Transforming the culture of healthcare: sick doctors and the GMC

Just culture

There is a natural tendency to blame people for errors rather than investigating systems.5 Lucian Leape, adjunct professor of the Harvard School of Public Health, cited healthcare’s blame culture in his testimony before the Congress on Health Care Quality Improvement. “The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes,” he said.

Problems with the blame culture in medicine have been highlighted in a series of reports over the past 15 years. The US based Institute of Medicine’s 1999 report To Err is Human concluded that of nearly 100 000 patient deaths a year owing to medical errors, 90% were not down to physician negligence, but to system-wide procedural failures at medical institutions.6 The 2001 inquiry into children’s heart surgery at the Bristol Royal Infirmary stated, “The culture of blame is a major barrier to the openness required if sentinel events are to be reported, lessons learned and safety improved. The system of clinical negligence is part of this culture of blame. It should be abolished.” 7

The 2013 report by Robert Francis into the failing at Mid Staffordshire NHS Foundation Trust stated, “Where there is a safety incident, you at least start with a no blame culture, because the moment that there is a blame culture, and staff feel they’re going to be blamed, these things will go underground.” The Francis report also quoted England’s former chief medical officer Liam Donaldson as saying, “Honest failure is something that needs to be protected, otherwise people will continue to live in fear, will not admit their mistakes and the knowledge to prevent serious harm will be buried with the patient.”

Don Berwick’s 2013 review into patient safety in the NHS began by saying, “Abandon blame as a tool, NHS staff are not to blame—in the vast majority of cases it is the systems, procedures, conditions, environment and constraints they face that lead to patient safety problems.”8

When airline pilot Martin Bromiley’s wife died in 2005 during a routine operation he wanted to find out what had happened. In an interview with the New Statesman he explained that he had assumed that the next step after his wife’s death would be an investigation, something that is standard practice after an accident in the airline industry.9 “You get an independent team in. You investigate. You learn,” he said. When Bromiley asked the head of the intensive care unit about whether there would be an investigation, the doctor shook his head and said, “That’s not how we do things in the health service. Not unless somebody complains or sues.”9

This captures so much of what is wrong with how we deal with errors and complaints. Bromiley set up the Clinical Human Factors Group in 2007 (http://chfg.org/). His key message is the importance of openness, candour, and honesty, as set out in the Francis report. In a video of Bromiley teaching healthcare professionals, he talks about those who were involved in his wife’s death, and says, “You will be pleased to know that they all returned to work … and that is exactly what I wanted, they can spread those very personal lessons on to their colleagues and all of them will be much better clinicians as a result of what happened, of that there’s no doubt.”10

Accountability, according to aviation and patient safety expert Sidney Dekker, is the ability and willingness to share accounts.11 The actions of the GMC, as the Civitas report makes clear, make doctors very afraid and unwilling.

The ability of patients to speak up and share their concerns about care is vital for patient safety.12 This depends on good relationships with healthcare professionals. When relationships are poor, patients are afraid to speak up and this puts safety at risk. Patients need to be able to express their concerns, and complaints if necessary, without contributing to an adversarial culture.

Doctors as victims

The emphasis in the Civitas report is on doctors as victims. Doctors can be victims not only of the excessive and bungling efforts of the GMC, but also of vexatious patients or employers, an intrusive and salacious media, and unaccountable users of social media and feedback websites. The Civitas report claims that the rhetoric of patient entitlement and choice has contributed to “a massive escalation in cases dealt with by the GMC.” I think we should be very wary of implicitly blaming patients.

A report from Plymouth University commissioned by the GMC and published just after the Civitas report showed that complaints are being driven by an increased, but poorly informed, public awareness of the GMC’s role in disciplining doctors.13 The increase in complaints appears to be fuelled by traditional media’s portrayal of “bad” doctors and facilitated by social media.

The Plymouth researchers describe the considerable public confusion about complaints procedures, which has led to complaints being made to the GMC that ought to have been dealt with locally without escalation. They found no direct links between media coverage of high profile cases and spikes in complaints. But they did, in common with the Civitas report, find more complaints relating to doctor-patient communication and relationships, higher expectations of professionals and less deference, and a greater ease of sharing information between patients on social media.

Both the Civitas and Plymouth reports emphasise the influence on complaints of changing relationships between patients and doctors. The Plymouth researchers report the “general perception that the nature of the doctor-patient relationship has changed, with patients becoming less deferential, better informed and more willing to question the care they receive.” The authors of the Civitas report appear to view this changing relationship as a threat, rather than an opportunity.

A considerable number of doctors and patients use social media to challenge one another, and the wider goals of medicine and health policy, in a spirit of enthusiastic curiosity. There are vigorous and encouraging debates challenging medical paternalism and the notion of doctors as victims.1415

The King’s Fund and The BMJ are doing excellent work with patients as partners.1617 Shared decision making between patients and professionals is a philosophical and moral position that challenges medical paternalism, but it also has a rapidly growing evidence base and an NHS website.181920 Patients’ preferences matter and so does good communication.2122

The Civitas report’s rose tinted view of the competent, skilful doctor who “lacks empathy and wastes little time on social niceties” as the innocent victim of unreasonable complaints doesn’t stand up to evidence linking good communication with appropriate clinical decision making, nor the importance of kindness in care.23 Patients have every right to want to be treated kindly and to be involved in decisions about their care, and doctors (even older, male surgeons) can do this.24

Wider cultural issues

The extent to which the activities of the GMC are responsible for doctors’ distress is important and underappreciated. The authors of the Civitas report and the qualitative study are absolutely right to draw our attention to the sad fact that the GMC is not providing support where it is needed and is almost certainly contributing to the problem.

Nevertheless there are many other important reasons for doctors’ distress, some of which will increase the likelihood of a doctor being reported to the GMC. Surgeons and physicians who make errors are badly affected, even without being investigated.2526 They tend to blame themselves and are more prone to burnout and future errors. Burnout is a serious issue among doctors, and recruitment to general practice has reached crisis point.2728 The appalling government policy of naming and shaming GPs who are below average in diagnosing cancer adds to our despair.29 Increasing competition at a time of austerity in hospitals leads to them being castigated for “failing,” leading to a spiral of decline, demoralisation, and cultural drift.30

Work pressures and poor management identified after Mid Staffs remain a serious cause of stress and illness among staff in the health service.31 Many NHS staff are also under increasing pressure to work when they are unwell.32 All these factors are undermining the good health of professionals on whom patients depend.

The Civitas report has implications far wider than the treatment of individual doctors by the GMC. Added to evidence about just culture, patient safety, kindness in healthcare, and doctor-patient relationships, it should prompt a considerable cultural shift towards much more compassionate relationships between institutions, professionals, and patients that will benefit us all.