HICFG Conference – November 2013

1. HICFG Conference – November 2013 Regulating Doctors: investigating concerns about fitness to practice Dr Kirstyn Shaw (ELA South Central)

2. Employer Liaison Advisors • Regular meetings with Responsible Officers and Medical Directors in South Central region • Discuss all open and recently closed GMC cases • Provide advice and guidance about GMC thresholds • Discuss any local concerns including anonymously • Provide advice and support about revalidation recommendations • Act as a point of contact for any queries related to GMC • Presentations on revalidation and fitness to practise

3. The standards expected of a doctor

4. Fitness to practice enquiries

5. Sources of enquiries • Complaints • Patients, Carers or Family Members • Other doctors • Referrals (PAPC) • Employers • Police • Coroners or other judicial bodies • Pharmacists • Other regulators

6. Why are doctors referred to the GMC?

7. The fitness to practise procedure Three stage process: Triage Investigation stage Adjudication stage

8. Triage – categories for opening a case The medical act requires the GMC to investigate allegations that a doctor’s ftp might be impaired. Public Interest Test – the 5 year rule and consent Possible new category – English Language Misconduct Adverse physical or mental health A conviction or caution Deficient professional performance Impairment Determination of another body

9. Triage – when we do not open a case • More than half of all enquiries are never opened as cases for investigation. The GMC cannot: • Deal with concerns about anyone who is not a registered doctor • Arrange an apology, help with compensation, provide an explanation of what happened or order a doctor to provide a particular treatment • Arbitrate in practice or departmental disputes or intervene in local disciplinary procedures Triage 2011 4,914 closed 1,917 cases considered by Case Examiners 8,781 complaints assessed 1,537 employer Follow-up

10. Clinical underperformance – common issues • Poor record keeping • Poor communication skills • Poor clinical examination skills • Failure to diagnose • Poor prescribing

11. Misconduct – common issues • Fraud and/or Financial Misappropriation • Dishonesty including plagiarism or misrepresentation on CVs or applications • Sexual Misconduct and Relationships with Patients • Violence, Bullying and Harassment • Social Media

12. Health – common issues • Alcohol and/or drug dependence • Depression • Stress • Other mental health • Physical health

13. Criminal Convictions – common issues • Drink Driving • Other Motoring Offences • Public Order Offences • Assault • Domestic Violence

14. Investigation Process Case assigned to an Investigation Officer (IO) Interim Orders – risk assessment Doctor Disclosure (Rule 4) and EDF Form RO/Employer Disclosure • Expert Reports • Witness Statements • Court Documents • Health Assessments • Trust Investigations • Performance Assessment • Police Investigation • College Reviews • Fraud Investigation • Regulator Actions Final Disclosure (Rule 7)

15. Case Examiner Decisions - 2011 Close 1,358 (70%) Issue a warning 199 (10%) 1,917 cases considered by Case Examiners Undertakings 148 (8%) Refer to a Fitness to Practise Panel 212 (11%)

16. How does a Panel determine sanctions? In our guidance for panellists, the Public Interest test is defined as: Protection of patients Declaring and upholding proper standards of conduct and behaviour Maintenance of public confidence in the profession Enabling a doctor’s return to safe practice

17. Panel Decisions - 2011 Close 35(14.4%) Warning 23 (9.5%) Undertakings Fitness to Practise Panel hearing Refer to a Fitness to Practise Panel 1 (0.5%) Conditions 24 (10%) Suspension 93 (38%) Erasure 65 (27%)

18. Revalidation Encouraging ROs/employers to identify and tackle concerns early Employer Liaison Advisers Fitness to practise experts with close links with ROs supporting revalidation and early identification of concerns Changes to investigation process Early identification of likely outcome and faster progression of case. Regional teams with better local links. Changes to the way we deal with cases at the end of an investigation More discussions with doctors so we better understand seriousness of case and encouraging them to accept our proposed sanction as alternative to a hearing. Adjudication reform Enhancing confidence in independence of panel decisions and streamlining and modernisation of the hearings process. Fitness to Practise Reform

