Suspension of doctors
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7433.181 (Published 22 January 2004) Cite this as: BMJ 2004;328:181All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Suspending a consultant over a bowl of soup really makes a mockery of
current disciplinary procedures in our NHS. Of course it is not the
procedures we should blame, but the individual who suspended the
consultant should be held accountable. Accountability is absolutely
essential not just for the doctors but also for the managers and Directors
including the Chief Executive Officer (CEO). If Mr. Hope was suspended for
not paying for crouton or soup, then God save the NHS and the disciplinary
procedures. It is rather shame that the Nottingham Trust did not consult
the National Clinical Assessment Authority (NCAA). In the best interest
of the NHS and to make sure that the doctors can trust existing
disciplinary system, there must be an investigation which should be
conducted by an independent body in to this whole ‘soup affair’ and people
who made the error in judgement must be held accountable.
I am not saying this just because Mr. Hope was a neurosurgeon or a
doctor. This should apply to all the staff in the NHS. I thought this type
of incidence happened only in Nottingham, until my friend told me that in
his Trust a few years ago a nurse was dismissed for stealing a packet of
crisp from a patient! Of course it is not acceptable to steal from anyone
that too from a patient, however punishment should be proportionate to the
crime and accountability doesn’t necessarily mean suspension or dismissal
Competing interests:
None declared
Competing interests: No competing interests
One of Mr Hope's colleague's at Queen's Medical Centre is reported as
saying, "To pull a neurosurgeon for anything, unless he is technically
dangerous, must hazard the whole service". [1] That is perfectly true
especially when the consultant's work is not properly covered. Lord Warner
reassured Baroness Knight and the rest of the House of Lords at around 8pm
on Monday evening that very expert care would not be denied to very needy
people and that there would be no detriment to patients as Mr Hope's
colleagues would cover the work that Mr Hope was due to perform. He had
been "reliably informed" of this;no doubt that was by the managers at
Queens or his own officials.[Lords Hansard, 22 March 2004 column 558]. The
very next day on Tuesday 23 it was reported that three patients who should
have been operated on were not operated on. Exactly when they were
cancelled has not been disclosed but hopefully it was after 8pm Monday
evening. There was "detriment" to those three individuals contrary to the
reassurances that Lord Warner had given to Baroness Knight to set her
mind at rest.
Now that Mr Hope is operating again he has these three patients on a
new list and as a result other patients planned for in the future will
have their surgery dates pushed back further. Will any of those patients
come to harm - possibly fatal harm by for example a rupture of an aneurysm
- by the longer delay in their treatments caused by the rash, rushed
suspension of Mr Hope? Such a suspension is contrary to the priority
stated in the 2002 Code of Conduct for managers to protect patients from
risk. The Department of Health had clearly signalled the mandatory need
for the NCAA to be involved in a doctor's suspension. It seems to be
splitting hairs for it to be pointed out that it was not necessary to do
this until April. The manager who took the decision to suspend Mr Hope
should be held to account using the 2002 Code of Conduct. However, that is
very unlikely to happen as this Code is not widely accepted within the NHS
according to a trust chair person.[2]
Codes alone are useless for fair, effective manager regulation and
the responsible minister, Mr Hutton, should be well aware of that by now.
Positive steps are required to bring senior managers into line with all
other NHS professionals as was stated after the Bristol Inquiry. This
should be done for public safety and in the public interest and Mr Hutton
should push for a review to consider establishing a proper register and
regulatory body before it is too late and the next Bristol emerges. Too
much can remain hidden under the minister's current chosen and favoured
system of regulation. Regulation failures should not be so readily
tolerated and excused by the Department's ministers.
[1] Verbatim. T2 23 March 2004, The Times
[2] Sir Nigel Crisp NHS Chief Executive.
www.nhsexpose.co.uk/sir_nigel_crisp.htm (accessed 16.2.04)
The views expressed are my own and not those of my employing
organisation.
Competing interests:
None declared
Competing interests: No competing interests
Editor,
The Editorial by Professor Empey on the suspension of doctors(1)
provides a sound insight into what has become one of the most shameful
episodes in the history of the NHS with profound wastage of money and
enormous damage to many competent and caring doctors and their families
over the past twenty years or so. The report from the National Audit
Office(2) makes grim reading.
When this thorny issue has been discussed or written about, the
emphasis has generally been misleadingly on how to deal with the situation
when doctors transgress, yet in the vast majority of instances the final
analysis shows that there has been no transgression – and this is the
scandal.
