DOCTORS SUICIDES-REPORT 1
Doctors who commit suicide while under GMC fitness to practise investigation
Internal review
Sarndrah Horsfall, Independent Consultant
14 December 2014
Executive summary
Introduction
This report was commissioned by the GMC to review those cases where doctors have committed suicide while under the fitness to practise procedures between 2005 (when the GMC introduced electronic data systems) and 2013. The aim was to establish whether the GMC’s processes could be improved to reduce the impact on vulnerable doctors and whether there is more the GMC can do to prevent these tragedies from occurring. The report addresses lessons that can be learnt from these deaths, as well as any changes the GMC could make in the way it handles vulnerable doctors.
During the period under review there were 28 reported cases in the GMC’s records where a doctor committed suicide or suspected suicide while under their investigation procedures.
The case reviews showed that many of the doctors who committed suicide suffered from a recognised mental disorder, most commonly depressive illness, bipolar disorder and personality disorder. A number also had drug and/or alcohol addictions. Other factors that may have contributed to their deaths included marriage breakdown, financial hardship, the involvement of the police and the impact of the GMC investigation.
Case reviews
The review identified 114 doctors that had died during 2005 and 2013 inclusive and had an open and disclosed GMC case at the time of death.
An assessment was then undertaken of each case to ascertain the cause of death against case definitions of suicide and suspected suicide.
24 cases were classified as ‘suicide’ and 4 as ‘suspected suicide’. The total cases under review are 28.
The review also included an overview of the GMC fitness to practise policy and process as well as interviews with GMC staff and associates and external stakeholders.
Recommendations
Recommendations for current GMC practice:
Doctors under investigation should feel they are treated as ‘innocent until proven guilty’
Reduce the number of health examiners’ reports required for health assessments
Appoint a senior medical officer within the GMC to be responsible for overseeing health cases
Introduce case conferencing for all health and performance cases
Set out pre-qualification criteria for referrals from NHS providers and independent employers
Make emotional resilience training an integral part of the medical curriculum
Expose GMC investigation staff to frontline clinical practice
Develop a GMC employee training package to increase staff awareness of mental health issues.
Recommendations for GMC stakeholders:
Establish a National Support Service (NSS) for doctors
Doctors who commit suicide while under GMC fitness to practise investigation
Introduction
The GMC commissioned this independent report to review cases where doctors have committed suicide while involved with its fitness to practise procedures between 2005 and 2013.
The report considers whether the GMC’s processes or procedures could be improved to reduce the impact on vulnerable doctors and whether there is more the GMC can do to prevent these tragedies occurring.
Within this context it is important to understand the GMC’s role and procedures and the legal framework within which it operates.
The GMC
The GMC is an independent organisation, established by UK statute. Its purpose is to protect, promote and maintain the health and safety of the public by ensuring proper standards in the practice of medicine. Under the Medical Act 1983 the GMC has four main functions:
a) Keeping up-to-date registers of qualified doctors
b) Fostering good medical practice
c) Promoting high standards of medical education
d) Dealing firmly and fairly with doctors whose fitness to practise is in doubt.
The GMC defines the knowledge, experience and behaviours that are required of doctors. It decides which doctors are qualified to work in the UK.
The GMC also oversees doctors’ training and education and makes sure that they continue to meet these standards throughout their careers and that they are supported in doing so. The GMC looks into concerns about doctors and is charged with taking firm but fair action where the safety of patients or the reputation of the medical profession is at stake. It is committed to the idea that every patient should expect a high standard of care and that its role is not just about minimum standards but also includes improving the standards of medical practice across the UK.
The GMC fitness to practise process
When the GMC receives a complaint an initial assessment is carried out to decide if, on the face of it, the matter raises questions about the doctor’s fitness to practise and if the GMC needs to investigate. The complainant, the doctor and the doctor’s employer(s) are notified of an investigation.
Where a doctor is not managing his or her health adequately and it is judged that there is a risk to patient safety, the GMC will normally order an assessment of the doctor’s health. This is carried out by two independent doctors (known as health examiners) appointed by the GMC. Where there is an immediate concern about patient safety or public confidence in doctors, the case may be referred for a hearing by a Medical Practitioners Tribunal Service (MPTS) Interim Orders Panel. The Interim Orders Panel carries out a risk assessment based on the available information and can restrict the doctor’s practice or temporarily suspend them from the register while the GMC investigates.
Once the GMC has completed its investigation two decision-makers (known as case examiners) decide what should happen next. The case examiners, who work in pairs, one medical and one lay, consider the health assessment reports to determine the extent to which any health concerns may impact on the doctor’s fitness to practise and whether they are safe to continue to practise with or without restrictions. The case examiners may close the case with no further action, give the doctor advice, issue a warning, agree with the doctor that restrictions are placed on their practice (called undertakings) or refer the case to a hearing of the MPTS. In most cases where action is required, the case examiners agree with the doctor that restrictions are placed on their practice. A case involving ill health would only usually be referred to a hearing if it also involved other serious concerns such as misconduct or because it has not been possible to reach agreement with a doctor about restrictions on their practice.
MPTS FITNESS TO PRACTICE HEARINGS
If the matter is referred to a hearing, the MPTS may also request a health assessment if this has not been carried out during the investigation. At the end of a hearing, the MPTS panel may close the case with no action, issue a warning to the doctor, place restrictions on the doctor’s registration (when these are imposed by a panel they are called conditions), or suspend or erase the doctor from the medical register. If the concerns relate solely to the doctor’s health, and not to performance or misconduct, then a panel cannot remove a doctor from the register.
Although MPTS hearings are generally held in public, matters relating to a doctor’s health are considered in private session. Outcomes of hearings where doctors are found to have impaired fitness to practise are published against the doctors’ names on the online medical register and any warnings remain in force for five years. However, any matters relating to a doctor’s health are treated as confidential and are not published or disclosed by the GMC or the MPTS.
After a case is concluded
The GMC monitors the progress of any doctor who is subject to GMC restrictions or has been suspended from the register. A dedicated GMC caseworker is allocated to each doctor to ensure appropriate management. As part of this process, the GMC will receive reports from a number of people working with the doctor, including a medical expert who acts as a medical supervisor for the doctor, someone in the doctor’s place of work, their occupational health physician if they have one, their treating doctors, their clinical supervisor and their Responsible Officer. If the doctor has been assigned a mentor, this relationship is considered to be a confidential source of support and there is no requirement to provide a report on matters discussed to the GMC. These progress reports help the GMC decide when the doctor may be ready to return to unrestricted practice and GMC restrictions removed. Restrictions may also be varied to reflect improvements in the doctor’s health.
Voluntary erasure
Where concerns relate solely to a doctor’s health, the GMC will usually grant a request from a doctor to have their name removed voluntarily from the medical register (called voluntary erasure) without concluding the fitness to practise proceedings, as long as to do so would not undermine public confidence in the profession. This principle applies at any stage of the fitness to practise investigation and hearings process.
