4 Professional regulation |
Trends in complaints against
80. The GMC recorded 8,781 concerns about doctors'
fitness to practice in 2011, compared with 7,153 in 2010, a 23%
increase. There had
also been a 24% year-on-year increase between 2009 and 2010 (from
5,773 to 7,153) a matter on which we commented in June 2011 and
on which the GMC indicated it planned to commission research.
The GMC Annual Report for 2011 gives an overview of the outcome
of that research, indicating that factors driving the increase
were "changing attitudes on the part of doctors and the public
towards raising concerns, and improved clinical governance".
Older doctors were more likely to be the subject of a complaint
to the GMC: doctors who qualified 20 years ago or more are overrepresented
in complaints relative to their representation on the GMC register.
The GMC points out that there has been a wider increase in litigation
brought against the NHS in England, and that a comparative survey
of other regulatory jurisdictions had revealed similar trends
in Belgium, Denmark and the USA.
81. The GMC has since indicated that the volume of
complaints in 2012 had also increased: figures available for the
year to July 2012 indicated a 27% increase over that period, continuing
the steep upward trend.
82. While the GMC has stated that many complaints
do not meet their criteria for investigation, the overall upwards
trend has led to an increase in the number of doctors being investigated:
one doctor in 64 was investigated in 2011, compared with one in
68 in 2010. The inference the GMC draws from this trend is that
"over a working career [. . .] a doctor has a significant
chance of being complained about [to] and investigated by the
GMC", an observation which the GMC believes raises questions
about the relationship between the GMC and the profession and
requires the GMC to investigate "the right cases" and
deal with complaints "effectively and efficiently" to
83. The GMC proposes to commission further research
into the reasons for the rise in complaints from across the UK,
specifically seeking to understand the increase in complaints
from members of the public and the complaints which are closed
in the early stages of the GMC's fitness to practice process.
84. The increase in complaint volumes may be explained,
as the GMC's initial research suggests, by a general increase
in willingness to raise concerns about the practice of doctors:
it should not necessarily be taken to indicate a decrease in standards,
and we do not interpret it as such on the evidence before us.
We welcome the intention
of the GMC to commission further research to understand the sustained
upwards trend in complaints against doctors. The GMC should seek
to learn lessons from this research to inform its regulatory practice.
We look forward to discussing the outcomes of such research at
the next accountability hearing.
Fitness to practise investigations
PROPOSALS FOR PROCEDURAL CHANGE
85. The GMC has set out the measures it plans to
take to revise and speed up fitness to practise procedures:
- where there is no significant
dispute about the facts of a case, doctors should be able to accept
sanctions (suspension, erasure etc) without a case going to a
hearing. Decisions and the reasons behind them would still be
in the public domain. Doctors would be offered this approach,
where appropriate, in a face to face meeting at the end of an
- From September 2012 the GMC will pilot face to
face meetings with complainants to explain processes and ensure
it fully understands the nature and scope of the complaint, together
with a later meeting to explain the outcome of the case.
- The changes require amendments to legislation,
but will be piloted under current legislative arrangements while
the GMC discusses a legislative timetable with the Department.
- The period before an Interim Orders Panel has
been reduced to 21 days, in order to provide greater reassurance
that swift action is being taken where there are concerns about
a doctor's practice.
86. Niall Dickson expected that by the end of 2012
the GMC would begin to pilot its proposed meetings with doctors
under the investigations process in order to agree sanctions without
a referral to a panel of the Medical Practitioner Tribunal Service
(MPTS). The aim in entering into discussions with doctors under
investigation and their legal representatives would, he said,
be to encourage them to be "more frank and open" about
the pending charge and to agree what sanction would be appropriate
to protect the public.
87. Allowing a doctor to accept a sanction in a clear-cut
case without a hearing may speed up procedures and conserve resources,
and Niall Dickson indicated to us that the decision made would
be clear and public and subject to external review by the CHRE.
The avoidance of an open hearing may not necessarily serve the
interests of patient safety and public protection. There is a
potential reputational risk to the GMC and the medical profession
more widely if the perception is established that doctors are
able to accept the facts of a charge and negotiate a sanction
without any appearance before a panel or the presentation of any
evidence in public.
88. We note
the proposal to pilot arrangements where a doctor may accept a
sanction in a 'clear-cut' case without requiring a panel hearing.
We recommend that the GMC evaluate such pilots carefully to ensure
that there is no detriment to the public interest in not holding
a hearing, and publish detailed and clear guidance on the circumstances
in which such a procedure may be considered appropriate.
COMPLETION OF FITNESS TO PRACTISE
89. The CHRE set a target for the GMC of completion
of 90% of fitness to practice cases within 15 months of the date
of the enquiry. The GMC met that target in 2010 and 2011, and
agreed with the Committee in 2011 that the target was not sufficiently
90. We are encouraged in general to note the measures
which have been proposed to speed up the GMC's investigatory and
disciplinary procedures. While fairness demands due process to
be observed in all cases, it is in no-one's interests for cases
to be unduly delayed. We
continue to believe that the present fifteen-month target set
for the GMC to conclude 90 per cent of its cases is insufficiently
challenging; we invite the GMC to report to us in 2013 on the
proportion of cases concluded within 12 months in 2012.
