Professor Louis Appleby talks about his recent work helping to identify what changes could be made to GMC processes to help make investigation procedures more compassionate.
Four months ago I began working with the GMC, reviewing the fitness-to-practise process with the aim of reducing the risk of suicide in doctors facing investigation. During this time many people have written to me about the effect of investigation on their emotional health, sometimes long-term, and on their careers, even when no restrictions were placed on their practice in the end.
I have also met people at all levels in the GMC who recognise this distress and want to make their procedures more compassionate. And I have heard from patients who feel that a process that can be protracted and hard to follow may leave them, as victims and witnesses, just as traumatised as the doctors.
Two principles have guided my approach to this work. First, doctors who are ill need to be treated, not punished – investigation is frequently punitive in effect, even if that is not the intention. Secondly, suicide is not confined to those who are known to be mentally ill – it can be those who are thought to be coping that are most at risk – so reducing risk is a task for the system as a whole.
Doctors who are ill need to be treated, not punished – investigation is frequently punitive in effect, even if that is not the intention.
Detailed proposals have now been drawn up. There should be fewer investigations – the current rate of 2750 per year translates into a 40% chance that doctors will come before the regulator at some time in their careers. Yet only 13% of investigations lead to any sanction – such a low figure does not justify the impact on individuals. Most complaints from patients about a doctor’s performance could be dealt with by the doctor’s employer. Cases in which health is the root of the problem should avoid full investigation whenever possible, moving instead to early treatment. A new senior medical post will help ensure mental health expertise has a stronger influence on these decisions.
Most complaints from patients about a doctor’s performance could be dealt with by the doctor’s employer.
But in all cases, whether or not the doctor is seen as vulnerable, the process should be sensitive. Doctors can be distressed by the tone, timing and frequency of letters – they may become avoidant, reluctant to open letters from the GMC who therefore assume they are not co-operating. In future, one person in the GMC should co-ordinate communication with a doctor and ensure a more personal approach. The extent of scrutiny – contacting past employers, checking case files – should be proportionate to what has gone wrong. Meetings with the doctor should help clarify what will happen next and give the GMC a human face. Agreement should be the preferred outcome.
Employers have a crucial part to play, ending the use of GMC referral to resolve conflicts with medical staff and tackling their high rate of referral of BME doctors.
Not everything that is needed can be brought about by the GMC alone. Employers have a crucial part to play, ending the use of GMC referral to resolve conflicts with medical staff and tackling their high rate of referral of BME doctors. The GMC should fund an expansion in the availability of doctor support services – the 11% who attend tribunals unsupported are a particular concern. The patchy provision nationally for doctors who need treatment for mental illness or addiction should finally be addressed. Comprehensive data on doctor suicides should be routinely collected to feed future improvement.
The GMC can now turn a tragic problem into positive steps that others can follow. It can make mental health safety a thread that runs throughout the organisation, influencing training, standards, leadership & culture. A permanent focus on mental health safety will help doctors who might otherwise be at risk of suicide but it can go further – in time it can extend the potential benefits of these proposals to patients and staff.
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.
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Improving medical education and practice across the UK 
This is long overdue
The GMC has for too long failed to see that patients are not helped by persecuting doctors, and that this failing is aggravated when the doctors themselves may be patients.
The lack of humanity demonstrated by the GMC over the last few decades is shameful
My thanks to those individuals who have worked hard to bring about these changes
Having worked in industry for some time and with experience of disciplinary processes on both NHS and industry, I agree there needs to be a more balanced approach. I suggest a much shorter investigation in the first instance, with a focus on learning and avoidance than punishment.
The current process is too complex, too detailed, not compassionate enough and is frightened of pragmatic decisions. Even in serious cases, the process should be quick, succinct and be on the basis of ‘balance of probability’ and should be handled locally.
Thanks prof. Appleby most welcome. I work with NHS staff and see the results of heavy handed treatment. You are quite right in much of what you say; We would not treat vulnerable patients in this way. Caring for the carers is essential and humane.
Prof Appleby
I totally agree with your views. However when something has gone wrong and you ask the employers what they have done or are going to do about the conduct of their member of staff and are told that they will not discuss the matter with you at all, then you are left with no alternative other than to make a complaint to the GMC in order to be sure that something does happens.
I decided to complain to the GMC and the investigation started over two years ago and they have informed me recently that they may deal with it at a hearing in the autumn. Why the delay.
There is a complete lack of communication between the GMC and the person making the complaint. I have had to constantly email and phone them. I have had numerous case workers. Perhaps retention of staff at GMC is an issue.
The process is far too long for all concerned and needs to be streamlined and shortened.
“And I have heard from patients who feel that a process that can be protracted and hard to follow may leave them, as victims and witnesses, just as traumatised as the doctors”- I love how this comment is just dropped in at the start and then completely ignored for the rest of the article. I can well understand the trauma that many good and moral doctors undergoing GMC investigation may feel. But what about the sheer scale of the trauma, damaged mental health and suffering that poor clinical practice can cause to patients? Or does that not matter since it has not been audited? To blithely conclude that the solution to this is to leave most complaints the doctor’s employer is to completely ignore the purported purpose of the GMC. Either there exists a body there to uphold medical standards and protect patients or there does not.