In cases involving health and other issues such as performance and/or misconduct, GMC decision-makers weigh up the seriousness of any underlying health condition, the impact on the doctor’s ability to instruct legal representatives, the likelihood of recovery and the impact on public confidence in deciding whether to grant a doctor’s request to have their name removed from the register without concluding the fitness to practise proceedings.
Doctors and suicide
Doctors and mental illness
A wealth of research suggests that doctors have higher rates of mental health problems, including depression, anxiety, substance misuse and ‘burn-out’1,2, compared to other occupational groups.
UK studies suggest that between 10% and 20% of doctors become depressed at some point in their career.3,4
In a 2011 review of literature on the mental health of doctors the authors state that doctors may be slow to seek help or indeed may not seek help at all, perceiving it as a sign of weakness.5 For instance:
- Many are clearly concerned about the implications of disclosing an illness, particularly where illegal or stigmatised activities such as substance misuse or alcohol are involved.
- Some worry that occupational health departments may not be independent of employer interests; others are understandably anxious to avoid a threat to their registration or employment.
- Even when doctors do disclose health problems, these often take the form of informal discussions with colleagues rather than formal consultations.6
Suicide and doctors
A number of studies point to a higher rate of suicide among doctors compared to the general population. One US study suggests the overall suicide rate among doctors is between 28 and 40 per 100,000, compared to 12.3 per 100,0007 in the general population. An examination of suicides in England and Wales between 2001 and 2005 showed that health professionals (not exclusively doctors) had among the highest suicide rates for both men and women.8 In a different US study the rate for female doctors was 2.5-4 times that of women in the general population.9 Certain medical specialties, such as psychiatry, appear to have higher rates of suicide than others. Others, such as paediatricians, have relatively low rates.10
An Australian study into doctors’ mental health in 2013 reported higher rates of general distress and suicidal ideation than the general population11. Female doctors were at greater risk for both depression and suicidal ideation than male doctors.
In a survey of almost 8,000 US surgeons 30% of the sample screened positive for symptoms of depression, with rates of depression increasing as workload (and in particular night work) increased.12 In a follow-up article the authors noted that as many as one in 16 (6.3%) had experienced suicidal thoughts in the previous year yet only 26% of those were seeking professional help. Making a medical error was significantly associated with suicidal thoughts.13
Risk factors for suicide
In the general population when someone is diagnosed with a mental health condition they are at particular risk if support is not sought or provided by qualified experts. 90% of suicide victims suffer from a psychiatric disorder at the time of their death14 and this is often compounded by other risk factors. Unsuccessful suicide attempts are an indication of risk. Approximately 20% of survivors of unsuccessful suicide attempts will attempt harm within a year and as a group they are twice as likely to succeed in committing suicide compared with those who have never attempted to take their own life.15
The risk factors for suicide among health professionals, including doctors, are similar to those found in the general population.16 However, there are some additional risks among doctors such as their unwillingness to seek timely help, access to potent drugs and the skills to self-medicate.17 Other risk factors include exclusion from work, poor support networks, ongoing investigations, complaints, court cases and inquests18 and multiple jeopardy from having a complaint considered by a range of bodies including employers and the GMC.19
A UK study analysed 38 doctors’ suicides over a three-year period20 and found that most were suffering from a psychiatric disorder at the time of their death, with depression the most common diagnosis. Five had co-morbid psychiatric disorders, typically substance misuse. Eight had primary or secondary diagnoses of alcohol and/or drug abuse, all of several years’ duration. Only two doctors had taken voluntary leave from work because of their mental health problems.
Depression: Rates of depression among training grade doctors in their first internships in the US have been reported to be 27%21 and 30%.22 A Canadian study showed that 23% of over 1,800 doctors had significant depressive symptoms, with female doctors twice as likely to be depressed.23 A New Zealand analysis has suggested that mental health problems are nearly three times as prevalent in general practitioners than in the general population,24 and another New Zealand study of hospital doctors found that 29% of doctors showed psychological distress – higher than in the general population.25
Substance abuse: Recent data suggests that the prevalence of alcohol dependence and illicit drug abuse by doctors is similar to that among the general population, however doctors may be at an increased risk for prescription drugs.26 However, doctors used prescription drugs such as benzodiazepines more frequently,27 presumably because of their relative ease of access. Self-reported drug use surveyed in a large US study28 was most common in emergency medicine doctors (who used more illicit drugs) and psychiatrists (who used more benzodiazepines). Paediatricians had low overall rates of use, as did surgeons. Anesthesiologists had higher rates of use only for major opiates. In a sample of doctors attending the NHS Practitioner Health Programme, a confidential service for doctors and dentists living in London who have mental health and/or addiction concerns, anaesthetists, dentists and emergency medicine doctors were most likely to present with addiction problems.29
Work and home: In a study of 38 doctors who committed suicide in England and Wales between 1991 and 1993, 71% had significant problems at work. Seven were facing complaints and in five cases this appeared to be a key factor leading to suicide. These doctors were also facing other problems at work and at home.30
Many doctors prioritise their work over everything else. It has been suggested this serves the purpose of avoiding intimacy, which may place strain on both personal and working relationships.31 Doctors may also face stigma if they admit they have a mental health problem and are unable to work as a result.32
Personality factors: The high-risk doctor has been described as driven, competitive, compulsive, individualistic, ambitious and often a graduate of a prestigious school.33
The American Medical Association and American Psychiatric Association conducted an extensive study of physician suicide in the 1980s.34 It found that doctors who killed themselves were reported to have fewer friends and acquaintances and were emotionally detached.
A further US study found that physicians were more likely to show traits of dependency, pessimism, passivity and self-doubt.35 Another study highlighted that doctors also tended to be perfectionists.36 Perfectionism may lead to conscientiousness during medical school and to a thorough clinical approach but it may also breed an unforgiving attitude when mistakes inevitably occur.
Involvement with the regulator: Doctors with severe mental health or addiction problems are referred to the GMC. Until recently37 when a doctor was referred to the GMC for investigation they received no support unless they happened to be in a medical specialty that provided this type of support directly.38 Doctors referred to PHP with some form of regulatory involvement ranged from one third of all doctors at the start of the programme in 2008 to less than 10% in 2013. This significant decrease may be attributed to doctors accessing support services before they get to the point where a regulator needs to be involved.39
Often a doctor will be involved in a number of investigation processes at the same time
(multiple jeopardy), with the complaint process being stressful; the nature of multiple investigations including employer disciplinary processes means investigations can take many years, be intimidating and can lead to mental health problems and even suicide. During an investigation doctors could have their professional work dissected by a wide range of bodies, including:
- Employer
- Regulator
- Clinical commissioning group in England
- Criminal Court
- Civil Court
- National ombudsman and other bodies who handle complaints.
