2012 accountability hearing with the General Medical Council - Health Committee Contents


4  Professional regulation

Trends in complaints against doctors

80. The GMC recorded 8,781 concerns about doctors' fitness to practice in 2011, compared with 7,153 in 2010, a 23% increase.[66] 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".[67] 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.[68] 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.[69]

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.[70]

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 protect patients.[71]

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.[72]

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:[73]

  • 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 investigation.
  • 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.[74] 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 CASES

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 demanding.

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 Service

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 functions.[75] Establishment 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.[76] 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
Assessment

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.

Investigation

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.

Determination

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.

94. We 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.[77] The GMC says that the necessary legislative changes will be proposed by the Department of Health in 2013 subject to the legislative timetable.[78] We 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

67   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

68   Ibid, p. 39 Back

69   Ibid, p. 34 Back

70   Ibid. Back

71   Ibid. Back

72   Ibid., p. 37 Back

73   Ev 36-37 Back

74   Q89 Back

75   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.  Back

76   Q77 Back

77   HC (2010-12) 1429, para 36  Back

78   Ev 36, paras 47-48 Back


 
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© Parliamentary copyright 2012
Prepared 3 December 2012