No evidence yet of any improvement . 4 years of hassle for doing nothing wrong. I wait for any glimmer of improvement but there is none in this utterly dysfunctional organisation. They try to drive even those of us without mental health problems to utter despair. There is no justice no sense no reasonableness no sense of proportion just endless unreasonable dysfunctional rubbish. Retirement or leaving is the only way out clearly of the never ending institutionalised emotional abuse that we are forced to face daily. Clearly the effects of emotional abuse are significant but does the GMC care ? No of course not they just continue to beat us over the head all the time .
Am I reading correctly? Compassion, we mustn’t have any of that at the GMC. Having figure heads interested in seeing things from the practitioners’ viewpoint is one thing. Having the admin staff at the GMC do that is something else. They have become institutionalised over the last ten or more years. Do what the regulations say needs to be done; wash your hands and wash away any doubts regarding the suffering at the other end; and finally make sure there is time for pleasant thoughts over lunch. Recent dealings over licence renewal suggest to me that old attitudes remain alive and well. Appointment of a senior adviser is but a start on the road to a more equitable relationship, doctor vs GMC.
This isnt going to undo the significant harm that the GMC has caused doctors whose fitness due to health issues has meant they have had to deal with this poorly run organisation but its a start.
I have been on the receiving end of the prior aggressive, threatening and punitive approach the GMC took to fitness to practice due to health issues some 15 years ago. It nearly broke me but thankfully I am rather more resilient than I suspect they hoped. I always felt that ideally they wanted me to simply walk away from the profession. The incident still follows me though as I still have to declare that due to mental health issues brought on by stress I was under review by the GMC in 2002 despite no restrictions being put in place. Only last year this was the case.
I have also seen a dear friend end his life the day after the GMC informed him of a hair test result by emaildespite knowing he was a highly vulnerable bipolar individual and yet brilliant physician whose clinical acumen had never been in question. Was the GMC to blame for this, the manner in which the information was passed cant of helped.
I welcome the GMCs effort to balance the rightful need to protect patients with a swift and non punitive approach to health issues that result in a fitness to practice procedure. I am however also aware of some of the ridiculous cases that it has dealt highly inappropriate sanctions on, for example a colleague was involved in a case where a doctor involved the GMC when a colleague who happened to rent a property from the complainant failed to pay his rent due to a dispute over maintenance of the house. The GMC actually took this on and used it as a way to show the failure to pay rent was a sign of lack of integrity and dragged this individual over the coals for what was a civil matter.
Keep the reforms coming GMC, step by step I think you are getting back to being close to being fit to practice although you still need a lot of supervision and modernisation.
We’re very sorry to hear about your and your friend’s experiences. We hope the changes we’re making in response to Prof Louis Appleby’s review of our fitness to practise processes will ease the pressure our investigations can put on doctors, particularly those with health concerns. We will keep posting updates on our work in this area, so you can stay up-to-date on our progress.
It is so sad that many doctors have had to lose their lives by suicide before a research and initiatives of these nature are being developed.
I must commend the efforts of Prof Appleby and co,
Whether we wish to admit or not, there is institutional racism and ‘modern day slavery’ pervasive within the medical profession in the U.K. Many doctors of ethnic minority are heavily marginalised and treated more harshly and unfairly compared to white counterparts.
I speak as a doctor of many years experience both here and abroad it is sad to see fellow humans suffer in silence and accommodate various forms of bullying and harassment and sometimes have their human rights so unashamedly violated by employing trusts.
While not being blind to the fact the some doctors may actually and genuinely have issues with fitness to practice; I have also witnessed some employers bully and harass doctors to states of “learned helplessness”.
Some Trusts treat doctors in ways that is unfit for animals let alone fellow humans. This is common place amongst doctors from ethnic minorities. Failed promises, pay inequalities and overt ethnic cleansing practices that strip a doctor of their “sense to self “in a career they worked so hard to obtain and in which lies very much their sense of identity. It is common place that lies and fabricated unsubstantiated “concerns” become the legitimate reasons for employing Trusts not to put a doctor forward for revalidation for instance. Without revalidation the doctors are “stuck” with that singular employer and can not but suffer in silence.
GMC proposed the revalidation process to ensure high quality safe care is delivered to patients at all times, while this is a noble thing to do; GMC failed to put caveats within the system to make employing Trusts accountable so that unfair and discriminatory behaviour such as unduly withholding or stalling GMC revalidation for a doctor can be promptly identified and investigated. Some Trust unashamedly use such unhealthy practices as a way to address the recruitment and retention problems.
Admit it or not, doctors are humans who are subject to physical, emotional and social impact of facing often protracted investigations and the like. What injustice done at the end even if there no consequences following to the investigatory processes.
GMC needs to understand that there are certain people who are evil and heavily prejudiced working within employing organisations who have genuine deep hearted hatred for doctors. These people can lie manipulate and use all forms of bullying and harassment to make lives of doctors “ living hell’. But should this be as such?
Little wonder most doctors have low morale and increasingly suffer with various forms of mental health problems. It is high time that GMC become more responsive to the reality of a good chunk of doctors working here in the United Kingdom.
I dread to encourage my children to step into the medical profession because of the pressure of work, feeling undervalued and low morale. And God forbid if one ever faces a problem within the domains of FTP then that is the SUICIDE broadway to early death. I use this forum to call out to all doctors, to look out for one another and treat your colleagues fairly as you would like to be treated.
At the end of the day, we are all humans and susceptible to mental health problems given the right intensity and duration of stress.
Future generation must learn to watch out for one another irrespective of race, gender or tribe. We are humans and most of all we belong to a noble caring profession. Let us build each other and stop the tearing down and discrimnatory attitudes.
Thank you. NJ