Experience shows that the making of allegations (which is how
suspension commonly occurs) most often reflects some personal ill intent
or over reaction to an incident or situation, whilst the ‘knee jerk’
response to receiving allegations (of misconduct) is to instinctively
believe them and too quickly launch the roller coaster of suspension with
lasting damage, ultimately to all parties. Apologies to the victim,
following exoneration, have proved all too rare and many exonerated
doctors never return to work.
Let us hope that this report from the National Audit Office will
represent a watershed and provide the opportunity to move on and that a
mature, measured and humane way forward will emerge.
1. Empey D, Suspension of Doctors, BMJ 2004; 328; 181-182
2. National Audit Office. The management of suspensions of clinical
staff in NHS hospital and ambulance trusts in England. London: Stationary
Office, 2003.
(HC 1143 Session 2002-03)
Competing interests:
None declared
Competing interests: No competing interests
Dr Nigel Dudley comments above that there is a case for establishing
a unit that has the expertise to handle suspensions. I rush to correct
him. There is a case for re-establishing a unit to handle suspensions.
This was a function that was carried out by the old Regions, and ceased
when they were dissolved.
Ten years ago, a regional medical officer commented this power would
devolve to local trusts. Each medical director would face the problem for
the first time, and there would be no corporate knowledge.(1) In fact the
author felt sorry for the Medical Directors and not the poor practitioners
in the front line.
In short each Trust would make its own mistakes and would learn
nothing, only for another trust to repeat its learning curve. All this
valuable repeated learning about disciplinary procedures would always be
done at the expense of someone else’s career by the way. The RMO was the
later knighted Dr Liam Donaldson – what better man to undertake the
resolution of the problem he predicted all those years ago, as he is now
Chief Medical Officer?
I pointed out the conjunction of Trusts lying about waiting lists and
other trust making less than frank referrals to the GMC a year or so
ago.(2) What I said was that trusts have demonstrably lied about waiting
lists and are not so picky either about what they allege to the GMC.
Trusts are not registered with and answerable to the GMC as medical
practitioners are, and so basically they can say what they like. That is
why I suggested to the GMC that they put in observers into hospital
inquiries – so that really they could see the hanky-panky first hand. The
GMC demurely declined the invitation. (3) That is why I regard the GMC
packed as it is with Whitehall appointees, as both deaf and blind, and
therefore has something in common with the BBC board of governors (itself
exhibiting a short shelf life).
Both institutions have not aged well, are unfit for purpose and
should be pensioned off.
Oliver Dearlove FRCA
Refs 1 Donaldson LJ Doctors with problems in an NHS workforce
BMJ 1994 308 1277-1282
2. Dearlove O Liar! :Liar! (e) British medical Journal 2003
http://bmj.com/cgi/eletters/326/7388/517 10 Mar 03
3. Tupper J The usual unaccountable mess continues.
http://bmj.bmjjournals.com/cgi/eletters/327/7426/42145
Competing interests:
The author is a Councillor of the Royal College of Anaesthetists and is a full time NHS consultant. These views are his own and are not shared by the The Royal College of Anaesthetists or his employer
Competing interests: No competing interests
Like Duncan Empey, I welcome the new guidance and directions from the Department of Health on the suspension of doctors.1 I was suspended for 6 months by my NHS Trust from October 2000, before the establishment of the National Clinical Assessment Authority (NCAA), and had to undergo a period of supervision for a year following a recommendation from the Royal College of Psychiatrists. I, therefore, speak with experience about clinical governance.
According to the National Audit Office (NAO), I am in the minority of suspended doctors that have returned to work (40%).2 The length of my suspension was below average (47 week average), not least because I went along with the recommendation from the College even though I did not accept it. As noted by NAO, there are concerns about the thoroughness and rigour of external assessments.
My problem is the potential ideological nature of suspensions. Medicine, perhaps particularly psychiatry, is not an exact science. Attitudes and approaches vary from the biomedical to the psychosocial, and biomedical bias is reinforced by defensiveness about the personal nature of medicine.3 Psychiatry especially has been infused by conflict, perhaps best reflected in the debate about so-called "anti-psychiatry".4
In my own case, for example, I was told I needed retraining and would be sent for further education in organic psychiatry. The College assessors indicated that if I did not accept their recommendation that my philosophy about psychiatry would need to be examined and my scepticism about the use of medication challenged. Although none of these things happened, it is difficult to think they were not motivating factors in my suspension.
