMC complaint, one of the primary roles of our medico-legal advisers is to put that fear into context and to explain the procedure. We don't underestimate the shock of receiving a letter from the GMC – and many members tell us their first thought is of erasure.
Of course that can happen, but for the majority of doctors subject to a GMC investigation the prospect is remote. GMC fitness to practise (FTP) statistics for 2018 show fewer than 80 erasures. Suspension as an FTP sanction is also, understandably, a concern, and there were 101 suspensions in 2018. However, these outcomes need to be seen against a background of 298,704 doctors on the GMC register in 2018 and 1,402 FTP investigations in that year. Even when facing an investigation, the chances of erasure or suspension are extremely slim.
Most members would not be surprised to learn that the main allegations leading to a sanction of erasure in 2018 were that doctors had not acted 'with honesty and integrity' or that their 'knowledge and experience' were seriously deficient, or there were concerns about 'probity (criminality)'. There is a high threshold for the GMC to refer these doctors to FTP tribunals and the allegations are invariably serious, usually multiple and challenging to remediate.
In most cases, however, when our medico-legal advisers get the details of a GMC complaint from the member, they can see that the case is unlikely to reach the referral threshold. They assist the member in providing a detailed response to ensure the GMC has the information it needs as soon as possible, to provide reassurance that the doctor in question is not a concern and to close the investigation. In some cases they may need to instruct a solicitor, but few members' cases are referred to FTP tribunals.
The fact that our medico-legal advisory and legal teams are so successful in assisting members and ensuring their GMC cases are closed after investigation, and mostly in the early stages, is a tribute to the skill and dedication of my colleagues. It is also a reflection of the way in which the GMC has changed its FTP procedures and its approach to FTP investigations over recent years.
The MDU has always collected data and information about the regulator's procedures and treatment of doctors subject to them and shared it with the GMC in order to assist them to improve the process and the experience. There were times in the past when our feedback was not welcome and we met considerable resistance – for example, when advocating on behalf of members about the distressing impact of the GMC's procedures on doctors under investigation. But that has not been our experience for some time and, while we may still occasionally need to draw a concern on a particular case to the GMC's attention, our contributions are generally sought, considered carefully and taken account of. We believe the GMC now understands the significant impact of its procedures on doctors.
By 2018, of 519 provisional enquiries, 371 cases were closed, sparing those doctors the prolonged distress of a full FTP investigation.
It is clear that our experience is not unique. The GMC actively seeks views from a wide range of experts and interested parties, with the aim of informing itself about the impact of its procedures on registrants and others so it can identify areas of concern and address them. This is then carried through; for example, in improving the time taken to investigate and in doing its best to ameliorate what is always a distressing experience for doctors.
A practical example is the GMC's introduction of preliminary enquiries in 2014. This identifies cases that are unlikely to reach the threshold, even if proven, and tries to secure within a few weeks all the information necessary to reach a decision on the case. By 2018, of 519 provisional enquiries, 371 cases were closed, sparing those doctors the prolonged distress of a full FTP investigation.
We shouldn't and don't take a GMC investigation lightly. It is unlikely ever to be anything but a distressing experience for any doctor, no matter how soon it is over and no matter how well you are assisted by the MDU – and for a few it will end in erasure or suspension. There is definitely room for improvement, and the GMC is as aware of that as we are.
The regulator should be able to reach a decision that protects patients in most cases, even those that look destined to end in erasure or suspension, without an FTP tribunal, but doesn't currently have the legal powers. We are all trying to persuade the government to introduce the legislation it desperately needs to enable the GMC to be more flexible in its procedures, and I urge members to add their voice to this.
None of this answers my question as to whether we should fear the regulator. I can only put the GMC in context and leave it to you to decide. I can observe, however, that too many members tell us they are fearful every day of being in a position where they make a mistake that has unintended but unfortunate or even tragic consequences for the patient, and that this will lead to the unravelling of their career, and possibly loss of liberty, and destruction of many professional and personal relationships.
All doctors may be subject to multiple jeopardy if something goes wrong and can be held to account in many ways – but the GMC is only one of them. There is also the potential for an employer's disciplinary proceeding, an NHS complaint, a civil claim and, depending on the circumstances, an inquest, a police investigation, trial by media and possibly even a public inquiry.
Doctors must be held to account if there are valid reasons to do so, but an assumption of guilt and pointing the finger of blame shouldn't be the starting point.
Given all of this, it is not surprising that doctors are fearful, and the question should really be what are we doing about it? How are we going to turn things around so that doctors don't work in toxic environments and fear making a mistake will be the end of their career, but instead where they are supported when something goes wrong? Where local investigations are fair and aimed at identifying what went wrong, so the organisation can address any problems and improve patient safety. Of course doctors must be held to account if there are valid reasons to do so, but an assumption of guilt and pointing the finger of blame shouldn't be the starting point.
For our part, the MDU does all it can by advising and assisting members when things go wrong. In a wider sense we work with policy makers and individual organisations to persuade or help them to improve the fairness of their procedures. Our members need a sustained and widespread effort from every individual and organisation that has any effect on their practice and control over the resources available to them.
Doctors must have the support they need to do their jobs and to provide the best care they can for their patients. They need to believe they are valued by their employer and, if it is necessary to hold them to account, they must be treated fairly by all who do so. We are a long way from that at present but there is some hope that changes are afoot and that regulators and others whose role it is to investigate when things go wrong are starting to understand that unsafe systems and human factors have a contributory role and to take this into account.
I draw your attention to the recommendations of a new independent report, Caring for doctors, caring for patients, commissioned by the GMC. The report outlines a number of practical steps to improve the working environment and conditions for doctors. It includes a call for action to NHS leaders and others who are able to implement the changes and has the GMC's support.The MDU also pledges to do what we can to help to implement the changes. We must all work towards a culture of compassion because a system generating fear among those we all rely upon to care for us is destructive and damaging to everyone.
Doctors choose medicine as a career intending to help people. Because of the complexity associated with the delivery of healthcare things will continue to go wrong, but we must move away from a persecutory approach when this happens. The system needs fundamental change.