Medical professionalism and regulation in the UK

Our response to BAPIO’s open letter on the Dr Bawa-Garba case

Dear Dr Mehta and Dr Bamrah

Thank you for your letter of 12 January. We do understand the strength of feeling this tragic case has raised for many doctors. We know we can’t simply undo all the anxiety generated by it but we are committed to listening to doctors and addressing their concerns.

However, the charge that the GMC acts in a discriminatory way is troubling and without merit.

We champion overseas doctors

As many of our recent statements show, we recognise that the NHS is hugely reliant on the skill and dedication of overseas trained doctors. We have worked hard over a number of years to understand the particular challenges faced by this group of doctors.

This has been a specific thread of many of our comments and analyses over the last year, for example in our description of a “crunch point” in the medical workforce, and in our analyses of what doctors from overseas have been telling us about their future intentions in the context of Brexit.

We have also gone to some length to publicly recognise the contribution of SAS doctors and have been clear about our desire to reform the process of entry onto the Specialist or GP Register with a Certificate of Eligibility for Specialist Registration or GP Registration (the CESR/CEGPR process).

The Black and Minority Ethnic Doctors Forum

These analyses underpin discussions in the Black and Minority Ethnic (BME) Doctors Forum, chaired by Professor Iqbal Singh, and hosted by the GMC.

In my very first day in this post, I attended this Forum to hear about the factors driving differential attainment in medical education and training. It was a discussion that showcased the complex range of factors that may impact on a doctor’s progression – the role of secondary education, different approaches to learning, institutional support systems, and wider sociocultural factors including personal support systems. It reinforced my own personal commitment to working together to address these complex issues. It also underlined the important role that the GMC has in deriving understanding from its data, and then acting across the system to address these issues.

Complaints and our fitness to practise processes

You ask about our efforts to monitor whether doctors of certain ethnicities are more likely to be subject to fitness to practise procedures. On an ongoing basis, we conduct detailed research to improve our understanding of what drives overrepresentation of different groups, and whether cases are treated fairly.

The consistency of our fitness to practise decision-making is also audited independently to ensure it is in line with our published guidance, and is not discriminatory. These audits have always found our decisions to be consistent with this guidance, and that the guidance itself does not introduce bias.

We make every effort to be as transparent as possible about our fitness to practise data, and analyse it to understand what drives particular trends. It is true that certain groups, including BME doctors, are disproportionately represented in the complaints that are made to us, and the figures show that between 2012 and 2016, 10.2 per cent of all BME and 8.8 per cent of all white doctors had a complaint made to the GMC about them.

We conduct analyses to improve our understanding of what drives those trends, and we publish our data every year in our State of medical education and practice report.  Looking across all of our analyses and research we see no evidence of bias in GMC decision-making related to ethnicity.

We also identify a wide range of factors that influence the proportion of complaints about doctors that are formally investigated and from there, result in sanctions or warnings. These include the source of complaint, type of work done by the doctor, and the types of allegations made about them. For example, a higher proportion of complaints about BME doctors are made by employers (10 per cent) than white doctors (6 per cent). In turn, these employer complaints are more likely to be investigated (84 per cent) than complaints from the public (16 per cent).

We also know that a lower proportion of BME doctors are specialists (28 per cent) than white doctors (34 per cent), and that specialists have lower rates of being complained about compared to, say GPs (11 per cent of specialists and 17 per cent of GPs from 2012-16). We continue to investigate these and other factors as part of our ongoing research and will continue to publish our analyses as they are completed.

Our new Equality, Diversity and Inclusion Strategy

One of the aims of our Equality, Diversity and Inclusion (ED&I) Strategy 2018-2020 is to provide leadership and use our influence to identify, understand and address inequalities for doctors in the wider healthcare system. We now have better data and understanding of the barriers that different groups of doctors face in progression. For example, we have already begun a dialogue with employers around the fairness of local systems for referral with a survey of staff in 11 acute trusts.

We want to continue our dialogue with key stakeholders including working with Responsible Officers and employers to understand the patterns for referral and the trends for some groups of doctors in fitness to practise and revalidation in their local areas and any outliers. Our aim is to triangulate our data with others, and to use this data to foster collaborative and joined-up thinking about some of the solutions and interventions that might support different groups of doctors, including BME doctors and International Medical Graduates.

Welcome to UK Practice

We use data to inform our actions and to encourage action from others. We do know, for example, that doctors who are trained overseas and are new to UK practice are much more likely to be complained about. That is not because they are bad doctors. Indeed, it is often because they are poorly inducted in the NHS. We know that training can help, and that our own free training is very highly regarded by doctors new to work in the NHS. That is why we have decided to invest to ensure that our Welcome to UK Practice training is taken up by many more doctors. Our ambition in the medium term is to increase take up from around 33 per cent to over 80 per cent.