Some commentators have described this as ‘death by 1000 arrows’.40 In recent years the GMC has taken steps to help doctors who find themselves in this situation. In January 2012 it launched a website ‘Your Health Matters’ 41 which provides support and information for those who may for health reasons be involved in the GMC's fitness to practise procedures. In May 2012 it also set up a pilot which provides any doctor subject to a GMC investigation with confidential, independent emotional support from another doctor throughout the process. The GMC commissioned the British Medical Association’s Doctors for Doctors Service to provide the support - the pilot is still running and an independent evaluation of the service is due to be published before the end of 2014.
Complaints against doctors: Research published in New Zealand in 200442 looked at the immediate* and long-term† impact on doctors who receive patient complaints. Of the 221 doctors who had received a medical complaint, the immediate impact revealed:
Specific risk factors are discussed in more detail below:
- 72.5% of respondents expressed feelings of anger
- 65.1% felt depressed
- 38.4% indicated they had reduced levels of enjoyment in practising medicine
- 36.4% had feelings of guilt and being shamed.
Longer term, 36.6% of respondents continued to have feelings of anger. Feelings of depression, guilt, shame, and loss of enjoyment in being a doctor fell to around 10%.
*first few days, and up to six weeks, after receiving a complaint
†After a six-week period
Review
The review used three sources of information: a desk-based case review of doctors who had committed suicide while going through the GMC process; an examination of the GMC processes; and interviews with GMC staff and associates as well as external stakeholders who have an interest in this area.
Case review methodology
A desk-based case review was undertaken of doctors who had died during the years 2005 to 2013 where those doctors were known to have had open GMC cases at the time of their death. The aim was to identify those deaths that were considered to have been due to suicide or suspected suicide using a specific case definition approach (see below). Following the initial review those cases were subsequently reviewed by a medically qualified GMC staff member (a GMC Employee Liaison Adviser*).
The identified suicide cases were then subject to a more in-depth review of the records held by the GMC to identify specific demographic, case investigation and death related characteristics and factors.
Data sources used included GMC ‘Siebel’ management information system, GMC Livelink document storage systems, FOI requests, GMC investigations teams, GMC case note archives (cases prior to 2006), death certificates from the General Register Office, Google search terms (doctor’s name, death, coroner, inquest, obituary, BMJ).
Methodological issues
Research involving deaths from suicide can be methodologically difficult because of acknowledged limitations in the recording and coding of such deaths. The use of open, misadventure, accidental and, increasingly, narrative verdicts by coroners where some doubt exists on suicidal intent can lead to under-recording of cases. The use of a specific case definition in a study that accepts the use of multiple sources of data rather than relying solely on coroner verdicts can potentially minimise the risk of under-recording. This helps ensure consistency and comprehensiveness of ‘case’ capture.
*
Conflicts of interest: The reviewer was involved in advising and supporting the doctor’s MD / RO in three cases in his role as GMC ELA.
A desk-based review of cases also has its own limitations as important data may not have been collected previously within the information systems being used eg full reports of coroners’ inquests, views of family, colleagues, death certificate copies not being present.
Given the sensitivity involved in publishing information relating to suicides and suspected suicides, efforts have been made to try to avoid identifying specific doctors within the data analysis to protect deceased doctors, their families, friends and colleagues.
Case definition of suicide:
An open GMC fitness to practise (FTP) case at the time of death where death occurred during 2005 – 2013 and where doctor disclosure of the case had occurred
AND
Death certificate / coroner report confirmation of cause of death = suicide / open / narrative verdict suggesting intent
OR
Reputable source of information (GP / treating psychiatrist / immediate family member / medical defence organisation / police / employer) raising strong possibility of death by suicide
OR
Multiple media references to the strong possibility of suicidal intent
Case definition of suspected suicide:
An open GMC fitness to practise case at the time of death where death occurred during 2005 – 2013 and where doctor disclosure of the case had occurred
AND
Death certificate / coroner report confirmation of cause of death = misadventure or accidental verdict but significant concerns raised about suicidal intent by one other party
OR
Awaiting inquest and death certification but reasonable evidence of suicidal ideation prior to death
Data capture
The following data ware captured for those cases that met the definition of suicide or suspected suicide.
Doctor information
Name / GMC UID / Age at death / Gender / Marital status / Employment status at death / UKPMQ / CCT Specialty / Training status
GMC investigation related
Case Reference / Date case opened* / Date case closed† / Date of removal from register / Referral source / Investigation stage at death / No of days in GMC investigation / GMC registration status at death / Health allegation / Performance allegation / Conduct allegation / Fraud or criminal allegation / Ongoing police or NHS Counter Fraud investigation at death / Ongoing National Clinical Assessment Service assessment where known / GMC health assessment or medical supervision / Date of most recent GMC health assessment or medical supervision / Most recent health assessment or medical supervision outcome / Health assessment or medical supervisor diagnosis / Whether GMC staff or medical supervisors had concerns over suicide risk / Doctor accessed other support services where known /Current medical care / Previous known self-harm attempt
*Date of earliest case opened eg date of initial referral case opened that was closed subject to being transferred to a new case review case.
†Date that last case closed ie may be unrelated to original case opened.
Death-related information
Date of death / Country of death / Cause of death / Additional details on cause of death / Suicide method known / Death certificate available / Coroner inquest held / Coroner details / Coroner verdict
Other information
GMC Serious Event Report conducted
Results
The case review identified 114 doctors who had died during 2005 – 2013 inclusive and had an open and disclosed GMC case at the time of death.
Having applied the case definition, 24 were classified as ‘suicide’ and 4 as
‘suspected suicide’ ie a total of 28. The following analysis has been applied to all these 28 cases treated as a single group.
