Complaints and Raising Concerns - Health Contents

4  Professional regulators and complaints

92. The GMC and the NMC both gave evidence on their handling of complaints made against their registrants. This builds on work we have previously undertaken in accountability hearings.

93. Both have undertaken to give greater assistance to the public in supporting complaints made against medical professionals, for instance in support to witnesses appearing in disciplinary cases. Niall Dickson, Chief Executive of the GMC told us:

    …one of the key areas that we highlighted in the pledge to the Clwyd/Hart review was about how we support complainants through our process. Traditionally, it has to be said that the GMC…historically have dealt with complainants by writing them letters, often fairly legalistic letters, which are sometimes difficult for complainants to understand, and then the only time that they would see the complainant would be when they turned up for a hearing, if there was a hearing in that particular case. So we have started a process…whereby we actually meet complainants…at the start of the process…

    This gives us an opportunity first of all to set expectations, because sometimes complainants have unrealistic expectations of what our processes can do, but also to listen to them, what is really concerning them and what they wish addressed. There is that initial meeting and then there is somebody there to whom they can go during the process. We are also meeting them at the end of the process, when the process is concluded, to explain what has happened during the process and why the decisions, whatever the decisions are, have been made in that. That process of face to face meetings is, as I say, obviously at a very early stage…but the early signs are that patients and relatives really welcome this. Inevitably, you will get more positive at the beginning than at the end because, in our business, inevitably, some people are disappointed at the end of the process, whether they are the doctor or indeed the patient who is complaining.[54]

94. For the NMC, Sarah Page, Director of Fitness to Practise, told us that

    …during last year we spoke to a number of witnesses who had been involved in our hearings and asked them about their experience, from making the referral or the complaint to us in the first place through the process up to the point of attending one of our hearing centres. Using that information, we identified some of the things that we needed to improve. One of them was around having, for example, a single point of contact for a witness through the proceedings. Another was about just making sure we kept people informed at the various stages as things progressed. Witnesses also told us that the actual environment where they had to attend to give evidence was very important to them, and we have made a number of improvements based on that—to make the hearing centre a place that is more comfortable to wait in so that witnesses feel more relaxed when they are called upon to give evidence and various other changes of that type, including providing better training to our staff and our panel members so that they are all aware of how difficult it is to carry through a complaint to the end. What we are intending to do later on this year is to go back and do the evaluation of that by asking another group of witnesses whether or not the changes we have made have brought about improvements.

    …One of the things that is important for us to address right at the beginning is managing the expectation of the person who is complaining to us in terms of what we can do—what changes we can effect…we are a regulator that regulates individuals. We can take action to protect the public. We can't necessarily resolve all the issues that the witness may have brought to the table, so part of what we do at the beginning is making sure that the witness understands the part they are playing in the process and what the possible outcomes may be. Also, in terms of demystifying the process, we offer an opportunity to witnesses to come and have a look at a hearing centre, sit in the place where they are going to give evidence and also understand some of the jargon and some of the questions they may be asked, to try and help people through that process.[55]

95. The GMC also made clear that its purpose is to hold to account the practice of its registrants only: it does not seek to involve itself in examining the clinical governance arrangements in Trusts. Niall Dickson told us:

    Our focus is on individuals, not on the hospitals themselves. That does not mean, of course, that we are not concerned with or do not seek to influence the culture within organisations, nor does it mean we do not have to rely on—which we do—the recommendations, for example, for revalidation, which are based on clinical governance arrangements within these institutions. But we have neither the statutory powers, nor the resources, frankly, to start second guessing and inspecting the clinical governance arrangements, including the culture of safety…[56]

96. The GMC has a helpline for staff to raise concerns about medical practice, including about the practice of its own registrants. The GMC told us in August 2014 that since its establishment in December 2012 the helpline had received over 1200 calls: these had covered a wide range of issues, and were not always about the fitness to practice of a doctor. 191 of the calls received had been about matters specific to the fitness to practise of one or more doctors, and 81 investigations had been opened as a consequence. 87 of these 191 calls had been made by people who wished to remain anonymous. The GMC told us that "we believe that the helpline will continue to be a useful tool in helping doctors to navigate their way through the complaints/raising concerns system. We also believe it gives doctors the confidence to act when they have concerns. We will continue to support this helpline and to increase awareness of its operation among doctors and professional bodies."

97. Of the 191 people who have contacted the GMC's confidential helpline to raise concerns about the fitness to practise of a GMC registrant between its inception in December 2012 and August 2014, just under half have not been prepared to identify themselves. This appears odd, given the confidential nature of the helpline: it may reflect an initial lack of confidence in any protocols surrounding the helpline's operation in its early days.

