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FTP, do no harm

10 Feb 2015


Caroline Spillane, Medical Council CEO

In the first of a two-part report, IMT examines the findings of a UK study on the high level of stress experienced by those involved in FTP hearings — pressure which led to 28 suicides. By Dara Gantly.

News that the Medical Council is due to release a five-year study of complaints it received between 2008 and 2012 will be welcomed by a profession that has had little insight into just how much of an impact fitness to practise (FTP) hearings can have on doctors.

The fact that the review — due to be published in the second quarter of 2015 — will include an analysis of feedback from both doctors and complainants since 2011 should bring up a number of important themes and concerns that the regulator, the profession, patients and other stakeholders in the system will need to address.

Among these concerns is likely to be the impact FTP inquiries can have on the general and mental health of doctors, particularly following two separate reports from the UK showing that doctors facing complaints are dogged by severe depression and suicidal thoughts.

According to a recent report in BMJ Open (doi: 10.1136/bmjopen-2014-066687), UK doctors subject to complaints procedures are at significant risk of becoming severely depressed and suicidal, with those referred to the General Medical Council (GMC) most at risk of mental ill health.

The researchers base their findings on an anonymised online survey of more than 95,000 doctors in 2012, all of whom were members of the British Medical Association (BMA). Almost 8,000 (8.3 per cent) completed the questionnaire fully and were included in the final analysis.

Around one-in-five respondents (22.5%) had no personal experience of a complaint; almost half (49%) had faced a complaint in the past; and more than one-in-four (28.5%) had done so recently.

Around one-in-six (just under 17%) of those with a recent complaint were moderately to severely depressed, and they were 77 per cent more likely to report these symptoms.

They were also twice as likely as those who had no personal experience of a complaint to harbour thoughts of self-harm or suicide.

A similar proportion (15%) of those in the recent/ongoing complaints category were also twice as likely to have clinically significant levels of anxiety as doctors with no personal experience of a complaint.

Depression and self-harm
The study found the level of psychological distress paralleled the type of complaint. Doctors who had been referred to the GMC reported the highest levels of depression (more than 26%), anxiety (more than 22%), and thoughts of self-harm (more than 15%).

Doctors subject to a recent or ongoing complaint were also more likely to have poorer health and well-being, including gut problems, insomnia, and relationship issues.

Defensive practice was common, as you might expect, with most (80%) of those who had experienced a complaint saying they had changed their clinical practice as a direct result, deploying tactics such as avoidance — not carrying out difficult surgery, for example — or hedging — ordering too many investigations — and in some cases, acting against their professional judgement.

Furthermore, almost three out of four of those who had not been the subject of a complaint said they had also changed their clinical practice after witnessing a colleague’s experience of going through the process. “These behaviours are not in the interest of patients and may cause harm, while they may also potentially increase the cost of healthcare provision,” noted the researchers.

The process itself was often an unpleasant experience for the doctors involved. One-in-five of those who had been subject to a complaint felt victimised for having blown the whistle on poor clinical or managerial practice, and almost four out of 10 (38%) said they felt bullied during the investigation. And around one-in-four had taken more than a month off work.

Most of the respondents who offered suggestions for ways to improve complaints procedures focused on boosting managerial competence in complaints handling or greater transparency.

The researchers caution, however, that the overall response rate may mean that these findings are not truly representative of the UK, and as this was an observational study, no definitive conclusions about cause and effect can be drawn. Yet as the largest UK study of its kind, they believe the findings are relevant.

They emphasise the importance of protecting patient safety and of enabling complaints to be raised as a way of improving standards of care, but go on to say: “However, a system that is associated with high levels of psychological morbidity among those going through it is not appropriate. Most importantly, a system that leads to so many doctors practising defensive medicine is not good for patients.”

Commenting on the BMJ report, Irish Medical Council (IMC) CEO Caroline Spillane pointed out that most of the respondents in the study who offered suggestions for ways to improve complaints procedures focused on boosting managerial competence in complaints handling.

“Being competent means that you need to have a proper degree of training and development, and we feel there has been quite a significant advancement here with the establishment of case officers to manage cases,” the CEO told Irish Medical Times, adding that all of these Irish officers had been trained via a bespoke programme externally validated by the Chartered Institute of Arbitrators.

Spillane believed the Council’s imminent five-year study of its complaints book would provide much information with regard to what were the main themes arising from the process, and would shine a light on what the regulator, profession, patients and other stakeholders needed to address.

“It will inform us of how we can learn from the kind of themes and issues that are coming up through the complaints and inquiry process, and what actions to take, perhaps through the development of better guidance for the profession, programmes of education at undergraduate and specialist training, or programmes that are rolled out for the continuous professional development of doctors.”