Doctor Characteristics
(NB: percentage totals do not necessarily add to 100% due to rounding)
CASE DEFINITION
SUICIDE 24 86%
SUSPECTED SUICIDE 4 14%
28 100%
GENDER
MALE 20 71%
FEMALE 8 29%
28 100%
AGE GROUP ATT DEATH
Age group (at death)
Under 30 1 4%
30-39 10 36%
40-49 7 25%
50-59 7 25%
60-69 1 4%
70+ 2 7%
Total 28 100%
Marital status
Married/Partnered 13 46%
Single 10 36%
Unknown 5 18%
Total 28 100%
PMQ
UK 22 79%
OTHER 6 21%
28 100%
EMPLOYMENT STATUS at Death
Employed (including self-employed) 15 54%
Unemployed 6 21%
Retired 1 4%
Unknown 6 21%
Total 28 100%
SPECIALITY
GP 9 32%
SPECIALIST 9 32%
NEITHER GP OR SPECIALIST 10 36%
Total 28 100%
TRAINEEE STATUS
Trainee 2 7%
OTHER 26 93%
28 100%
Investigation Related Characteristics
CASE REFERRED BY
Employer 15 54%
Police 4 14%
Self-Referral 3 11%
Complaint 2 7%
Other 4 14%
Total 28 100%
Length of GMC investigation at death
Under 1 month 2 7%
1-3 months 5 18%
4-6 months 3 11%
7-12 months 5 18%
1-2 years 4 14%
2-5 years 5 18%
Over 5 years 4 14%
Total 28 100%
Concerns Investigated
Health Performance Conduct Police/fraud
YES 20 (71%) 4 (14%) 16 (57%) 11 (39%)
NO 8 (29%) 24 (86%) 12 (43%) 17 (61%)
Total 28 28 28 28
YEAR OF DEATH
2005 4 14%
2006 3 11%
2007 1 4%
2008 1 4%
2009 1 4%
2010 2 7%
2011 3 11%
2012 4 14%
2013 9 32%
Total 28 100%
Place of Death
UK 26 93%
Other 2 7%
Total 28 100%
Suicide Method
Self-injury 10 36%
Self Poisoning 11 39%
Both 3 11%
Unknown 4 14%
Total 28 100%
Of the 11 doctors that took their own lives through self-poisoning, three (27%) are suspected to have obtained the drugs through their workplace and five (45%) used medication prescribed for them.
Coroner’s inquest held
YES 22 79%
OTHER 6 21%
28 100%
Of the 22 inquests known to have been held, the verdict was suicide in 19 cases (86%), misadventure in one case (5%) and a narrative verdict in one other (5%). The outcome from one inquest is not known.
Other Characteristics
GMC management review
It is current GMC practice for a senior manager to review all known or suspected suicide cases through a formal significant enquiry report (SER). All SERs are reported formally to Directors of the GMC on completion to ensure all lessons have been learnt and appropriate management actions implemented. Prior to 2007 some cases would have been reviewed by the investigation officer and their manager to identify relevant issues.
SER DONE 13 46%
CASE REEVIEW 5 18%
AWAITING SER COMPLETION 2 7%
NO REVIEWRECORDED 8 29%
Total 28 100%
GMC fitness to practise process
An overview of the GMC fitness to practise process was undertaken to understand and assess how these cases were dealt with at the time and identify any areas of improvement.
Interviews
A number of GMC staff and associates involved in the GMC investigation process were asked to provide input into the review:
GMC medical and lay case examiners
Medical supervisors
Other GMC fitness to practise staff.
The review also sought the views of a wide range of external stakeholders, including:
- BMA Doctors for Doctors support services
- Practitioner Health Programme (PHP), London
- Royal College of General Practitioners
- Royal College of Psychiatrists
- The Sick Doctors Trust
- The Royal Medical Benevolent Fund
- Connecting with People
- Medical Protection Society
- NHS Clinical Leaders Network
- Patients First
- South London & Maudsley NHS Foundation Trust
Review findings: interviews with staff and key stakeholders
Following the case reviews a number of GMC staff and associates and key stakeholders, including doctors who had been subject to the GMC’s investigations, provided feedback on the fitness to practise process. A range of concerns were raised that require further consideration. These include:
- GMC’s fitness to practise process
- Communication from the GMC
- Timeframes
- Undertakings
- Contributory factors leading to a referral to fitness to practise Medical supervisors
- Health examiners
- GMC medical structure
- Local procedures
- Support services for doctors
- Transition from medical school to the foundation programme
1. GMC’s fitness to practise process
The GMC’s fitness to practise (FTP) process is well defined and has undergone significant improvements over the past few years. In particular the GMC has looked at the way it corresponds with doctors and others and has sought to reduce legal language and references and to be more sensitive in the way it words its letters. However, the responses of external agencies and those outside the organisation suggest that many still believe the GMC is a ‘process’ driven organisation focused on protecting the public and that the doctor can become marginalised with little interpersonal communication, support or compassion.
The administrative processes for dealing with a fitness to practise case are clearly defined. However, external commentators argue that because the system has been developed with a very specific structure and set of legal parameters, it at times lacks the flexibility to accommodate the circumstances of an individual case. The chart below outlines the current process.
There is also concern that once a case has been deemed to merit further investigation there is no way of stopping or shortening the enquiry period. One commentator described it as ‘one size fits all [process] and once you are under investigation you need to endure the full timeframe determined by the GMC’. A process is needed that accommodates cases that do not need the full weight of the GMC FTP structure and can be expedited more promptly.
Many commented that the fitness to practise process creates an environment of uncertainty and makes doctors feel that they are judged ‘guilty until proven innocent’.
The impact of the legal demands of the process can be considerable. For example, during one investigation a doctor was unable to attend the Interim Orders Panel (IOP) because they were in hospital. The IOP carries out a risk assessment based on the available information and can restrict a doctor’s practice or suspend them from the register on a temporary basis while the GMC investigates.
The GMC is legally required to inform the doctor of what it is doing, and in this case went to some lengths, including couriering a letter to the hospital inviting the doctor to attend the panel. An email from the GMC to the doctor’s treating psychiatrist said: ‘I would
therefore be grateful if you could confirm whether you would be willing to pass a copy of a letter regarding the hearing to Dr X, confirming in writing that this has taken place’. While it is extremely important to ensure a doctor is notified of an IOP and is given every opportunity to attend if they are able, this does appear to be a very rigid process.
One medical supervisor wrote to the GMC after the doctor under their care died saying:
‘The present arrangement discourages doctors from coming forward for treatment of mental health issues. The GMC health procedures put doctors under additional strain whilst unwell, and the delays in GMC procedures prevent their return to work at the time appropriate for their successful rehabilitation’. Another supervisor caring for a doctor who was in difficulties wrote requesting ‘that the GMC reopen discussions with a view to developing a positive and supportive approach to the mental health of doctors’.
2. Communication from the GMC
As each part of the process was completed, documentation was generated and issued to the doctor and all other relevant parties. This meant that the doctor often received multiple correspondence dated at the same time or within a matter of days.
In one instance, a doctor received multiple letters, all marked with the same date, and in another case a doctor received five letters over a four-day period from the GMC’s investigation team. This can obviously create further stress and confusion. While it may be difficult to streamline and coordinate every piece of documentation, the GMC has an obligation to help the doctor understand the information it issues and to be sensitive about when letters are despatched.
In other case reviews, doctors received no notification from the GMC over a significant period and felt excluded from the investigation and did not receive any support during the delayed period of communication.
In one case the coroner asked the GMC to comment on a note in which the doctor said: ‘I am extremely stressed and cannot carry on like this. I hold the G.M.C. responsible for making my condition worse with no offer of help’.
