Dr Christoph Lees, MD MRCOG, is Reader in Obstetrics and Fetal Medicine at Imperial College London; Honorary Consultant in Obstetrics and Head of Fetal Medicine at Imperial College Healthcare NHS Trust, Centre for Fetal Care, Queen Charlotte’s and Chelsea Hospital; Visiting Professor at the Department of Development and Regeneration, KU Leuven, Belgium; Founder, Doctors Policy Research Group, Civitas. His non-clinical interests are in the field of medical regulation. He spoke about lessons that can be learned from the UK at the Medical Advocates’ conference ‘Fit for purpose: The role of just culture in transforming medical regulation in Ireland’, on Friday 6th October.
In what capacity have you mentored other doctors who have received a letter from the General Medical Council (GMC)?
My mentorship and help to doctors who have ended up in difficulty is not just exclusive to Obstetricians and Gynaecologists. General practitioners and surgeons also contact me informally and I think they do so because I was the subject of one of these processes many years ago and from then on I became known as someone who spoke out against these processes.
Formerly, I was the Chairman on a local negotiating committee, and mentored doctors who ran into difficulties. We had constructive discussions with the medical director’s office about how exclusions could be best handled.
We managed to improve the way in which suspensions and disciplinary issues were dealt with because there has traditionally been a very binary view: either you’re working or you’re suspended and can’t come near the hospital.
In many cases that is disproportionate; it is appropriate to exclude doctors if there is an obvious patient safety concern but often issues arise because of disagreements within the department and then one clinical error is escalated inappropriately.
Disciplinary proceedings need to be split between whether it is a problem primarily for the hospital’s internal processes or whether it truly is a case for the GMC but both are increasingly conflated into one.
What are the main concerns that doctors come to you with?
Firstly, every doctor caught in these processes thinks it will or could end their career. Secondly, the concern is economic; whether they’re going to be able to afford to keep their house, pay for schools, and pay for a mortgage.
Thirdly, they risk a loss of reputation and a loss of their standing within the community.
All these matters play a major part in their fears. What’s more, there is often a real feeling of anger because these cases may have been blown out of proportion by someone within the organisation with a grudge or, of course, an unhappy patient and when you get down to it, there is often little substantive that merits the severity of process that they are undergoing.
The majority of the cases that I see, informally and formally, are single clinical incidents or occur where a department is dysfunctional and anyone could have ended up referring anyone to the GMC.
Doctors sometimes feel that they are being victimised and that a colleague might have done the exact same thing without any complaint. It’s the apparent randomness that affects people.
How probable is it that a doctor will be brought before the GMC?
We’ve estimated that there is roughly a 50 per cent likelihood of being brought before the GMC in a career spanning 35 years but there is no concrete data on this.
It’s a very important statistic and one that students should be told as they enter into medical school because it can be life changing.
It’s one of these things that no one wants to talk about and there remains a certain view that such disciplinary matters happen to someone else and not to you, which is simply not true, it might have been the case 20 years ago but not anymore.
Why does the GMC have a less than favourable reputation among doctors?
What we’ve had is a collision of a Victorian punitive system, which is how the GMC was set up, with the much more complex issues relating to modern day medicine and how doctors are managed.
The GMC was set up initially to deal with what you might call medical crime; doctors abusing drugs, incompetence, or abuse of patients.
What happened in the late 1990s was that the system had to adapt to all sorts of other issues, ones that couldn’t have been dreamed of over one hundred years ago, and it adapted badly to it meaning that the GMC was, in a sense, its own worst enemy.
Often it’s not a question of charges being found proven or not but more whether a department was functioning properly, whether there really is a safety concern, whether there is a problem with this doctor or with other doctors that is due to training, resourcing, support or insight, and how this issue might be remediated.
Most doctors are working to the best of their abilities and if they’ve done something wrong it’s an accident or error, therefore applying a punitive system to that is inappropriate and will compromise attempts to get things back on track.
When scandals occurred in Bristol (paediatric heart surgery) and in Liverpool (pathology) regarding poor performance, the system couldn’t deal with them properly and this led to political and media pressure.
There was an almost perfect storm whereby rash of medical errors ended up on the front page of the Daily Mail and BBC news.