The Medical Practitioner Tribunal
91. The Medical Practitioner Tribunal Service (MPTS)
commenced in June 2012 as a service operationally independent
of the GMC's complaint handling, investigation and case presentation
of the MPTS fulfilled an undertaking given by the GMC in 2011
that it would make a clear separation between its role of investigator
and presenter of cases and the adjudicator on those cases. As
part of the GMC, the MPTS also considers itself accountable to
Parliament, and we plan to examine its work as part of our future
programme of accountability hearings.
92. Based in Manchester, the MPTS is chaired by the
circuit judge His Honour David Pearl. The GMC told us that HHJ
Pearl had set as one of the first priorities for the MPTS "improvements
to the way that panellists are trained and performance managed
to ensure high quality and consistent decision making".
93. HHJ Pearl made clear to us that the MPTS was
in its early days, but in evidence he indicated the strategic
direction he had set for the service.
A three-person governance committee had been established to consider
high-policy strategic issues and matters concerning the procedure
and operational framework of the MPTS. Case management would be
a significant and consistent feature of the new service: while
case management of fitness to practise cases handled by the GMC
had been "sporadic and confined to some of the more high-profile
cases", HHJ Pearl considered that all cases required case
management, in order to eliminate, for example, "days being
lost on procedural wrangles that, frankly, should have been sorted
out at the beginning of the hearing". The MPTS had set up
a quality assurance group, which he chaired, looking at the quality
of decisions made Figure
1: how the GMC handles complaints
Complaints - 'enquiries' in GMC parlance - are assessed within a week of receipt to determine whether the information received raises a question about a doctor's fitness to practice.
If the information provided could never raise such a question, the enquiry is closed.
If the information raises serious allegations which themselves call into question a doctor's fitness to practice, a full GMC investigation is carried out, known as a 'Stream 1'.
If the information is less serious but may be part of a pattern, enquiries are undertaken with the doctor's employers or contractors to ascertain whether there are wider concerns. This information is then assessed to determine whether a full investigation should be carried out. The process is known as 'Stream 2'.
Two GMC case examiners consider the outcome of every GMC investigation of allegations against a doctor. They can:
- conclude the case with no further action
- conclude the case with advice
- issue a warning to the doctor
- agree undertakings with the doctors, or
- refer the case to a Fitness to Practise panel hearing
In certain circumstances an assistant registrar can also refer a case directly to a Fitness to Practise panel.
The GMC Investigation Committee will consider cases where the examiners have been unable to agree on a suitable outcome or where a doctor has opted for an oral hearing instead of a warning.
Interim Orders Panels and Fitness to Practise Panels are now operated independently by the Medical Practitioner Tribunal Service, which is operationally independent of the GMC.
An investigation may be referred to a MPTS Interim Orders Panel at any stage. This panel may suspend or restrict a doctor's practice while an investigation continues.
MPTS Fitness to Practise panels hear cases against doctors, decide whether facts are proven, determine whether the registrant's fitness to practice is impaired, and, if so, what actions are appropriate (erasure from the register, suspension from the register, conditions of practice, undertakings, and a determination of impairment with no further action).
in all fitness to practise and interim orders decisions,
and he had on occasion written to members of a panel to indicate
the importance of the reasons given for a judgment:
Whatever the decision of the panel, it needs to give
reasons that can be understood by [ . . . ] the doctor, the GMC,
the patients and the patients' relatives, anybody who reads the
decision and [ . . . ] if the matter goes to a higher court, by
the higher court.
Good decisions would be circulated to members to
reinforce best practice, and appraisal schemes would be introduced
for existing panel members alongside mentoring schemes for new
panel members: the MPTS proposed to recruit 80 medical members
to its panels in 2013.
are encouraged by the establishment of a functionally independent
Medical Practitioner Tribunal Service, which we believe will provide
greater assurance to the public about the quality of decisions
made by the regulator about the fitness to practise of doctors.
95. The emphasis placed by the Chair
of the MPTS on the consistency of its decision making, the effective
management of its cases and the dissemination of best practice
throughout the service is welcome. We look forward to examining
the progress of the MPTS in 2013.
RIGHT OF APPEAL AGAINST MPTS DECISIONS
96. In 2011 we recommended that the GMC press for
legislation to allow the GMC to appeal to the High Court against
MPTS decisions when it disagreed with the outcome of a hearing.
The GMC says that the necessary legislative changes will be proposed
by the Department of Health in 2013 subject to the legislative
welcome the commitment of the Government to propose legislation
to enable the GMC to appeal against decisions made by the Medical
Practitioner Tribunal Service. We ask the Government to make clear
when it intends to introduce legislation to fulfil this commitment.
66 GMC Annual Report 2011, para 28 Back
Further details of the volume of complaints are contained in The
state of medical education and practice in the UK 2012, General
Medical Council, September 2012, section 2.2. Back
Ibid, p. 39 Back
Ibid, p. 34 Back
Ibid., p. 37 Back
Ev 36-37 Back
The most high-profile case undertaken by the MPTS to date has
been the consideration by a fitness to practise panel of a case
of impairment by reason of misconduct against the pathologist
Dr Freddy Patel, which was concluded on 23 August 2012 with a
recommendation that he should be erased from the GMC register.
HC (2010-12) 1429, para 36 Back
Ev 36, paras 47-48 Back