98. While we agree with the GMC that people wishing to give information about poor practice should be able to do so anonymously, we consider that medical professionals raising concerns about poor practice via a confidential helpline are under a professional duty to provide as much information as possible to enable the matter to be investigated and to put patients first.

99. We raised with the GMC witnesses the handling by the GMC of fitness to practise cases against registrants which had been initiated by other registrants, sometimes as counter-complaints, and by Trusts. There could often be strong conflicting claims of malpractice which were difficult to resolve, including instances where registrants were reported to the GMC for not themselves having reported instances of poor practice to the GMC earlier. Niall Dickson set out the GMC's general approach to dealing with such contested cases:

    [T]he basic principle is—and I do not think we should depart from this—that we should treat everybody the same in the sense of looking at the circumstances of their case, taking into account the context within which they have been working and then assessing the evidence to the best of our ability. The fact that somebody has complained about somebody else and then gets referred themselves—either way round—means we need to look at the circumstances of each case and examine its strengths and merits.[57]

100. Mr Dickson freely acknowledged that there were instances where a Trust could seek to use a referral as retaliation against a registrant raising legitimate concerns about practices in the Trust, and told us that "there is history around this of individuals who are classic whistleblowers".[58] In such cases, he observed that trying to differentiate instances where a registrant was raising genuine concerns from instances where a registrant's practice was giving genuine cause for concern and investigation was difficult. In such cases the GMC's approach had to be evidence-led:

    […] trying to sort this out, as it were, is part of what our investigations have to do. We have to try and establish where the truth lies. We should not automatically accept, because it is a trust's management, as you put it, putting in the complaint, that they are right and that the individual is wrong. You have to take it on the basis of the evidence that we are presented with.[59]

101. Niall Dickson was clear in evidence that the GMC wanted to support a more open culture in response to complaints, but that the way to achieve this was not to be heavy-handed in disciplinary matters:

    The idea that people will become more transparent and open because there is more threat on them I don't think works. I think we have to use another set of levers, more difficult and more complicated levers.[60]

He said that his concern was "the responsible officer level, the medical directors, who are, I think, beginning to take on the role of revalidation. We will absolutely hold them to account for what they do, but we also absolutely want to support them in doing what I think is a really difficult job".[61]

102. In response to concerns raised by the Committee about past disciplinary treatment of medical professionals who have raised concerns, the GMC has established a review chaired by Sir Anthony Hooper to examine how it deals with doctors who raise concerns in the public interest. Niall Dickson told that "One of the things we are prepared to do is to review how we handle the whistleblowing area and how we manage to deal with people who are saying they are whistleblowers. We want to get this right."[62]

103. The GMC acknowledges the complexity of many the cases it has to deal with, particularly where registrants and Trusts are involved in referrals and counter-referrals, and where there are strong conflicting claims of malpractice. The GMC has to take such cases on a case by case basis, and has defended to us its approach, which is to examine the evidence on all sides and see where it leads. It is inevitable that in such cases fine judgments will have to be made between competing claims in the GMC's adversarial and evidence-based processes which determine fitness to practise. The GMC has committed itself to a review of its practices, which we discuss further below. We welcome the willingness of the GMC to review its practices and investigations to ensure that they adequately support registrants who genuinely raise patient safety concerns in the public interest, and protect them from retaliatory action. Such a review must have as its primary purpose the establishment of an open reporting culture.

104. The Committee welcomes the GMC initiative in establishing the Hooper Review to examine how it deals with doctors who raise concerns, and looks forward to examining its conclusions.

105. Professional regulation is not formally part of the complaints system, but holding clinical professionals to account for failings which may have had significant effects on patients is an important part of protecting patients. Both the GMC and NMC are grappling with the issue of how to support those who raise concerns about clinical staff and advise them on what is and is not likely to be the outcome. Given the seriousness of the sanctions that can be applied by the professional regulators, the processes are necessarily very formal and, as with other issues we discuss in this report, change is an incremental process. Linking together professional regulation, system regulation and the complaints system is essential. Progress towards this goal is another issue that our successor Committee will need to monitor in the next Parliament.

54   QQ 340-41 Back

55   Qs 355-56 Back

56   Q359 Back

57   Q 374 Back

58   Q 381 Back

59   Q 382 Back

60   Q 389 Back

61   ibid Back

62   Q 383 Back

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© Parliamentary copyright 2015
Prepared 23 January 2015