The performance of doctors. II: Maintaining good practice, protecting patients from poor performanceBMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7094.1613 (Published 31 May 1997) Cite this as: BMJ 1997;314:1613
- Donald Irvine, president, General Medical Councila
The public now seeks assurances that doctors remain capable and safe throughout their practising lives. For the profession this means refocusing self regulation on fully established doctors.1 For the General Medical Council it means that all doctors on the register working in Britain must maintain an appropriate standard of practice. Where doctors do not, the GMC must ensure that action is taken, either locally or by itself. The first concern is to protect patients. The second is to find out what has gone wrong and to establish the cause. The third, wherever possible, is to help doctors recover their fitness for normal practice.
The principle that doctors should be able to show that they practise safely is unarguable. Unfortunately, discussion of the means tends to be contentious because of the threat of “recertification,” implying the regular testing of all career doctors. Yet there must be considerable doubt about whether, in our current state of knowledge, a formal national programme of periodic recertification would achieve the results that its advocates claim. There is no consensus on method, and the benefits would be small when measured against the cost of assessing large numbers of doctors already considered to be performing well. Given these uncertainties, a different approach may be more constructive.
All doctors have a duty to maintain good practice
Patients must be protected from poor practice
Dysfunctional doctors should be helped back to practise wherever appropriate
Openness about doctors' performance is essential to public trust
Interests of the public and the profession may best be served by the development and implementation of a coherent, properly paced, and well balanced strategy of quality assured, professional self regulation based on the principle of management by exception.1 This would allow flexibility through strategies tailored to differing needs and circumstances. Practitioners who were known to be working well would be encouraged to continue, while proper attention would be given to doctors at risk or in difficulty.
Such a strategy would rest on a strengthening of our culture of professionalism.1 It would be inclusive, involving all doctors and embracing continuing medical education, personal professional development, clinical audit and quality improvement methods.2 It would have six core components:
a clear ethical framework and, wherever possible, the use of explicit professional and clinical standards1;
effective local professional regulation for maintaining good practice;
regular publication by the royal colleges and others of data showing doctors' involvement in continuing medical education, audit, and other performance related activities;
sound local arrangements for recognising dysfunctional doctors early and for taking appropriate action;
well defined criteria and pathways for referral to the GMC when severely dysfunctional doctors cannot or should not be managed locally;
at all stages, practical help and support so that doctors who get into difficulties can be restored to full practice, wherever possible.
Maintaining good practice
The universities, royal colleges and professional associations, with the NHS, are already strengthening the continuing professional development of established doctors. Each college is showing what is required for effective practice in its branch of medicine. But there is an underdeveloped area–local self regulation–which needs to be highlighted.
Local professional self regulation
The term local self regulation embraces the policies, arrangements, and processes used by doctors at their place of work, in their locality, and within their specialties to maintain and raise standards of practice and to tackle dysfunctional practice when it occurs.
The starting point remains the duty of the individual doctor. However, today most doctors work in medical and multiprofessional clinical teams. Most general practitioners belong to medical partnerships and practice teams, and comparable arrangements exist in hospitals. The idea that doctors in teams should assume some collective responsibility for their standards of practice is now taking root. It makes sense to create a mutually supportive environment which helps to maintain the clinical effectiveness, integrity, and good name of the team as a whole, including its individual members (box).3 4 5 Everybody benefits.
Maintaining good practice
Doctors are most likely to maintain good practice when they work in teams which
Have clear values and standards
Are collectively committed to sustaining and improving quality
Foster learning through personal and team professional development
Care for each member
Have a “no blame” culture
Are committed to the principle of external review
Are open about their professionalism
Effective teams use
Clinical guidelines and operational protocols
Focused education and skills training
Systematic audit of performance with feedback
Regular, formative peer appraisal
Critical incident review
Risk management methods
Teams working in this way are able to document and demonstrate the results of their work, including insights on their performance, so that the outside world can see that their members are functioning well.
This kind of proactive, team based, self regulation needs proper resources. It takes time and effort to do well. NHS trusts, health authorities, and health boards should value and support it as a tangible expression of their commitment to supporting modern professionalism in health care.1 The achievement of management's aims is critically dependent on the sense of professionalism, and commitment, among doctors and other health professionals.6
Handling dysfunctional practice locally
The GMC has said in Good Medical Practice that doctors have an ethical responsibility to act where they believe that a colleague's conduct, performance, or health is a threat to patients–if necessary by telling someone from the employing authority or from a regulating body.7 Doctors who ignore this responsibility place themselves at risk of action by the GMC.
