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For Primary Care| View from the ground

The Nuclear Option

View From the Ground, by Dr Toni Hazell 

‘All doctors have a duty to raise concerns where they believe that patient safety or care is being compromised by the practice of colleagues.’

This extract from Good Medical Practice makes it clear that the General Medical Council (GMC) expects us to report any dubious practice, but in reality things aren’t always clear cut. Every doctor has a different threshold for investigating and prescribing and the actions of a newly qualified GP might be very different from those of a GP who is nearing retirement, with neither necessarily being wrong. The GMC is often seen as the enemy (especially in recent months after the furore over the Hadiza Bawa-Garba case) and reporting a doctor to the GMC feels a bit like telling tales at school.

So, what to do when there are genuine concerns and you have nowhere else to turn? This was the situation that faced me about 10 years ago. I had become aware of a local private clinic whose prescribing was unconventional, to say the least. Several patients of mine had been given prescriptions where, in my opinion, the risks outweighed the benefit.

But the clinic treated a condition for which NHS treatment wasn’t available, and one in which I wasn’t an expert, so maybe I was just inexperienced? I had, after all, only been qualified as a GP for a few years. I rang the clinic, only for my concerns to be dismissed with a suggestion that their doctors were much more senior than me and I shouldn’t be worrying about it. Local arrangements, such as discussing with medicines management or the primary care trust, weren’t appropriate for a non-NHS service, so it was the nuclear option of going to the GMC, or nothing.

I dithered for a few months, vaguely aware that I should be doing something but I didn’t want to face the dilemma head on. Then I saw a young patient with raised blood pressure. As I talked to her about secondary hypertension, renal scans, and blood tests, she handed over a packet of pills and asked if they could be causing the problem. It was the same tablets, prescribed by the same clinic, and yes—they do cause high blood pressure, as well as being associated with a host of other cardiovascular risks. This patient was adamant that she hadn’t been informed about the risks and I believed her; her sister had died suddenly at a young age from presumed sudden cardiac death, and she was very aware of her family history and unlikely to disregard any such warnings.

I could no longer continue to ignore the situation so I rang my defence union for their advice—they confirmed that I had a duty of care to act. I composed a letter expressing my concerns about this patient and others, sent it off, and waited. An acknowledgement came soon after, followed by a request for a more detailed statement and I soon found out that those sky-high defence union fees are worth it, as I had plenty of support and help with drafting the statement. The GMC took my concern seriously and, to my horror, I was asked to attend the hearing as a witness.

Walking through the doors of the GMC’s London offices gave me palpitations, and I wasn’t even the one in the dock! I sincerely hope that I am never on the other side of these proceedings. I sat in full view of the doctor concerned, who stared at me the entire time and visibly sneered during my evidence; I was very glad when the day was over. The expert witness evidence was startling—it seemed that what I had uncovered was the tip of the iceberg, with many other examples of reckless and dangerous prescribing going on. The verdict was suspension for 18 months and at the end of that time the 79-year-old doctor was persuaded to retire, so I didn’t have to go back and attend another hearing.

In retrospect, I have no regrets about making the referral and only wish I had done it earlier—I will never know if patients came to harm as an indirect result of my inaction. I wonder how many other local GPs were pondering the same action and how many other clinics up and down the country get away with dubious prescribing because no-one wants to be the tell-tale. Being referred to the GMC is a hugely stressful thing to go through and carries a significant risk of mental ill-health and suicide, but this episode showed me that we do have a regulator for a reason and I was impressed with their ability to cut through excuses and get to the point.

I hope I never have to make a GMC referral again, but if a similar situation arises then I might be more confident next time. 

Dr Toni Hazell

Part-time GP, Greater London