In a paper published in 2014 You feel you’ve been bad, not ill43 researchers explored the views of sick doctors about the GMC process and their perception of its impact on return to work. Many participants described their interactions with the GMC as stressful and confusing. They highlighted what they saw as the ‘accusatory’ tone and legal jargon in GMC correspondence, which they found particularly uncomfortable. The length of the process was also considered stressful and some were left confused about whether they could continue to work during the process. On the other hand, many acknowledged that the GMC processes were necessary, particularly in protecting patients, and some felt it had been useful to undergo the GMC assessment and were grateful for the ‘breathing space’ they were given when declared not fit to work.
Several other participants described communication from the GMC as overly negative, accusatory and judgemental; they felt that the GMC implied they were a ‘bad’ doctor rather than an ‘ill’ doctor who might need treatment and support.
While these participants recognised the need for a regulator, they argued that processes employed by the GMC and the communication style used were often distressing, confusing and impacted negatively on their mental health and ability to return to work.
Some of the GMC’s correspondence with the doctors under review reflected these shortcomings. They were clearly written from a legal perspective and did not show compassion nor did they reflect sufficiently the fact that some of these doctors were being assessed under health procedures. In short some of this correspondence did not acknowledge the fact that the doctor was ill or undergoing treatment; it simply outlined the next step of the process and detailed the next course of action.
3. Timeframes
The time taken to complete the initial investigation process and conclude a case can differ significantly from one individual to another. This is due to the nature of an investigation and the wider requirements in completing the case.
While acknowledging that the GMC is not always responsible for delays, for example the GMC usually waits for the outcome of criminal proceedings because prosecuting authorities are reluctant to disclose their evidence until the prosecution process has finished, the case reviews suggest that the length of time the GMC takes to complete investigations causes stress for vulnerable doctors and needs to improve.
Below are two examples:
Example 1:
One doctor who referred a colleague to the GMC for investigation has grave concerns over the timeframe and investigation process. The doctor that was referred subsequently
committed suicide and the referring doctor felt that ‘if the GMC had responded in a more timely fashion the death may have been prevented’.
Example 2:
The GMC overestimated the number of cases that could be heard at an Interim Orders panel sitting. As a result, one case was deferred and allocated a new sitting date. The doctor involved subsequently committed suicide before the new IOP review date and, following the coroner’s inquest, it was noted that one of the contributing factors to the suicide was ‘matter of a regulatory nature’. In a letter to the GMC the doctor who initially referred this doctor commented: ‘We cannot know whether this doctor would be alive today had we not referred them to the GMC, however neither can we exclude that
possibility’.
In both these examples there are a number of contributing factors to the loss of life. But it is evident that the timeframes of an investigation case and the associated stress on a doctor could be one factor.
4. Undertakings
In a number of these cases undertakings imposed by the GMC had perhaps unintended consequences for the doctor and their livelihoods. In some cases medical supervisors requested that the GMC reconsider its position on individual doctors’ undertakings because they felt the recommendations were not appropriate and would be detrimental to the doctor’s rehabilitation. The examples below suggest that the GMC should at least consider carefully any concerns raised by medical supervisors and others involved in a doctor’s care. It is also clear that some stipulations - while quite possibly justified in the circumstances - leave doctors in a position where they can only comply by not working at all.
Example 1:
One medical supervisor was so concerned about the state of the doctor under their care they requested the GMC to remove undertakings and allow the doctor to do some form of work as they were becoming extremely distressed about their financial situation. The GMC response was that the undertakings had recently been reviewed and the doctor would
need to wait until the allocated time for them to be reviewed again.
Example 2:
A medical supervisor wrote to the GMC after the doctor under their care had committed suicide. They said they thought the GMC could have been more supportive and
accommodating about their request for this doctor to do further locum work. ‘This doctor was floundering early on and we (medical supervisor and the GMC) failed to pick up on it and make reasonable adjustments’, they added.
There will always be a tension between the GMC’s obligation to make sure patients are protected and the desire of all parties to see the doctor rehabilitated and back to work as soon as possible. These are complex and difficult decisions and it is easy with the benefit of hindsight to advocate a different approach. There must be a case though for the GMC to ensure it considers carefully, and at an appropriate level, any proposal to amend what it is doing to have less impact on the doctor within its procedures.
5. Contributory factors leading to a referral to fitness to practise
There are many contributory factors that lead to a doctor being considered for a fitness to practise investigation.
The GMC understandably concentrates on areas of impairment and the doctor’s ability to practise medicine safely, and this should be the priority. However, in some instances the wider factors that contributed to a doctor’s referral are not always taken into account. The GMC is concerned about risk and therefore focuses on assessing the symptom rather than understanding the cause.
In each of the reviewed cases there were a number of factors that contributed to the complaints or referrals of the doctor. These factors (not ranked) could include:
- Breakdown of a marriage
- Financial hardship
- Mental health (excluding drugs and alcohol)
- Poor career choice (not suited to being a doctor)
- Occupational
- Legal issues
- Police investigation
- Bereavement
- Workload
It is also clear, as noted earlier, that the GMC referral itself is very often a compounding factor, adding to the stress the doctor is under.
It is not for the GMC to address these wider factors and it has neither the resources nor the expertise to do so. However, it is important that the contributory factors in any fitness to practise investigation case are recognised, that there are services that can help doctors to address the whole range of their circumstances and that the GMC has processes to refer doctors to appropriate services, swiftly and effectively. At present no single organisation or service exists that could fulfil this function.
Although beyond the scope of the review, there is a strong case for establishing a national support organisation (see recommendation 9. National Support Service) to ensure appropriate services and support are made available to doctors in need.
6. Medical supervisors
Medical supervisor
- External specialist medical practitioner – majority are psychiatrists – cannot be the doctor’s treating physician
- An associate contracted by the GMC
- Meets regularly with doctor to discuss progress
- Carries out testing in substance abuse cases, approves posts and prescribing arrangements
- Provides periodic 3-6 monthly reports to the GMC case review team:
- Doctor’s progress and compliance with conditions or undertakings
- Any significant problems
- Advises GMC regarding:
- the doctor’s fitness to practise in general
- any variation to the undertakings
- doctor’s readiness to return to unrestricted practice
In most cases medical supervisors’ recommendations are accepted by the GMC and doctors are often able to return to full practice. However, there are occasions when this does not happen. This is usually because a health examiner (a psychiatrist appointed by the GMC) has taken a different view of the risks involved. Better communication and discussion around each case could help to resolve some of these differences and make agreement about next steps more likely.
There is certainly a feeling among some medical supervisors that their decisions are increasingly being superseded by the health examiner’s reports.
A few medical supervisors also felt their induction with the GMC should include more about the assessment standards required for their supervisory role.
Some medical supervisors also noted that their role can be quite a lonely one. While they do have GMC-organised sessions together and can contact one another, there is no process after a doctor’s suicide for debriefing to reflect on what has happened and consider any lessons for the future.
