At the BMA’s Annual Representative Meeting on Monday 26 June 2017, delegates voted in favour of a motion calling for us to acknowledge that good doctors can harm patients when working in a poorly resourced environment. Here, Mary Agnew, our Assistant Director for Standards and Ethics, addresses this issue.
‘Mistakes can be a product of the environment and not the fault of the practitioner’ – words taken from the North East Regional Council’s motion, which was passed following a debate by BMA representatives.
This is of course true – late last year we highlighted the pressures on the profession, the state of unease within it, and our concern about the impact this might have on the professional standards for which we are responsible.
Then, as now, we are clear that we have an important role to play in making sure that all our actions are as light touch as possible and that our guidance is helpful and accessible. Equally, we have to balance this out with our responsibilities for patient safety and often we need to investigate where patient harm has occurred.
Guidance to support doctors
We have developed all our guidance with the medical profession, the public and a range of other experts. It represents a general consensus on what good medical practice looks like and it is there to support doctors to practise ethically and within the law.
It is absolutely not there to be punitive when doctors make mistakes – any doctor, no matter how experienced, can make a mistake, particularly when working under pressure. Nor are our standards a rigid rule book – we expect doctors to use their professional judgement in applying the principles in the guidance to the situations they face. It is only serious and/or persistent breaches of the guidance that pose a risk to patients, or to the public’s trust in the profession, that could call into question a doctor’s fitness to practise.
We expect doctors to raise their concerns if they believe that patients are at risk because of inadequate premises, equipment or other resources, policies or systems, and to keep a record of the steps they have taken. We also expect that doctors are open and honest with patients and families when something goes wrong, that they engage in individual and wider reflection, and that they contribute proactively to support wider learning to reduce the risk of future harm.
Where doctors are taking such steps, acting professionally, and doing their best to deliver good care for their patients, it is highly unlikely that we would have concerns if we received a complaint about them.
Taking proportionate action
When we consider a complaint we look at potential individual or system failings (or a combination of both) and we take that into account when considering whether action is needed. Our focus is on whether the concern and the doctor’s response suggest that the doctor is likely to pose a risk to patients or to public confidence in doctors in the future, rather than on punishing doctors for what has gone wrong in the past.
In the majority of cases the key question we ask ourselves is whether a mistake or behaviour is likely to be repeated. The risk will be lower for a doctor who shows insight into what has happened and retrains to make sure that mistake can’t happen again.
We have made significant improvements to our process for filtering out matters that do not require GMC action and these will include those where system failures caused the concern or significantly contributed to it.
Our Employer Liaison Service provides advice and support to Responsible Officers on our thresholds. We are currently piloting carrying out provisional enquiries in the majority of cases involving single clinical incidents (which most of the concerns that result from pressured environments will be), before deciding whether a full investigation is needed and the majority of these matters close at that provisional enquiry stage with no further action. This process is also swift and enables us to significantly speed up our resolution of such concerns.
Understanding doctors’ environments
First and foremost we are a professional regulator but in recent years we have become increasingly interested in the environments in which doctors practise and train – because we know they have a major influence on their actions and behaviour.
Understanding that context is crucial, which is why we are making a real push to improve the data that we collect on employers and training bodies (through our national training surveys, for example), and why we are starting to explore the issue of ‘harms’ and the contribution we could make to help reducing them.
Right now though, we do set clear expectations for employers in providing safe and high quality training for doctors, and in supporting them with appraisal and revalidation. We work closely with system regulators to ensure our training standards are met.
We will not hesitate to take action with national educational bodies where there are concerns that the training environment is not safe for doctors, so that doctors in training are well supported. Without proper supervision, they could make a mistake that harms a patient and indeed their future within the profession. When there are those kinds of concerns, it’s important that we step in.
We know the vast majority of doctors are committed to doing their best for their patients, despite hugely challenging circumstances, and demonstrate tremendous professionalism. We also know that doctors are human beings and that they will make mistakes, especially in those trying circumstances.
We would of course be happy to discuss any specific elements of the guidance that the BMA has concerns about. But as a matter of principle, we believe that to dilute the standards within Good medical practice and our wider guidance would be wrong for the profession and wrong for patients.
The gmc do not represent the patient’s you only work in the drs interests as they are the ones paying you
Last year GMC had two Chatham House discussion about Whistleblowers protection and also mental health in doctors and both were brilliant and I took part in both of them and really commend GMC. GMC has come a long way but so far GMC has refused to have such a workshop to look at the plight of Black and Minority Ethnic Doctors in the NHS and their daily suffering because of club culture, bullying, old boys network and so on.
In Wigan we reduced harm to patients by 90% and the whole GMC senior leaders attended and everyone was amazed at the excellent governance and accountability and I am grateful to GMC for their visit. But sadly nothing much has happened. This was before the current CEO took his position.
If GMC really wants to protect patients then they must understand the daily suffering of staff in NHS in a culture of bullying it is innocent patients, staff and NHS who suffer. Every day I hear the suffering story of BME doctors and BME staff in our NHS.
I sincerely request GMC to have a Chataam House discussion with all relevant leaders of NHS and some of senior BME leaders who have given their lives to NHS to have discussion about BME issues and how we can all work together and make NHS safest and the best.
I hope to hear from GMC soon. GMC must be proud of your transformation but can do lot more to make the whole of NHS safest and the best. Equality and inclusion is important but sadly in a kind caring and compassionate NHS bullying, club culture and old boys network is rife and patients, staff and NHS suffer every day.
Hi Umesh,
Thanks for getting in touch. We know that some BME doctors and IMGs are among the cohorts of doctors who may feel particularly vulnerable in the current environment of significant pressures on the NHS, particularly when raising concerns in the public interest.
At the recent meeting of the BME Doctors Forum we heard at first hand the personal experiences of one doctor who was referred to the us after whistleblowing in his local trust. We know that there will be many other doctors who will be worried and stressed in similar circumstances.
We’ve been piloting a range of safeguards for doctors who have raised concerns in the public interest who are subsequently referred to the GMC. These include:
• Introducing a mandatory referral form that includes a requirement to disclose any whistleblowing history and to sign a statement of truth about the contents of the referral.
• All referrals where a whistleblowing history is confirmed are referred for provisional enquiry. The enquiry focuses on obtaining information to corroborate the referral that is objective of those who are employed by, or closely connected to, the organisation that was the subject of the whistleblowing.
• Where a whistleblowing history is disclosed during an investigation, a process to focus the investigation plan on evidence to corroborate the allegation is triggered. This process is objective of those who are employed or closely connected to the organisation that is the subject of the whistleblowing.
• A doctor’s whistleblowing history is disclosed to case examiners when making their decision about referral for hearing.
• We have developed guidance for case examiners and tribunals on weighing evidence in such cases, including being aware of the possibility of witnesses colluding with each other.
I know you’re meeting colleagues here shortly and we can discuss then how we could best facilitate further conversations with a wider group on the issues you raise.
Kind regards,
Mary