19. Case Study: Dr J • The police notify GMC that Dr arrested and cautioned for Assault • The doctor says he was out at a bar with some friends celebrating a Birthday. A disagreement broke out between himself and friend and resulted in the friend punching the doctor. The doctor claims retaliated by punching his friend which resulted in a black eye. • Police attended the scene and took statements from both men and the doctor assumed this was the end of the incident. He claims he has never received any paperwork from the Police and was only made aware that he had been cautioned when he applied for a CRB check. • The doctor claims that after finding out about the caution he informed his employer, explained the situation and assured them that this was an isolated incident. He has also consulted with the MDU who advised that he should immediately inform the GMC and locum agency where he is registered. • The police send a copy of the doctor’s caution. Feedback from all of the doctor’s employers indicates that they have no concerns about his practise.

20. Case Study: Dr C • Cardiologist is aware that there is a family history of hearing loss at a relatively young age, and during his first appraisal mentions his father has just had a new hearing aid fitted. He currently feels no hearing loss, but is planning to get tested in the near future. • Next year, he notices that he does have high frequency hearing loss in both ears, preventing him from hearing high-pitched sounds very well. He worries this will interfere with him using his stethoscope and begins to keep a diary of when he used his stethoscope and what he hears – though he does not make any changes to his practice. • He didn’t make a health statement but bought an enhanced stethoscope. The following year he has become very insecure about his clinical judgement when auscultation was involved, despite him using an “enhanced” stethoscope. He switches to hearing aids and is delighted with the results, in all aspects of his life. • He has admitted to his colleagues he needs and uses hearing aids, and they have offered to provide a second opinion if he ever feels insecure again. To date, he has received no clinical complaints or missed any obvious diagnoses.

21. Case Study: Dr E • GP in his mid-50s and is the senior partner in a practice which has four partners • Is a member of the LMC which he has been active for several years.   • Has a reputation for being difficult to work with, sometimes dismissive of colleagues within the practice and in local hospitals and community services • Steady trickle of patient complaints about his rudeness, condescending attitude and resistance to engaging in listening and responding to complaints.  • Dr E has had three new complaints about him in the last year • The CCG medical chair and the area team medical director has asked the LMC Chair to try to get him to reflect on his attitude and behaviour but he states that he has been practising medicine for 30 years and has no intention of changing how he responds to patients and colleagues. 

22. Case Study: Mr F • Newly appointed consultant cardiothoracic surgeon, in post for about 9 months. • Concerns have been raised by Mr F’s clinical director (CD) about his performance:  • Appears to have a high rate of operative complications in cardiac surgical patients – a disproportionate number of patients have had to be returned to theatre urgently for control of postoperative haemorrhage • Operative mortality rates following first time coronary artery surgery appear to be higher than those of his consultant colleagues, although the actual numbers are small • Anaesthetists and pump technicians report that Mr F’s patients seem to remain on cardiopulmonary bypass for longer periods than those of his colleagues and on occasions Mr F apparently has difficulty in performing technical procedures – he reportedly has to ‘redo’ coronary arterial grafts on a fairly frequent basis • Senior theatre nurses report that Mr F can be demanding and volatile when things are not going well in theatre – apparently on one occasion he threw a soiled swab across the theatre in the direction of a nurse, but in the event it did not hit her and she made no formal complaint about the incident • A patient complained that Mr F was ‘brusque and dismissive’ during a recent outpatient consultation • When your ask Mr F about these concerns he becomes very defensive, arguing that his workload is excessive and that his high rate of complications can be explained entirely as a result of his colleagues ‘palming off’ more complex cases to him so that they can concentrate on their lucrative private practice. He says he gets little or no support from the junior staff, who are far too inexperienced to help in technically-difficult cases; and he considers that the senior nursing staff had ‘got it in for him’.