Support to doctors going through our processes

We have significantly reformed our fitness to practise processes to increase support to those involved, recognising the potential vulnerability of all doctors, regardless of background, who are undergoing investigation. For a number of years we have provided a support service for all doctors, including a confidential helpline provided by the BMA and funded by the GMC.

We also asked Professor Louis Appleby to lead a review of improvements that the GMC can make in this area. As a result of his work we have improved the way in which we engage with doctors by making sure that staff attend mental health awareness training and improving the tone of our correspondence. We have also created a new specialist team for cases about doctors who are unwell.

We are determined to reduce the number of unnecessary investigations that we conduct. Whilst we are constrained by the thresholds for investigation set out in legislation, we have made use of a “provisional enquiry” process that has enabled us to halve the number of full-blown investigations commenced over the last 3 years.

Working at the frontline

Over the last few years, we have also significantly expanded our capability to provide direct support to doctors working at the frontline. In 2017, we engaged with over 46,000 doctors, patients and medical students and other individuals. 18,000 of these were medical students. A further 23,000 were doctors, of which over 7,000 were foundation doctors and more than 5,000 GPs. The remaining 5,000 were a combination of patients, nurses, commissioners, employers, royal colleges, regulators and medical educators.

Our Employer Liaison Service also provides a direct source of advice to Responsible Officers in handling complaints made about doctors. They have made a big difference in ensuring more consistency in local decision making. Given that complaints are often best resolved locally, our new corporate strategy sets out a determination to work even more effectively with Responsible Officers to make sure that more complaints can be handled and resolved locally rather than go through a full GMC process.

We have also taken steps to make sure that whistleblowers are better protected and that our processes help minimise the number of vexatious complaints made about doctors who speak up. Following a review by Antony Hooper, in 2016 we introduced a referral form for Responsible Officers that requires them to answer specific questions about the whistleblowing history of the doctor being referred, and which requires them to sign a statement of truth about that referral. At the GMC we will review any referral of a doctor with a whistleblowing history before commencing an investigation.

Appeals

The GMC obtained a right to appeal the decisions of the Medical Practitioners Tribunal Service (MPTS) in 2015. Wherever a tribunal decision is different from the GMC’s sanction submission, we will consider whether to appeal that decision in line with criteria published on our website. In all of those appeals which we have brought against decisions of Tribunals determining allegations of impaired fitness to practise against doctors on the register the court has allowed our appeal. This suggests that, since we obtained our right of appeal, we are correctly and lawfully applying those criteria.

Systemic issues

Where we investigate a doctor, we will always take wider systemic issues into account in coming to a view about whether a doctor is impaired. We ask ourselves, taking account of all the circumstances the doctor found themselves in (including systems issues), what would have been expected of a reasonable doctor and, if they fell below that standard, how seriously below that standard did they fall? These questions did not arise in Dr Bawa-Garba’s case as, given the conviction in the criminal court, the GMC and MPTS were required in law to accept the findings of the jury about these matters.

You have questioned what steps we have taken to investigate whether racial factors may have influenced the Trust and Deanery, or our own response. The allegation of impairment which was referred to the Tribunal in the case of Dr Bawa-Garba concerned a criminal conviction for gross negligence manslaughter. In those circumstances both the GMC and the Tribunal must accept the conviction as proof not just of the fact of, but also of the basis of, the conviction. Our actions were therefore determined by the need to give effect to the findings of the criminal court in accordance with our legal obligations. As the Divisional Court has now confirmed, that is precisely what we have done.

The way forward

Although in this case the court has ruled that the Tribunal had no powers to take a different view to the findings of the criminal court about Dr Bawa-Garba’s personal culpability, it is clear there is a need to examine the wider issues around gross negligence manslaughter including the expertise and consistency applied in their initiation and investigation.

In recent months, our Chair, Sir Terence Stephenson, has been engaged in discussions about medical manslaughter. We have already announced that we will be bringing together health professional leaders, defence bodies, patient, and legal and criminal justice experts from across the UK to explore how gross negligence manslaughter is applied to medical practice, in situations where the risk of death is a constant and in the context of systemic pressure. This work will include a renewed focus on reflection and provision of support for doctors in raising concerns. There may be a role for updating relevant guidance in these areas.

I look forward to seeing you at the BME Forum meeting in a few weeks’ time. I hope that you will agree that we have a shared objective – the need for an open and honest culture in which doctors can learn from reflective practice and where that learning drives improvements in patient care.

Yours sincerely

Charlie Massey