7. Health examiners
- Health examiner
- Two external medical specialists for each fitness to practise case to assess risks relating to health issues (psychiatrist, if relates to mental health issues)
- An associate contracted by the GMC
- Liaise with the GMC health and performance assessment team regarding the health assessment
- Conduct health assessments (may include physical assessment/mini-mental test/chemical testing where concerns relate to substance misuse)
- Provide reports to the GMC HPA team for use by the investigation or case review team:
- diagnosis (ICD10 / DSM4)
- doctor’s insight into condition
- whether doctor is fit to practise generally, on a limited basis, or not at all
- recommendations about management of case
As part of the investigation process, the GMC requires a doctor with health concerns to be assessed by two GMC health examiners (psychiatrists) who provide independent reports on the doctor and submit their assessment as to whether the doctor is fit to practise. As part of this process the GMC asks the health examiners to address specific questions and these form part of the report.
A number of external stakeholders as well as doctors who have undergone a fitness to practise investigation expressed concerns about areas of this process, including:
1. There is an expectation that the doctor referred to the GMC health procedures should disclose all their medical records, including GP records and any relevant hospital records. While a doctor can choose to withhold their records, this may have a negative impact on the outcome of their case. This information can, and often does, involve personal data, such as sexuality, past psychiatric history, history of abuse in childhood or later as a victim of domestic violence, and third party information about family members, and covers the whole of the doctors’ life.
2. Where there is a prospect of the doctor’s fitness to practise being judged to be impaired, the case will be referred to an MPTS panel. This panel is expected to hear confidential health information and make a judgment based on this information and reports from treating psychiatrists. The panel will be presented with any information that the GMC considers relevant although any information about a doctor’s health is discussed in private and no health information is placed in the public domain. The panel consists of both medical and lay members and has a legal assessor who sits with each panel. Some doctors feel they lose their right to medical confidentiality as a result and that their medical details should only be made available to those within the medical profession.
It is important to note that both lay and medical members of the MPTS panel are bound by confidentiality when hearing information about doctors who are referred to them. It is also clear that the GMC must operate within pre-determined legal parameters which are necessarily complicated and may appear at times both rigid and impersonal. However, the views and comments raised independently by stakeholders are important and should be given due consideration.
The GMC continually refines specific areas of its fitness to practise procedures. It has also tackled the criticism that some health examiner reports failed to express an opinion on whether the doctor was fit to practise or whether supervision was appropriate. As a result the GMC has introduced more explicit guidelines to assist health examiners in completing their assessment reports.
A number of GMC case examiners and medical supervisors have questioned the quality of the health examiner reports. The GMC is currently undertaking a review of the role of experts and their contribution to investigations and decision-making and this issue should be included within that review.
8. GMC medical structure
At present 10 doctors are employed directly by the GMC as case examiners with a further four doctors as part of the wider GMC staffing. The GMC also has 877 doctors who provide services to the GMC. The GMC has a senior medical adviser who is a member of the senior management team.
More importantly it would appear that there are insufficient practising doctors employed by the GMC to support present caseloads and this is having a direct impact on areas like Health Assessments where there is no opportunity to ensure standards are being maintained in areas like reporting or developing further standards that medical, education or workplace supervisors should adhere to.
The medical supervisors and examiners have commented that they would benefit from a senior medical figure at the GMC who would provide the following:
- Clinical governance
- Quality assurance
- Oversight of the health procedures
- Training and development in best practice.
There is a case for appointing a senior medical officer who would provide strategic guidance on the overall fitness to practise process from a clinical viewpoint.
9. Local procedures
It would appear from the case reviews that a few doctors were referred to the GMC by their employer without going through the employer’s local procedures. It was felt that some doctors therefore missed out on local support services in helping to manage their specific situation and did not have access to the local network to provide an appropriate plan.
There are instances where local organisations provided an excellent support mechanism for doctors when required; this enabled close monitoring and interaction on a regular basis. However, in some instances local organisations for whatever reason referred the doctor to the GMC to resolve. There will be instances when a doctor needs to be automatically referred through to the GMC and it is crucial that both the GMC and local organisations ensure that support arrangements go hand in hand to protect both patients and the doctor concerned.
10. Support services for doctors
Doctors in secondary care can access occupational health services but that can be more difficult in primary care. Support services for doctors do exist around the country but they offer variable services and may only serve a specific geographical area. Many only offer assessment and/or brief psychotherapy (eg Mednet, Doctors for Doctors, House Concern Newcastle), peer support (Doctors’ Support Network, British Doctors and Dentists Group, Sick Doctors Trust), mentoring (Health for Health Practitioners West Midlands) or practical support when going through complaints or disciplinary processes. For instance, many local medical committees offer pastoral support while the GMC offers a support service via BMA Doctors for Doctors (see below).
These services provide a variety of telephone advice, web advice, face-to-face consultation, psychological treatment and advocacy services.
The GMC implemented a pilot support service for doctors undergoing its fitness to practise proceedings in May 2012, provided through the BMA’s Doctors for Doctors support service.44 The doctor ‘supporters’ from the BMA are experienced in providing unbiased peer support to those undergoing a GMC investigation.
Although feedback on this support service has been very positive, some doctors will not always phone the helpline as they are reluctant to disclose highly sensitive information that could have a direct bearing on their career.45
The lack of consistent local support clearly reduces the recovery opportunities for doctors and it is evident from the case reviews that receiving comprehensive support depended on geographical location.
The 2007 White Paper on medical regulation, Trust, Assurance and Safety – the
Regulation of Health Professionals in the 21st Century46, proposed a working group to advise on a national strategy on the health of all health professionals, including doctors. This recommended:
- Rapid access to confidential specialist assessment and treatment (particularly for mental health and addiction problems) to enable sick health practitioners to seek help promptly without fear of stigma or discrimination and minimising any potential impact on quality of care.
- Specialist services staffed by appropriately trained professionals with expertise in treating healthcare professionals with mental health and addiction problems.
The Boorman47 NHS Health and Well-being Review Interim Report in 2009 also examined the support and opportunities that staff need to maintain their own health and wellbeing.
The report recognised the difficulties that clinical staff can face in accessing health care:
‘In this context we are aware that there are very real complexities in dealing with sick doctors and other clinical staff who may be reluctant to admit to serious health problems, such as drug or alcohol addiction, or to seek early advice from occupational health
services. It is important that staff with such problems have sufficient confidence in local services to seek the support that they require; however, we recognise that some cases may raise issues that go beyond the capacity of occupational health units.’
In view of these reports and the increasing numbers of doctors presenting with mental health problems, it was proposed to establish a national health service for (mentally) sick health professionals to ensure that all health professionals had access to specialist health services if their needs could not be met by local services.