In practice the judgment is never easy,8 so the GMC is thinking about the best ways of helping doctors faced with this dilemma. Its approach starts with self regulating teams of the kind described above because they tend to have the will, policies, skills, and information necessary to identify, confront, and manage dysfunctional practice when it first appears. Firm but constructive handling at that stage can often limit the damage caused to patients and the colleague in difficulty. If team based attempts at remediation fail to resolve the problem, doctors are less likely to feel guilty about asking for outside help.
Beyond the immediate team are the local hospital and district arrangements for professional regulation. These arrangements range from informal peer networks, for example, through local medical committees in general practice and, in hospitals, peer driven NHS mechanisms such as the “three wise men” procedures designed originally to help manage sick doctors.
A determined effort is being made by the profession and the NHS to formalise and strengthen the local arrangements for managing problem doctors, whether they practise with others or are single handed.9 The chief medical officer has recently given guidance to NHS chief executives and trust medical directors in England.10 The GMC is working with the British Association of Medical Managers and the BMA to ensure that doctors in local positions of responsibility become thoroughly familiar with the GMC's procedures. It is ready to provide expert advice in confidence about difficult cases, and the boundary between the GMC and NHS complaints and disciplinary procedures is being clarified.
Within 12 months everyone should know what to do and when; what criteria should prompt colleagues working together to refer for local action; and what criteria should indicate onward referral to the GMC.
The GMC: fitness to practise
Some doctors seriously breach accepted standards of professional conduct and practice. Others become ill without recognising the consequences for their patients. Yet others show evidence of a pattern of poor practice, the causes of which include professional isolation, complacency, arrogance, idleness, and simply losing touch. Some are referred to the GMC by patients or are reported by the courts. But if local professional self regulation is working as intended, other dysfunctional doctors will have been identified by their colleagues and local action taken. Some will be beyond local care, necessitating referral to the GMC.
Examples of serious clinical dysfunction in doctors
Case A–A general practitioner, qualified for 25 years, refused to visit several patients whose histories indicated that visits were necessary. He prescribed erratically, often on the basis of inadequate information; in one case this led to a serious adverse reaction. Case notes, when present, were scanty and often incoherent. Despite two service hearings and counselling by a member of the local medical committee, the pattern of dysfunctional behaviour continued.
Case B–A consultant showed lack of skill carrying out practical procedures. In addition he habitually would not listen to patients or colleagues and would respond aggressively to expressions of concern. Time management was a major problem, with no sense of urgency when responding to requests for help from anxious juniors. Despite local offers of counselling, he refused to accept that there was a problem.
The Medical (Professional Performance) Act 1995 gives the GMC new powers to investigate a doctor's performance and, where it finds the standard of performance to be seriously deficient, to impose conditions on or to suspend a doctor's registration.11 From September 1997 the GMC will therefore have at its disposal a range of procedures–conduct, performance, health–for dealing with seriously dysfunctional doctors. Protection of the public is the first priority, coupled with the rehabilitation of the doctor wherever possible.
Under these performance procedures, a doctor's registration may be questioned by repeated or persistent failure to comply with the professional standards appropriate to the work being done by the doctor, particularly where this places patients or members of the public in jeopardy. This may include repeated or persistent failure to comply with the GMC's guidance in Good Medical Practice (GMC minutes, May 1996).
What will happen?
If one or more complaints suggest a prima facie case of seriously deficient performance, the GMC will trigger an assessment of the doctor's practice. The assessment will be carried out at the doctor's place of work by three assessors, two medical and one lay. The medical assessors will be from the same specialty. The initial appraisal of performance may be extended to cover the doctor's knowledge and skills in more depth. The assessment should give an accurate picture of the doctor's performance; this will form the basis for the GMC's decision about what should be done.
Doctors whose performance is found to be seriously deficient, whether locally or after referral to the GMC, should have every reasonable chance of putting things right through remedial action. Doctors will be able to seek preliminary advice and help through their regional postgraduate dean or regional director of postgraduate general practice education.
The public and the medical profession share a common interest in showing that doctors provide a good standard of practice and care, and that patients are protected from doctors who are not safe. The GMC's strategy offers a practical way forward. Good documentation at every stage, and openness with the results, will be essential to see what works and where the gaps are. The strategy can be developed and refined in the light of experience and on the basis of evidence. Success in implementing this strengthened professionalism should secure the public's trust and safeguard the independence of the profession.
These papers are based on the George Haliburton Hume, Cohen, and Telford lectures (1996) given in Edinburgh, Newcastle upon Tyne, and Manchester respectively. I thank the friends and colleagues who have commented on them.