I am not sure if critical psychiatry, which is the position I represent, has been strengthened by my experience. At least, information about critical psychiatry is now available on the Royal College of Psychiatrists' website.5
- Empey D. Suspension of doctors BMJ 2004; 328: 181-182 [Full text]
- National Audit Office. The management of suspensions of clinical staff in NHS hospital and ambulance trusts in England. London: Stationery Office, 2003. (HC 1143 Session 2002-2003.)[Full text]
- Stewart M., Brown J.B., Weston W.W., McWhinney I.R., McWilliam C.L. & Freeman, T.R. Patient-centred medicine. Transforming the clinical method. Second edition. Abingdon: Radcliffe Medical Press, 2003
- Double D.B. The limits of psychiatry. BMJ 2002; 324: 900-904 [Full text]
- Royal College of Psychiatrists webguide. Critical psychiatry. http://www.rcpsych.ac.uk/info/webguide/critical.htm [Full text]
Competing interests:
None declared
Competing interests: No competing interests
Sir,
Dr Empey's comments on the disgraceful way hospitals currently deal
with complaints with suspensions is welcomed and overdue - although may
still under-estimate the problem. His optimism that the situation will
improve with new guidelines may be misplaced.
From personal experience of several recent cases, I know that sadly,
Doctors - rather than the system are largely to blame. Most suspensions
are due to personality clashes with the most powerful figures in the
institution winning. If doctors stood up for each other and received early
support from their professional bodies and defense unions - most cases
would be averted. Once suspended the doctor (> 90% of whom are not
guilty of anything) are instantly ostracised and denied help or suport by
colleagues who fear for their own careers and merit awards and don't want
suspicion thrown on them.
Most doctors believe they can expect help from the BMA - but in the
cases I'm aware of - they are good at counselling - but completely
toothless in their ability to do anything to alter the situation. They
also advise most people against fighting the charges and ' making a fuss'
that could worsen their reputation and that of UK doctors. The BMA also
know precisely which Trusts and medical schools are the worst offenders in
employement relations - but refuse to make this crucial and influential
data public.
What about the Defense unions? The MDU refused to help defend one
suspended colleague falsely accused of ethical misconduct in research -
with the excuse that this was simply ' an academic tiff' and their cover
is always 'discretionary'. This should surprise (and frighten) most
consultants who do research and faithfully pay their annual subcriptions -
for whom a risk from 'academic tiffs' is greater than patient complaints.
This effectively leaves Dcotors with having to pay for their own expensive
defence if they wish to clear their name.
Until Doctors and their organisations get their act together and
start helping each other - and deal with the system that condones the
climate of false accusations and bullying in medical institutions - the
suspension culture (or a new substitute) will unfortunately continue.
Competing interests:
None declared
Competing interests: No competing interests
Although I would agree with Duncan Empey's comment that the recent
direction from the Department on the suspension of doctors represents
progress, and it is major progress with the mandatory need for the NCAA
referral, he has glossed over the fact that it has taken nine years for it
to be produced. He also failed to highlight the significant risk to
patient safety caused by suspensions and threats of suspensions as
exemplified by case 8 in the NAO report where a trust's culture was one
where consultants feared bullying and victimisation if they raised any
concerns about safety issues.
Badly planned and executed suspensions compromise patient care and
put patients at risk; in view of the requirements of the October 2002 Code
of Conduct for managers to give top priority to protecting patients from
risk the rash, rushed, arbitrary suspension of a doctor should simply not
be happening these days. If it does then the responsible manager should be
held to account by either the trust board or even the NHS chief executive
under the terms of the Code. If those pathways of accountability fail then
the Committee of Public Accounts (PAC) MPs can hold the Department to
account on behalf of the public.
The rash, arbitrary and inappropriate suspension decisions highlight
a lack of sufficient legal and HR expertise in many trusts dealing with
doctor suspensions. The same problem was also highlighted in the NAO
report about waiting list fiddles and managers that was published in
December 2001. Even after the meeting in Janaury 2002 between the PAC MPs
and senior civil servants representing the Department of Health ministers
there have been continuing manager disciplinary and suspension problems in
places such as Bath and Good Hope that have resulted in mistakes and
significant payments made to ex-managers by the taxpayer. In the case of
Good Hope there was even a confidentiality clause included that has
prevented proper public scrutiny of events leading to the unfair dismissal
of the chief executive and the size of the compensation payment made by
the trust from public funds; this gagging clause is against the express
wishes of both the Department and the PAC MPs as it is inconsistent with
the proper use of public money.
The main problem is that the procedure and processes around
suspensions of both senior managers and consultants are complex matters
requiring specialist HR and legal skills and good, non-biased judgment so
as to avoid unfair dismissal and inappropriate suspensions. Gisela Stuart
said in 2001 when Under Secretary of State for Health that "issues
regarding employees are the responsibility of the local employing trust,
which must take the decision. Our role is to ensure that proper processes
are followed" (Hansard Commons 27 March 2001:Column 944). There is a case
for establishing a central unit or alternatively gathering a more loose
network of appropriate legal and HR experts who could be called upon by
any trust to help in these difficult cases so that the proper processes
are followed. This should be done for the benefit of doctors, managers,
and most importantly the patients who are ultimitately the ones to suffer
either from the loss of resources to frontline care or the skills of
senior managers and medical staff.