The main justifications for a national service were:
- The insight of sick doctors into their condition and the impact that it has upon their performance may be compromised
- Illness in doctors may be poorly managed and appropriate assistance may not be sought for a variety of reasons (including low rates of registration with a general practitioner)
- Doctors may be able to mask their illness from others (perhaps through self-prescription)
- Where illness is recognised to adversely affect performance, there may be a reluctance to refer a doctor into a system that is perceived as ‘disciplinary’ and there is a lack of knowledge about alternatives
- An excessively stressful work environment may have a significant and negative impact on a doctor’s health and wellbeing
- The issue of doctors who become mentally unwell can be especially complex given the relationship doctors have with patients and the requirements of doctors under their GMC responsibilities. This means that expert services should be set up to provide accurate advice, sign posting and liaison with relevant bodies.
- On the basis of these reports, the NHS Practitioner Health Programme (PHP) pilot was established in 2008 with the expectation that if successful it should be rolled out across England; however to date this has not occurred.
Two doctors who committed suicide while under the GMC fitness to practise assessment procedure were in postgraduate training (2/28 7.1%).
Medical schools provide their students with a sound grounding in the knowledge and skills to practise as a doctor. But according to doctors in postgraduate training who the review spoke to they do not always feel they have the appropriate practical training to deal with the transition to a stressful work environment.
Both internal GMC staff and external stakeholders have pointed out that the transition between medical school and the foundation programme can be the point at which warning signs or difficulties arise.
The review has identified a number of contributing factors, which in many circumstances are experienced by junior doctors. They are as follows:
- Clinical responsibilities
- Unrealistic workloads
- Significantly long working hours
- Inadequate staffing levels
- Stressful environment.
A wealth of information and evidence exists about the transition between medical school and medical practice. The GMC explores the issue of preparedness as part of its National Training Survey. It has not been possible to review all of the literature as part of the review but, given the death of two young doctors during the period under study, it is important that the GMC and others look again at what pressures face doctors in the early stage of their career.
It would be helpful to ensure that there is sufficient resilience training or information on how to emotionally handle the transition from student to junior doctor. And to explore the need to help students develop other coping mechanisms to deal with stressful situations and the exacting demands of being a doctor.
Recommendations for current GMC practice
1. GMC investigation process
The GMC needs to create an environment where doctors undergoing a fitness to practise investigation feel they are treated as ‘innocent until proven guilty’ – as with any judicial process. Investigations need to be conducted in a compassionate manner and as quickly and effectively as possible, taking into account legal constraints and the need to protect patients. Perhaps, inevitably, doctors undergoing the process feel that it can stigmatise and often creates a culture of fear and discrimination.
The GMC’s Fitness to Practise team is currently undertaking an internal review to assess the organisation’s processes for triage and streaming of cases. The intention is to establish a new approach that extends the triage process and would only progress those cases that require a full and comprehensive investigation.
Adopting this new practice should alleviate some of the initial pressure and stress that an investigation generates for those complaints that do not meet the threshold for investigation.
It is recommended that the above changes be implemented as soon as practical.
It is also recommended that the fitness to practise process be reviewed from a doctor’s viewpoint (similar to the work already done around complainants and witnesses) to identify aspects of the process that have a direct effect on their wellbeing.
The doctor’s process review would also include minimising and streamlining the timing and quantity of correspondence forwarded to a doctor. It is important that investigation officers are as sensitive as possible when communicating with the affected doctor and that they understand the impact the investigation may have on that individual. At the same time they need to take a proactive approach in compiling and distributing the information that needs to be issued to a doctor rather than relying on a process-generated system that can lead to duplication and confusion.
This approach would include:
- Tailoring correspondence to doctors and including, where applicable, key information they need to understand
- Ensuring that the GMC maintains regular contact with doctors during the investigation process, not only through written correspondence but also by phone, to ensure a more personal approach
- Allowing, and encouraging where appropriate, medical supervisors and case examiners to work more closely and discuss directly any potential changes to a doctor’s undertaking. This would require all recommendations and agreements to be documented
- Promoting closer liaison between medical supervisors and case examiners
- Taking a personalised approach to a case where appropriate. This could include suspending the process if required. For example, where a doctor has been sectioned under the Mental Health Act and clearly is not practising or is unwell, they should not have to respond to an investigation. An interim order may of course be needed to manage any direct risk to patients.
Any doctor referred to the GMC should be considered to be vulnerable and therefore supported and assisted in a compassionate manner. Given the stress of the investigation process, it is possible any doctor could develop mental health problems or an addiction habit as the very nature of the investigation process creates significant stress and mental anguish.
2. Health examiner reports
Serious concerns were raised about the number of health examiners’ reports the GMC requires for health assessment cases.
It is recommended that the GMC consider reducing the number of health examiners’ reports that are required at the beginning and end of a supervisory period where the doctor has been deemed fit to practise by their GMC-appointed medical supervisor. At present there is a statutory requirement for two reports. Having two independent assessments at times creates conflict with the medical supervisors (who feel their recommendation and case knowledge at times are undermined). If there is no agreement on the doctors’ fitness to practise, the GMC will act to protect patient safety by taking the risk-averse option and potentially prolonging the supervisory period, which could prove to be detrimental to the doctor.
Therefore it is also recommended that one report should be required at the beginning of an investigation where the doctor is unwell but already has an agreed diagnosis and is engaging with treatment.
The medical supervisor’s report plus one further independent health examiner’s report should be sufficient at the end of a supervisory period to complete a health assessment case.
Such a change would require a change in legislation. If the GMC still feels there is a need for two independent psychiatric views, then it is strongly recommended that the two psychiatrists commissioned should be required to confer to produce one agreed report based on their independent assessments. This single report would, if possible, include an agreed diagnosis and treatment proposal for the doctor concerned and would outline any areas that the health examiners do not agree on and require further consideration by the GMC.
3. Medical staffing
The GMC should have an appropriate understanding of the medical input that doctors receive when going through the fitness to practise investigations process. In the past there was strong criticism that the process was too medically dominated and that the legal or objective oversight was insufficient. However, those who are involved with doctors who have mental health and related problems argue it is now too heavily weighted towards the legal aspects of the Medical Act. The creation of a senior post within the fitness to practise operation would help to ensure that medical considerations were being taken into account in the investigation process. An executive senior medical director could work alongside existing case examiners to improve areas of the health assessment within the process. At the moment, for instance, there are no standards for psychiatric reports being submitted to the GMC so there could be inconsistencies around diagnosis.
It is recommended that the GMC employ a senior medical officer to oversee aspects of its fitness to practise procedures. The role would include:
- Oversight of the current health procedures, developing opportunities to improve the overall process, reporting and outcomes.