I find it extraordinary that doctors could be accused and named in public and excluded from work, not because of any proof of wrongdoing but because there was a case brought against them about which they were unable to comment in public.
This complete mess led to a large increase in the number of complaints and public hearings. Funnily enough, it didn’t lead to a huge number of increased erasures because, when it came to the hearings, sense was seen and many charges dropped with only a very small number ending with serious sanction.
So that means either lots of people were doing bad things and weren’t getting punished or lots of people weren’t doing bad things and there was an overreaction occurring within the system. There is now a general consensus that it’s the latter.
One problem was the perception that the GMC were publicising these cases; the doctor couldn’t respond, while the GMC would pay expenses for the witnesses and complainants almost incentivising a complaint.
Many would do this as a prelude to taking it to a civil legal case, or if a civil case had failed and GMC inadvertently became a place where scores were settled.
But there is little doubt that the GMC has had a difficult last ten years; if it wasn’t strict enough, they would be subject to political and media pressure, and if they were inappropriately strict then doctors would have their lives ruined or even, in extreme circumstances, take their own lives.
Are there any figures relating to the doctors who die by suicide during or following investigation by the GMC?
The Horsfall report of 2014 gave a snapshot of deaths by suicide. I think it’s a problem that we still don’t really know the true numbers of doctors who have died while under investigation because the data consider only doctors who were registered.
It is possible that doctors under investigation would have deregistered and died by suicide, while others have died of “natural causes” because of the stress associated. These figures are not known.
Of course the stresses upon doctors are very significant so it’s no surprise that they would act in this way, as doctors tend to be very self-critical.
Three years ago I requested that the Health and Safety Executive investigate the number of suicides and the GMC’s response to suicides. If this had been an issue about deaths in prison, then there would have been an immediate inquiry, a report published and individual cases investigated.
Unfortunately, the HSE declined and to have appealed their decision would have required judicial review. It is likely that there have been further suicides among doctors but we don’t have reported statistics.
So where can we learn from and what can we do differently?
Every developed country has its own regulatory system but all seem to hear fewer cases and discipline a smaller proportion of doctors than in the UK.
I would like to see us devolve these cases to regional councils and I would like to see a form of jury being drawn from doctors.
This would mean that we, as doctors, would do jury service and would be there to try our peers and there should, of course, also be lay people involved. At the moment, lay input is greater than professional representation and what results is a panel who may not properly understand complex cases.
Are doctors frightened to admit to practising medicine defensively?
I’m not a cardiac surgeon but anecdotally cardiac surgery, for example, is less likely to be performed in high-risk cases because of the concern that the patient would die.
Ten, 15 or 20 years ago, a surgery might have been done because it was a patient’s only chance of survival. League tables and concerns about disciplinary action certainly make defensive practice more likely.
Another example of defensive medicine is well reported in Professor Tom Bourne’s Impact study, showing that doctors who have been through disciplinary processes in particular display avoidance behaviour.
The net effect of trying to improve patient safety through disciplinary processes may be that they haven’t improved patient safety at all. But this is important because after all, we are all patients.
Then we move to the apparent panacea: revalidation. Revalidation is costly in time and resources. There are no metrics to suggest that revalidation is working. But we all do it because we have to do it, and the GMC tells us that it improves patient safety and confidence in the profession.
Has the GMC made any progress in recent years?
I should emphasise that the GMC is now trying to listen and has been attempting to improve its processes over the last two or three years.
They have a really difficult job because they will get pressure from all sides. They are walking a tightrope.
It’s very important to mention because many doctors have a very bleak view of the GMC. It was established through Act of Parliament and in actual fact has limited room for manoeuvre.
What is the embryonic RCOG doctor’s support group?
The RCOG is a high-level group with representation from the GMC, from medical defence organisations, from trainees and from consultants, and from the education team within the college as well.
We are still defining exactly what we want to do and how we want to do it.
It’s designed to assist doctors who run into disciplinary and regulatory difficulties.
We know that Obstetricians and Gynaecologists are over-represented in complaints and disciplinary processes. So it’s sort of natural that if any college or group of specialists should get involved, the RCOG would be an appropriate college to take this further and is leading nationally on this at the moment.