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New research published in the British Medical Journal, BMJ Open, suggests doctors’ professional behaviours relating to self-reflective practice and raising concerns may be more likely to be influenced by their work environment and intrinsic principles of self-regulation and professionalism, rather than by extrinsic factors such as their obligations to comply with defined behaviours prescribed and monitored by the GMC, or the GMC’s handling of high-profile disciplinary cases.
Conducted by academic researchers at University College London (UCL), the research analysed survey responses from 474 doctors, collected from September 2017 to February 2019, a period of time which coincided with the disciplinary proceedings relating to Dr Bawa-Garba.
We blogged about this seminal case as the disciplinary proceedings were progressing; the underlying facts of the case can be reviewed here, followed by our commentary on the Court of Appeal decision, which reversed the decision to erase Dr Bawa-Garba from the medical register.
In summary, Dr Bawa-Garba was convicted for gross negligence manslaughter (GNM) following the death of a 6 year old patient who was under her care while she was a junior paediatrics doctor. Evidence before the Medical Practitioners Tribunal Service (MPTS) Panel confirmed Dr Bawa-Garba had failed to properly reassess the patient and/or seek advice from a consultant, but noted that there were systemic failures at the hospital, which included Dr Bawa-Garba being required to work an extensive shift without adequate breaks. In June 2017, the MPTS Panel imposed a sanction of 12 months suspension, which was subsequently appealed by the GMC for being too lenient. The High Court agreed, and in January 2018, it replaced the sanction with erasure from the medical register. This decision was overturned by the Court of Appeal in July 2018.
These proceedings generated widespread interest and critique, and led to the GMC commissioning an independent review of GNM and culpable homicide (Scotland), in order to formulate recommendations to encourage a renewed focus on culture, reflective practice, and learning (the ‘Hamilton review’). Indeed, it was our own view that there were clear learning points which the GMC could have cascaded to doctors and Trusts around the UK, especially in relation to the effect that avoidable systemic failures have on patient care and safety.
The research introduced at the beginning of this blog, and to which this blog relates, sought to understand the extent to which doctors’ attitudes towards the GMC had shifted during and following this case, and whether it had had any impact on doctors’ professional behaviours, specifically their self-reflective practice or attitudes towards raising concerns.
It is of note that the sample of responses from doctors analysed as part of this research represents a very small proportion of the number of doctors registered and/or with a licence to practise in the UK, and therefore the findings must be approached with this factor in mind.
The researchers split responses to their survey into 3 groups, based on the time-points when participants completed the survey: responses given before the High Court’s decision to erase Dr Bawa-Garba from the medical register, responses during the period between the High Court’s decision and the decision by the Court of Appeal, and responses gathered after the Court of Appeal decision.
They found that during the period between the High Court’s decision and the decision by the Court of Appeal, doctors’ attitudes towards the GMC were more negative compared to responses gathered before Dr Bawa-Garba was erased from the register, particularly concerning confidence that “doctors are well regulated by the GMC” and confidence that “the GMC’s disciplinary procedures produce fair outcomes”. Analysis of responses gathered after the Court of Appeal decision showed that attitudes had more or less returned to pre-case levels, suggesting that trust in the regulator had recovered somewhat within a relatively short space of time.
It is perhaps unsurprising that the profession felt more negative towards the regulator in the ‘Bawa-Garba period’ given the clear concerns many held about the prevailing issues in the case, notably working hours, adequate nursing support and access to consultant colleagues. What is perhaps more surprising is the suggestion of how quickly this trust seemingly recovered. One must wonder as to whether this genuinely reflected the profession’s view about the GMC, or whether the decision by the Court of Appeal was what actually weighed heavily in bringing about this U-turn.
Despite more negative attitudes towards the GMC being observed during the period between the High Court’s decision and the decision by the Court of Appeal, the research data showed that there was no concurrent change in doctors’ professional behaviours. Self-reflective practice and attitudes relating to raising concerns did not significantly change over the 3 time periods.
These findings suggest, the researchers conclude, that doctors’ professionalism is not as influenced by the actions of the GMC, or by its regulatory control, as might be expected; rather, they surmise that the locus of control for doctors’ professionalism and ethical conduct is more likely to be situated within more intrinsically-held professional principles and the work environment in which doctors practice. They conclude that fluctuating trust and confidence in the GMC may in fact have more influence on how doctors experience medical culture as being one of blame attribution, as opposed to their views of the regulator having any impact on their professional practice.
The researchers argue therefore that the causal relationship between workplace factors and clinical errors must be acknowledged to reduce the tension between the prescribed professional behaviours and the reality of medical practice. Ultimately such an acknowledgement will serve to safeguard patient safety and ensure that the systemic pressures faced by Dr Bawa-Garba are more adequately addressed in the future.
Since the Dr Bawa-Garba case, we have welcomed the GMC’s increased commitment to instil a ‘learning culture’ across the medical profession, and address issues concerning the environments in which doctors practice and the impact of systemic pressures. It goes without saying that a ‘blame culture’ can lead to poorer candour, doctor/patient experiences and morale. The Hamilton review, commissioned by the GMC following the case, highlighted the need to replace a prevailing culture of blame with a culture focused on learning when things go wrong.
Doctors’ loss of confidence in the GMC following the Dr Bawa-Garba case was at the heart of the Hamilton review, which as a result recommended urgent steps would be required by the GMC to regain doctors’ trust in order to repair its relationship with them. However, this latest research found that negative attitudes towards the regulator returned to almost pre-case levels within a few months of the case concluding, suggesting they were not as long-standing as initially expected.
The Hamilton review also recommended that the GMC and other professional bodies issue more guidance to better support doctors’ self-reflective practice. In response, more comprehensive guidance was subsequently published, developed by the GMC, the Academy of Medical Royal Colleges, the UK Conference of Postgraduate Medical Deans, and the Medical Schools Council.
While this guidance is undoubtedly helpful, the findings of this latest piece of research provide evidence that professional behaviours may not be purely driven by regulatory forces and doctors’ understanding of GMC guidance, but instead may be much more nuanced and be influenced by the environment in which doctors practice. This supports the fundamental need for the GMC, professional bodies, and Trusts to work together to acknowledge the critical role that workplace factors play, and to monitor and address poor practice cultures where they exist.
The full findings of the research may be accessed here
Shannett Thompson is a Partner in the Regulatory Team having trained in the NHS and commenced her career exclusively defending doctors. She provides regulatory advice predominantly in the health and social care and education sectors. Shannett has vast experience advising regulated individuals, businesses such as clinics and care homes and students in respect of disciplinary investigations. She is a member of the private prosecutions team providing advice to individuals, business and charities in respect of prosecutions were traditional agencies are unwilling or unable to act. In addition Shannett has built up a significant niche in advising investors and businesses in the cannabis sector.
Lucinda Soon is a professional support lawyer in the Regulatory team, and is responsible for knowledge management and practice development. Her work focuses on leveraging the team’s collective knowledge and expertise, ensuring that know-how and current and emerging regulatory developments are identified, evaluated, synthesised, and shared. She is particularly experienced in the adoption of technology to aid the delivery of these outcomes.
Professional Support Lawyer
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