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.