In 2015 we appointed Professor Louis Appleby, a psychiatrist from the University of Manchester, as an independent expert to advise us on improvements to our fitness to practise procedures.
He’s since worked with us to examine each stage of the investigation process to identify what changes could make the process more compassionate and supportive of people with mental health problems.
This resulted in a set of proposals for improvement that we’ve now implemented. Here Professor Appleby speaks about what his work with us involved and why it will make a difference.
Why was it important to review each step of the investigation process with the impact on the doctor involved in mind?
During my work with the GMC I heard from many doctors about how an investigation had affected their emotional health – letters, delays, the perception that the “system” was stacked against them.
The risk is often cumulative, from when the doctor first receives the news that they have been complained about, through to the final decision. Making that process shorter, more efficient and more consensual is a priority. People behave differently under stress – refusing to reply, becoming dismissive or angry. They may appear unco-operative and the result can be a vicious circle of distress and disengagement that GMC staff need to be alert to.
What did your work involve?
I tried to draw on my experience in suicide research, including the fact that suicides often occur in people thought not to be at risk. I tried to put myself in the shoes of a hard-working, decent doctor facing investigation – upset, probably remorseful, possibly despairing. I emphasised that suicide was rarely caused by one thing and that prevention would require a comprehensive look at how investigations worked.
What are the key risks for a doctor under investigation? If so, how will the changes the GMC has made ease the burden?
Being subject to an investigation can be a lonely and troubling time. Many doctors don’t disclose the complaint to their loved ones. They may feel trapped, humiliated or unjustly treated. Some don’t know who to turn to for support.
We aimed to change the culture, to increase “mental health awareness” not just in the abstract but in numerous practical ways. This included training for staff on how to provide information, how distress may manifest and on spotting the signs of increasing risk.
What are the greatest improvements you have seen to the fitness to practise process?
Some of the processes have seen real improvements that I feel confident will make a difference.
The GMC has worked with employers to help them understand which concerns can and cannot be dealt with locally. This has resulted in fewer doctors being referred to the GMC.
“Provisional enquiries” are now being made at an early stage of an investigation, to help the GMC decide more quickly whether a complaint should be investigated fully or closed with no further action. This early intervention saw the number of formal investigations reduce by 400 last year and the GMC is planning to expand this approach.
Doctors told me they found dealing with several different staff during an investigation frustrating and confusing. So now there is a single point of contact during the course of an investigation.
The GMC has developed systems for investigation staff to get advice from medical experts on spotting the signs that a doctor may be unwell and on how to respond appropriately.
When a doctor needs mental health treatment, this should be largely the responsibility of the treating doctor – often the GMC don’t need direct detailed involvement.
How do you think the work will change the experience for doctors who are referred to the GMC?
Doctors told me they felt ‘guilty until proven innocent’ when subject to a GMC investigation – that is the phrase that many used. Yet my experience of meeting GMC staff was that they wanted to be fair, supportive and compassionate. In future, we should see medical experience feeding into decisions more easily and earlier. Doctors should feel reassured to find they are speaking to someone who is trying to make balanced decisions, who understands it is stressful and undermining.
The processes will be regularly reviewed by a newly established Medical Advisory Board. It will meet twice a year to advise on the GMC’s approach to vulnerable doctors.
From your experience of GMC procedures, what advice would you give to a doctor who is referred to the GMC?
The GMC always advises doctors to contact their medical defence organisation as soon as possible after receiving a complaint. The defence bodies know the GMC’s procedures well and can give advice on how to respond. Sharing information with the GMC at an early stage in the process can help to get matters resolved quickly and the new provisional enquiries process that the GMC uses is designed to ensure that happens. It’s important to remember that the GMC is concerned with patient and public safety and will focus on whether there is an ongoing risk.
My advice is to be open, to try to reach agreement, to ask for help – there’s a free impartial support service available as well as other resources. And to remember that serious sanctions are unusual – it can be a difficult time but most people get through it.