At the end of 2015, Professor Louis Appleby was appointed by the GMC as an independent expert to help identify what changes could be made to improve GMC investigation procedures to help reduce the stress and impact they can have on doctors – particularly those with health concerns.
When the GMC asked me to examine its fitness to practise procedures following a report into suicides by doctors under investigation [PDF], it was the return of an issue that has been with me throughout my career.
When I was a junior doctor, someone who graduated with me from medical school took his own life after a fatal medical error. As a new consultant in psychiatry, based in a university, I found distressed doctors being referred to me because they did not want to be seen in the NHS, out of shame and fear for their careers.
Doctors are high-achieving and perfectionist. We work in a culture where it is hard to admit failure or ask for help.
During my time as national director for mental health a young psychiatrist killed herself and her baby. The inquiry report [PDF] highlighted gaps in the community care she received, not despite the fact she was a doctor but because she was a doctor. I met her husband – he started the meeting by placing a photo of his wife and child on the table beside us, an unforgettable statement about lives needlessly lost.
Future fitness to practise, not punishment for the past
Not one of the country’s 150,000 doctors came into medicine with the aim of harming patients, abusing colleagues or damaging public confidence in the profession. So when it happens, something has changed and any investigation should look for what has gone wrong and how it could be put right. At the heart of the GMC’s role is fitness to practise in the future, not punishment for past mistakes.
Doctors are high-achieving and perfectionist. We work in a culture where it is hard to admit failure or ask for help. We work long hours, lose our work-life balance and cope with stress through anger or alcohol. Recently, hardly a week passes without reports of doctors feeling the pressure or planning to retire or emigrate.
Any investigation should look for what has gone wrong and how it could be put right.
It is into this stressful cocktail that the GMC steps – 2,750 investigations were launched in 2014. In the last few weeks doctors have written to me about the distress an investigation can cause – the tone of correspondence, the delays, the sense of being guilty until proven innocent. For some it may be the last straw: 28 doctors with an open GMC case died by suicide in 2005-13 [PDF].
Doing more to support doctors
The GMC has recognised the problem and is committed to doing more to support doctors who may be vulnerable or at risk, to make the process more compassionate – though its over-riding remit remains the protection of patients. I will look at how mental ill-health is identified, how decisions are made, how letters are worded, how ‘difficult’ behaviour is interpreted. I will explore whether the system could be more consensual and whether all those investigations are needed: only 18% end with a warning or sanction.
It is not only those with explicit mental illness who are at risk: a common feature of suicide is that risk has gone unrecognised. Suicide can occur when problems both in and outside the workplace mount up or when a person feels trapped, humiliated or angry over unjust treatment. Suicide is rarely caused by one thing but when a GMC investigation plays a part, it is a high price to pay for public accountability.
Over the coming months I will oversee a GMC review to revise its way of working and proposals will be put forward in April to make these needless tragedies less likely.
If you’d like to contact Professor Appleby about this review, please write to him at email@example.com.
Louis Appleby is Professor of Psychiatry at the University of Manchester where he leads a group of more than 30 researchers at the Centre for Mental Health and Safety.
Anthony Omo, the GMC’s Director of Fitness to Practise and General Counsel, writes about our work to improve investigations for doctors and patients
Anna Rowland, Assistant Director of Fitness to Practise Policy at the GMC, outlines changes to the way we communicate to better support doctors during FTP processes
Anthony Omo talks about our response to the Hooper Review and the support available for whistleblowers