Competing interests:
None declared
Competing interests: No competing interests
When we work together in the NHS we believe in teamwork, teams
Decision. Achievements and progress by NHS trusts are regarded due to
Collective effort of the trust. But if something goes wrong or mistakes
are
made in the same trust then why is it that a single individual has to
take the blame and if it is serious he/she may even be suspended. Why
? Where is the team and why do they not want to take collective
responsibility?
We should stop this blame culture and suspension of doctors
would neither improve patient care nor prevent future mistakes from
happening. Rather I believe it is sidetracking. Moreover it is depressing
for the entire medical professionals who work very hard for effective
Patient care. The answer lies in taking necessary precautions to stop them
from happening. Trusts should take adequate steps in improving patient
Care. This involves retraining in dealing with similar situations,
learning
from mistakes, counseling, good teamwork, risk management, good leadership
and staff support at all levels.
Competing interests:
None declared
Competing interests: No competing interests
Realistically,there will never be a suspension-free medical
profession.There will always be cases,unfortunately, that suspension is
the only reasonable step to take until investigations are completed.As
many will know,genuine risks to patients is not the main or only reason
for suspensions. It is clear in DoH regulations and Trust policies(and as
far as I am aware the GMC too, guides similarly) that a doctor's unlawful
or improper conduct which could seriously damage the career
progression/practice of his/her colleagues, may also merit suspension. So
there are cases where individual blame should be aportioned rather than on
system failures.
In fact,I found such badly behaving Consultant while trawling through
an online forum for Indian doctors(1).I presume he will have to face the
'music' in due course, so no more unsuspecting doctors would become
victims of his unlawful conduct.However,I am not sure,what if any, remedy will be
there for his past victims.Fortunately (or perhaps,unfortunately),only
rarely one finds such evidence-based racism that could seriously damage
the career prospects of unsuspecting Asian doctors.
References
(1)Online Confession of an Asian Doctor
[http://bmj.com/cgi/eletters/327/7427/0-h#42432], 5 Dec 2003
Competing interests:
None declared
Competing interests: No competing interests
Do they really work?
A lot is talked about improving doctors working conditions. Millions
are being paid to do that. EWTD was /is implemented to make it easy for
doctors to have some quality time. New regulations are drafted at the drop
of the hat.
The documents on suspension are very much welcomed. Would it work?
Would it really be a helpful tool to identify under performing doctors?
That’s something that I am not sure about. Agree that suspension is
expensive. It is more expensive in the long run. Suspended doctors return
to work is fraught with difficulties. A sense of lack of confidence, fear
of being stigmatised is another issue altogether. More so if the
suspension is perceived by the suspended doctor as a mean to get them out
of the trust. Examples can be cited when doctors have been suspended for
whistle blowing. They find themselves unable to find work.
Many times, suspension of a doctor is triggered by the fact that they
have identified an under performing doctor who is liked by the management.
Is it doctors fault when they identify an under performing doctor? If they
do, what should they do? General Medical Council says they should speak to
someone to minimise risk to the patients. Medical directors of the trusts
do not feel this way. GMC takes no action unless the trusts have completed
their internal enquiry. Trust would not give out the evidence to prove any
point for the whistle blower. Trust would protect the favoured one and
crucify one who dare.
Trusts are getting more powerful. Foundation trusts shall have more
control on finances. Once a doctor is suspended, people are judgmental.
Though, onus is on the trust to prove that they were right in suspending a
doctor, does it help the doctor if they were not able to prove anything?
Would the trusts management be brave to accept the mistake of wrong
suspension and take the responsibility of incorrect use of public finances
in sustaining the expenses incurred that come bundled with the suspension
of a doctor.
I feel all the talks about safe management, avoiding suspension
unless patients safety is an issue, getting suspended doctors back to work
are nothing but sweet talk and brain storm of some one sitting in warm
comfy office with a vision.
Does it mean we should shut our eyes when we see an under performing
doctor? That would not only be unethical but unprofessional. I suggest
make a written record of everything, keep copies of all the notes, events
etc. Make sure one can prove the point and document that the doctor is at
risk to patient before you pick that whistle to blow!Otherwise, welcome to
the world of suspended doctors. All these documents are drafts only and
usually ignored or followed as it suits the trust aka management!
Competing interests:
None declared
Competing interests: No competing interests