Vexatious complaints
When they asked for feedback in the BMJ Open study, one of the other suggestions from doctors was to instigate disciplinary action or fines for vexatious complaints. It is interesting to note in this context the differences between the Medical Practitioners Act (MPA) 2007 and more recent legislation, for example the Protected Disclosures Act 2014, which became operational in July last year.

The latter states that anyone who “wilfully makes any material statement which the person knows to be false or does not believe to be true” is committing an offence and is liable on summary conviction to a class A fine or imprisonment for a term not exceeding 12 months or both.

However, the MPA stipulates that anyone can make a complaint to the Medical Council and the Council has a responsibility to look at each and every one. Spillane explained to IMT that in looking at each and every complaint, it had to be borne in mind that the Preliminary Proceedings Committee (PPC) was a medical majority committee, albeit chaired by a lay member, which had the benefit of case officers who provided case reports based on investigation, in order that it could make a reasonable decision.

“Considering that the Committee has a medical majority and is made up of medical members who represent a whole range of specialities, they are very well placed to assess the nature of the complaints that are arriving at the Medical Council, and to make a determination as to whether there is a case to answer,” said the CEO.

“If there are no grounds to support a complaint, then they will arrive at that decision and hopefully do so in a very timely fashion. But while it might seem that the Council has some discretion, particular with regard to vexatious complaints, the Medical Practitioners Act — the law — tells us otherwise.”

28 suicides
Last December saw an even more shocking report emerge on this issue. The GMC has since committed to reviewing the way it treats vulnerable doctors under its FTP investigations following the publication of an independent review it commissioned.

That report, which examined the period between 2005 and 2013, found that 28 doctors undergoing FTP investigations died by suicide or of suspected suicide.

The case reviews of doctors during this period showed that many of those who died by suicide suffered from a recognised mental health disorder or had drug and/or alcohol addictions. Other factors that often followed from those conditions that may have also contributed to their deaths included marriage breakdown, financial hardship, and in some cases police involvement as well as the stress of being investigated by the GMC.

The review recognised the significant improvements that the GMC has made to the investigations process in recent years, and the additional support offered to doctors. But it went on to make a number of recommendations for further reducing the impact of investigations on doctors who have health problems.

These include appointing a senior medical officer within the GMC to be responsible for overseeing health cases and ensuring that every doctor should feel they are treated as ‘innocent until proven guilty’.

The review also pointed out that there needed to be greater support for vulnerable doctors and recommended the establishment of a new National Support Service. Although this was a matter for those who commission or provide health services, the GMC said it would host an event to explore the idea further.

Niall Dickson, CEO of the GMC, said: “We know that some doctors who come into our procedures have very serious health concerns, including those who have had ideas of committing suicide. We know too that for any doctor, being investigated by the GMC is a stressful experience and very often follows other traumas in their lives.

“Our first duty must, of course, be to protect patients, but we are determined to do everything we can to make sure we handle these cases as sensitively as possible, to ensure the doctors are being supported locally and to reduce the impact of our procedures.”

Dickson added that although a referral to the GMC would always be a difficult and anxious time for the doctor involved, the Council wanted to handle complaints as effectively as possible and ensure its processes were as quick, simple and as low stress as it could make them. “We have made some progress on this, but we have more to do, and that includes securing legal reform.”

Dr Clare Gerada, Medical Director of the NHS Practitioner Health Programme, who attended the NAGP AGM in Limerick last November, welcomed this long awaited and important GMC review.

“I applaud the GMC’s openness in putting in the public domain the issue of doctors’ suicides whilst under their process. Going forward they need to continue to show their commitment to reducing the impact of fitness to practise investigations on vulnerable doctors whilst always maintaining patient safety — a substantial task.”

The NHS Practitioner Health Programme is an award winning, free and confidential NHS service for doctors and dentists with issues relating to a mental or physical health concern or addiction problem, in particular where these might affect their work. However, the majority of its patients are London based, due to the fact that its primary source of funding is from the Office of London Clinical Commissioning Groups (CCGs).

“Doctors are sometimes patients too,” commented Dr Gerada after the GMC report’s release, “and supporting vulnerable doctors is a shared responsibility. It is important that in taking forward the recommendations in the review the GMC works in partnership with everyone who has an interest in this area including the Practitioner Health Programme, the Royal College of Psychiatrists and the BMA.”

Wake-up call
Indeed, the GMC report has provoked a profession-wide response in Britain, with Dr Maureen Baker, Chair of the Royal College of General Practitioners (RCGP), describing it as a “wake-up call” to do more to support GPs and to prevent problems arising in the interests of patient safety.

“Patient safety must be paramount in any fitness to practise process, but it is also essential that GPs and all doctors are investigated fairly and sensitively. It is shocking that so many of them have taken their own lives while investigations have been ongoing.

“The alarming doctor suicide statistics are proof that something must be done to ease the stress on doctors undergoing fitness to practise investigations,” commented Dr Baker.

