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Wednesday 28 September 2016
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See no evil, hear no evil? Raising concerns in primary care

Ethics

Clare Gerada
MBE FRCGP MRCPsych

GP with special clinical interest in substance misuse

Vice Chair, Royal College of General Practitioners

Clare has been a GP in Lambeth since 1991, and was appointed Vice Chair of the Royal College of General Practitioners (RCGP) in November 2007. In addition to her work as a GP, Clare is also currently Chair of Ethics for the RCGP. Her special interests are mental health, women's health and substance misuse

Scenario one
Janice is the manager of a single-handed practice. She has been concerned for some time about Dr Browne, who has been looking unwell. He often comes in late, looking rather dirty – and smelling of alcohol and bad body odour. His surgeries are always running late. Janice tried to ask Dr Browne whether anything is wrong, but all he said was that he was having some problems at home. Janice is beginning to be concerned that patients will begin to notice.

Scenario two
Shortly after joining the practice as the manager, you become concerned about one of the doctors, Dr Smith. He has been at the practice for around five years and also works at the local Accident & Emergency department. You have noticed that a number of patients have left his consulting room requesting to see another doctor as "this one didn't listen". A number of reception staff have commented that patients never seem to book to see him, and quite often his list is empty except for emergencies. One day a rather serious complaint comes from an elderly woman on behalf of her husband. She says that Dr Smith failed to diagnose her husband's bony secondaries from cancer of the prostate – saying that Dr Smith said it was "just backache from old age".

Spotting problems
Practice staff are uniquely well placed to notice signs of poor performance – they may find themselves dealing with concerns from patients that "their doctor doesn't seem the same" or find themselves constantly covering up for doctors' behaviour or late-running surgeries.

Reception staff may be aware of complaints from patients, locums and others, such as the local pharmacists, or patients may simply say: "I don't mind who I see except …". Receptionists are in a good position to observe instances of poor or aberrant behaviour: a doctor who is constantly late on a Monday morning, or a doctor who does not follow up messages or who begins acting oddly – for example, smelling of alcohol – or who has bad body odour.

All of us, at one time or another, have had concerns about what is happening at work – whether this is about a member of staff who seems to be performing less well or about angry disagreements during partners' meetings. Usually talking with the person involved or discussing them with the partners
easily resolves concerns.

However, where an issue may arise relating to a risk to patients, professional misconduct or financial malpractice, it can be difficult to know what to do, especially where these concerns relate to one of the senior doctors, and where raising the matter may seem disloyal to your employer.

What should you do?
The General Medical Council (GMC) advises that all doctors must protect patients from risk of harm posed by another colleague's conduct, performance or health, and that if there is a good reason to think that patient safety is, or may be, seriously compromised then doctors have a duty to ensure that reporting procedures are in place and that staff are aware of them.

As a manager, it may be that you are reluctant to report concerns for a variety of reasons including, for example, because you fear this may cause problems for colleagues, adversely affect working relationships, have a negative impact on your career or result in a complaint about you. If you are hesitating about reporting a concern for these reasons, you should bear in mind that:

  • Your duty to put patients' interests first and protect them must override personal and professional loyalties.
  • The Public Interest Disclosure Act 1998 (see Resources) provides legal protection against victimisation or dismissal for individuals who disclose information in order to raise genuine concerns and expose malpractice in the workplace.

You will be able to justify raising a concern – even if it turns out to be groundless – if you have done so honestly, promptly, on the basis of reasonable belief and through appropriate channels.

Barriers to raising concerns
Despite the justifications to raise concerns, there are still many barriers to doing so.

The Shipman Inquiry highlighted the difficulty that practice staff have in raising concerns about their employer doctor. GP practices are small organisations and there may be conflicts of loyalties and a reluctance to bring criticism about one member of the practice to the attention of his/her colleagues. This reluctance is likely to be increased where a non­medical member of staff has concerns about the clinical care provided by one of
the doctors.

As a manager, you may feel unable to challenge the actions of a healthcare professional. You may worry that your concerns could prove to be unfounded, and fear that raising concerns might prove detrimental to your career.

There may also be a perception (whether justified or not) that, if a concern is raised, the doctors will "close ranks", with the result that your concerns will go unheeded.

Junior members of staff may worry that if they voice their concerns their relationships with their employers and colleagues will be irretrievably damaged and that their working life will be intolerable thereafter. The smaller the practice, the greater these problems are likely to be. In a single-handed GP practice, for example, there is likely to be no one within the practice to whom you can voice a concern about your employer doctor.