- A professional supervisory role for medical supervisors, medical case examiners and health examiners. Decisions in individual cases would continue to be made by medical case examiners
- Ensuring that training for all roles is reviewed and reshaped to deliver the best outcomes for both the GMC and the doctor being supervised
- Creating regional learning sets for medical supervisors and examiners who could meet regularly to share learning experiences and highlight outstanding issues. The objective is that every doctor under supervision would be discussed in a regular supervision group
- Overseeing meetings to review cases. This would ensure that medical supervisors are engaged on a regular basis and would minimise the perception that they are over-involved with the doctors they are supervising.
4. Case conferences
Case conferences bring the key parties together to agree goals and establish appropriate strategies. They are an efficient and effective case management tool that ensures all parties understand their roles and are committed to achieving agreed outcomes. Case conferences should be a regular part of the investigation process and held at regular intervals.
It is recommended that the GMC adopt case conferencing. This would ensure a more personalised approach to the fitness to practise process for both health and performance cases.
The purpose of case conferencing would be to progress an individual doctor’s investigation by bringing all the necessary parties together. This would include:
- The doctor involved
- Treating medical practitioners
- Work or educational supervisors (where applicable)
- The doctor’s representative or family (if applicable)
- The GMC.
The advantages of a case conferencing approach, particularly for complex cases (including health and performance assessments), include:
- Assessment on how to effectively manage the doctor to ensure any risk factors are mitigated. This would include input from all agreed professional support teams
- All parties are involved in assessing whether the doctor will ever be able to return to the profession. If it is agreed the doctor is competent, then a structured return to work plan and timeline can be developed in conjunction with that individual
- Case conferencing will ensure the doctor has focused involvement from all professionals who can discuss their progress and agree a treatment plan. This will guarantee that all parties’ expectations are maintained and provide for an accurate timeline for treatment. It also creates a positive and open forum for the doctor where there is no preconceived judgement, building a more transparent relationship of openness
- At the moment all data and documentation relating to a doctor’s case are held in the GMC’s data system (Siebel). However, this information must be made accessible online to all professional parties involved in a case to ensure transparency and timely access. At present the GMC sends hard copies of documentation to relevant parties by post but this is not efficient and in many instances prolongs the process. Case conferencing will ensure readily available information is accessible to the relevant participants at any time.
This case conference approach could also reduce the burden of unnecessary paperwork and create a more efficient process. It will enable case examiners to be more fully engaged and for the doctor under investigation to be directly involved in improving their situation.
5. NHS providers and independent employers
It was clear from the review that local NHS Trusts and Boards did not always undertake their own investigations before referring the doctor to the GMC. A number of these cases date back to 2005 when it may be some Trusts and Boards could not provide the support required.
It is recommended that the GMC ensures that local procedures have been exhausted before accepting a referral – unless it meets the required GMC threshold. The GMC introduced employment liaison advisers in 2012 to support employers in monitoring the quality of their medical workforce, advising on fitness to practise thresholds and on revalidation and related matters.
It should continue to increase the support its employment liaison advisors (ELAs) provide to employers and encourage closer working in deciding when a referral should be made to the GMC. In some instances it may be appropriate for the GMC to be listed as a notified party should specific cases need to be referred based on their severity and the fact they are at odds with the GMC’s Good
medical practice guide. In essence having the GMC as a listed party would ensure it is kept fully up to date with progress and any other relevant issues.
It is recommended that NHS England and the Devolved Administrations ensure all NHS Trusts, Boards and associated employing bodies undertake due diligence in relation to medical staff. This will ensure a case is referred once it has engaged the GMC threshold. Currently the GMC ELAs have an established programme of individual meetings with all Trust medical directors to discuss doctors in difficulty and the threshold for formal referral to the GMC, revalidation issues and other matters relating to regulation. In particular where NHS Trusts and Boards have specific cases the GMC could consider allowing greater local handling and remediation without a formal referral to the GMC. The Trust’s medical directors and ELAs would work closely together in managing such cases and could call on the GMC for formal intervention should local handling not prove successful.
6. Medical students
It is extremely important that medical students have not only the clinical skills and knowledge to move from medical school to the Foundation Programme but also have the resilience and coping techniques to help them face difficult circumstances as their careers progress.
It is recommended that:
- The GMC continue to work with medical schools to ensure that emotional resilience training is a regular and integral part of the medical curriculum
- Both medical students and doctors in training have specific training modules in their curriculum that explain the implications should they be subject to a serious complaint and investigation
- The GMC continue to work with medical students and doctors in training to promote its regulatory requirements
- The GMC continue to work with all medical schools to ensure its standpoint on recreational drug use and alcohol is better communicated to students.
- 7. GMC employees
- Most staff employed by the GMC (Fitness to Practise) have never worked in the health industry before joining the GMC and therefore have a limited knowledge or understanding of the day-to-day realities of frontline clinical practice. It would be beneficial for those GMC staff dealing with doctors under investigation to have a grounded understanding of doctors’ daily work environment.
- It is recommended that staff be given the opportunity as part of their personal development plan to spend time in a clinical setting on an ongoing basis.
- The benefits of this are twofold:
- The GMC staff member would have a greater appreciation of the working environment of the doctor, seeing first-hand the pressures and demands from patients, and perhaps have a greater appreciation and empathy when formally communicating on behalf of the GMC.
- The interaction between GMC staff and frontline doctors would help to provide a forum for greater communication and feedback. This in turn would reduce the perception of the GMC as a bureaucratic and uncaring organisation.
8. Workplace health and wellbeing
Given the nature of the fitness to practise work, it has been noted that despite the GMC’s wealth of training and development opportunities, there is an additional need to provide in-depth specific training for those individuals or teams servicing complex cases.
A number of GMC staff had direct contact with the doctors during the investigation process into these cases and were affected by the consequences. It is important that the GMC has the appropriate systems and training in place to support staff in cases that have a tragic consequence.
It is recommended that the GMC implement an employee-training package focused on increasing staff awareness of mental health issues and developing resilience techniques when coping with stress, anxiety or depression.48 It is important that both managers and staff have the appropriate tools, knowledge and mechanisms to discuss and cope with difficult situations.
Recommendation for GMC stakeholders
9. Consideration of National Support Service for Doctors
It is recommended that the Department of Health (England), NHS England and the Devolved Administrations (Wales, Scotland and Northern Ireland) consider making the legislative changes necessary to develop and establish a National Support Service. The service would be managed by a senior medical officer who would assume responsibility for the day-to-day management of doctors with health concerns incorporating the assessment (currently undertaken by the GMC), case management, monitoring, reporting, treatment, and education and prevention elements within a single system. It would be prudent to ensure that all medical students have access to this service. It would be important that the National Support Service refer immediately to the GMC any serious allegations it becomes aware of or persistent failures by a doctor to comply with an agreed treatment plan.
Further details on the benefits and indicative costs have been included in Annex A.
Supporting information
This report has been created based on GMC Siebel data and other information that I believe is reliable and accurate. I do not make any representations or warranties of any kind, express or implied, about the completeness, accuracy and reliability of the information used.
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