The RCGP welcomed the GMC’s assurance that no GP under investigation should be treated as a guilty party before the process had reached its conclusions, and that throughout they receive all the support and advice they need.

“We also support the proposal to speed up the fitness to practise procedures — the GMC must thoroughly investigate allegations of malpractice, but some investigations extend for many years and this adds extra stress for all parties concerned,” she added.

BMA Chair Dr Mark Porter added that while doctors’ first priority was their patients’ care, it must not be forgotten that they can face the same physical and mental health issues as everyone else.

The BMA provides counselling and support services for all doctors, but believes more must be done to help vulnerable doctors who find themselves going through what can be a prolonged and arduous process.

Incredibly stressful
In Ireland, the supports for the profession may appear more limited, and the IMC — which has yet to officially examine the GMC report, but is likely to do so — said that while it provides contact details for patient advocacy services for complainants and witnesses that are involved in the process, it could not do the same for doctors.

“Of course, we would like similar services to be available to support doctors,” commented Medical Council CEO Caroline Spillane, who wanted to acknowledge that the Council was fully aware that the complaints process could be incredibly stressful for all involved.

“We have met with doctor representatives bodies like the IMO and IHCA and we have asked them to consider the appropriateness of them providing support services for doctors who are subject to a complaint before the Medical Council — in particular, for doctors who find themselves in circumstances where they are unrepresented,” she explained to IMT.

According to the Council’s 2012 report, 45 doctors were involved in FTP inquiries: 39 were represented, six were not.

Support schemes
Spillane added that the Council has also raised this issue of support services with the postgraduate training bodies, who had access to communities of doctors through their programmes of professional competence. “We feel that, particularly with doctors who are in training, the postgraduate training bodies are well placed to do this, and a number of them have put in place programmes to try to respond to the health concerns of the profession and the stresses they experience.”


Dr Andrée Rochfort

Indeed, the RCPI Physician Well-being Programme provides support and education for trainees, members and fellows, and puts on several courses designed to help doctors manage stress and workplace challenges. Likewise, the ICGP Doctors’ Health Programme, under Dr Andrée Rochfort, consists of healthcare networks and an information service offering confidential healthcare through a GP for GP service, a network of occupational physicians, or networks of psychiatrists and counsellors.

Meanwhile, the Sick Doctor Scheme is accessible to all doctors from any medical discipline who may have a problem or are concerned about a substance misuse issue. However, its Chair, Dr Íde Delargy, has coordinated a group of practitioners in developing a proposal for a Practitioner Health Matters Programme in Ireland to replace it.

The Medical Council also has its own Health Committee, to which doctors can either self-refer or be referred through the Fitness to Practise process. Forty-five doctors were supported by the Health Committee in 2013, for reasons including mental, disability, substance abuse issues and neurological disorders. Fourteen of those 45 were self-referrals, 15 were referred by third parties, four by the Fitness to Practise Committee (Section 67), and 12 by an FTP inquiry.

“I think that is widely regarded as being quite a supportive structure for doctors either to self-refer to or to work with to try and make sure that they can do everything they possibly can to get back into mainstream practice,” commented Spillane.

In his response to the suicide report, GMC CEO Dickson pointed out the need for legal reforms. Is there a similar requirement here in Ireland?

The IMC CEO has already touched on how the Medical Practitioners Act requires the Council to investigate every complaint, even vexatious ones, and said Kingram House had ongoing dialogue with the Department of Health in relation to the provisions of the Act.

“When we look internationally at developments in medical regulation, of course you are going to see different and evolving approaches to how professional standards matters are dealt with in various jurisdictions,” commented Spillane.

“I think that the Medical Council is always open to presenting possible policy options to the Department of Health in order to ensure that — for the benefit of the public and that of the complainants — an enquiry process can be legislated for and then implemented in the most straightforward, efficient and effective manner.”

The finding that 28 doctors undergoing FTP investigations died by suicide or suspected suicide over an eight-year period has caused many in the UK to sit up, take notice and propose changes to how they manage complaints against doctors, and the ripple effect will surely be felt here in Ireland.

The GMC is already understood to be introducing ‘emotional resilience’ training and a national support service for doctors following the review. What changes emerge here may well become more apparent after the IMC releases its five-year-review in the coming months.

• Continued next week

Contacts
ICGP Doctors’ Health: Email andree.rochfort@icgp.ie or sallyanne.o’neill@icgp.ie.
RCPI Physician Well-Being Programme: Email wellbeing@rcpi.ie.
Sick Doctor Scheme: Email dridedelargy@eircom.net
• Medical Council Health Committee: Contact John Sidebottom at jsidebottom@mcirl.ie or tel 01-4983115.

Dara Gantly

Click here to view the full article which appeared in Irish Medical Times