The Shipman Inquiry heard evidence that managers in single-handed practices feared that if they raised concerns this could have a direct impact on the livelihoods of those employed in the practice if the doctor was suspended and the practice closed down.

These problems are exacerbated by the fact that GP practice staff often function in isolation, both from staff in other practices and from the local primary care organisation. Staff may have no experience of working in another practice and have little idea of which procedures are usual and which are entirely outside the norm. They may be uncertain whom to turn to for advice.

Raising a concern
Problems should be addressed as early as possible, either through discussion with the person concerned or through other mechanisms, which will be discussed below. If you have reason to believe that patients are, or may be, at risk of death or serious harm for any reason, you should report your concern to the appropriate person straight away. Do not delay doing so because you yourself are not in a position to put the matter right.

Ideally, concerns should be shared with a practice senior partner (unless the senior partner is the subject of the problem – in which case, seek out another partner). The practice manager and partner should have a "one to one" with the individual in question as soon as possible, keeping clear contemporaneous records of the meeting. An action plan should be agreed and, again, records kept of what has been agreed and any timescale. Most minor issues can be dealt with internally and informally.

However, it may not be as simple as this for managers who work in single-handed practices, or where the manager feels unsure that the matter will receive sufficient attention. For these managers, it may be necessary for staff to seek advice outside the practice. The local medical committee, the clinical governance lead or the medical director of the primary care trust (PCT) are useful sources of advice.

It is important to be clear, honest and objective about the reason for your concern, and to keep records of related problems and any steps you have taken to resolve them.

Involving the GMC and other means of raising concerns
If the case involves any suspected criminal activity, or if patients are believed to be in danger, then the PCT must be notified immediately and local procedures should be adopted for dealing with the situation.

In some situations, there may be a need to carry out interviews with the doctor concerned as part of a police and criminal investigation. The PCT will be able to advise on this process, to assist with the investigation and to advise when police should be called in. The NHS Counter Fraud and Security Management Service can also offer advice on dealing with cases of suspected fraud or where security is threatened (see Resources).

Yet the ultimate responsiblity for investigating and monitoring the behaviour and performance of registered doctors lies with the GMC. In the first instance, concerns can be discussed with the GMC without revealing the identity of the doctor concerned, and advice can be sought. If you have raised your concern through local channels but are not satisfied that the responsible person or body has taken adequate action, then it may be necessary to refer the matter to the GMC for further action.

In cases in which it is essential to draw attention to dangerous practice or substandard conditions, health professionals who have exhausted local remedies may consider raising the issues more widely using the powers within the 1998 Public Interest Disclosure Act (see Resources).

In addition, Public Concern at Work – a nonstatutory charity – provides free, confidential legal advice to people concerned about wrongdoing at work who are not sure whether or how to raise their concern (see Resources).

Professional responsibility
Raising concerns about a collegue's practice is always difficult. Raising concerns about an employer can seem a bridge too far. However, as the practice manager you have a duty to act if you feel a doctor's performance is causing risk to patients.

When doctors experience difficulties, early intervention is generally beneficial both for the doctor and their patients. Bringing to the forefront what most staff (including the doctor) are secretely aware of will enable the doctor to access the appropriate help. Doing nothing is not an option.

It is important to remember that managers notified of a concern:

  • Have a responsibility to ensure that concerns raised are taken seriously.
  • Where appropriate, should investigate properly and make an objective assessment of the concern.
  • Should keep the individual advised of progress.
  • Have a responsibility to ensure that the necessary action to resolve a concern is taken.

Key messages for practice managers:

  • Get intelligence early – use all the sources you have to pick up on issues before they become a concern.
  • Keep good records of concerns, dates, discussions and actions agreed, as they may be needed if things progress.
  • Seek advice – most doctors do not have performance concerns raised about them during their career, so this is something they will only have to deal with very rarely. So get help from others who have the information they need.

Resources

British Medical Association
www.bma.org.uk

General Medical Council
www.gmc-uk.org

NHS Counter Fraud and Security Management Service
www.cfsms.nhs.uk

Practitioner Health Programme
A free, confidential service for doctors who have mental or physical health concerns and/or addiction problems, and who live or work in the London area: www.php.nhs.uk

Public Concern at Work
www.pcaw.co.uk

Public Interest Disclosure Act 1998
www.charity-commission.gov.uk/supportingcharities/pida.asp