It has been more than 20 years since Liam Donaldson published the seminal report, An organisation with a memory. It urged the NHS to learn from other safety critical sectors and modernise its approach to learning from failure. It is widely acknowledged, however, that progress has been slow and we have seen a series of scandals from Mid Staffs and Morecombe Bay through to Shrewsbury and Telford Trust. When these high profile reviews are published, everyone says they will be a catalyst for change, so we never see the same thing happen again. But they always do.
Indeed, as healthcare workers increasingly report burnout and compassion fatigue, we may well see more examples of failing hospitals, with more individual doctors being singled out for criticism and regulatory action. For me, this raises the question: Does the current regulatory system help or hinder patient safety? And: At a time when reforms are being considered, can improvements be made?
Medical Protection Society (MPS) has long advocated a culture of openness and learning in healthcare, moving away from a blame-based system of individual accountability. However, the current regulatory system for healthcare workers is adversarial and blame oriented. Of course, the system must protect patients from the very small number of doctors who should not be practising, but there must be better ways of identifying these individuals earlier.
Can We Change the Way We Regulate Healthcare Workers?
A regulatory system that is focused on holding individual doctors to account when things go wrong in complex clinical settings runs the risk of impeding openness and learning from mistakes due to the fear of personal recrimination.
The current, and in my view, irreconcilable mixture of cultures in professional regulation seems to be based on conflicting ways of understanding healthcare and human behaviour. For a moment, let's think of healthcare and hospitals as giant machines, and the workers simply component parts programmed to do specific tasks in them. In such a world, everything is predictable and, therefore, should be manageable. "Errors" can all be eliminated, and the "faulty" components repaired or replaced.
This, of course, is very far from the environment doctors confront everyday with issues such as inadequate staffing levels, lack of resources, or faulty IT systems which they are powerless to influence. I think this disconnect explains the reaction a few years ago, particularly of doctors in training, to the Bawa-Garba case. Many could envisage themselves in the same situation and saw it as a stark example of how systemic and environmental factors play a part in medical error for which individuals are held to account.
So, when thinking of regulatory reform can we change things and rebuild trust in the system?
Harry Cayton CBE, former chief executive of the Professional Standards Authority, which oversees the work of the GMC, stated in a 2015 interview, that "regulation, by its legal and rule-based nature, sets standards and defines boundaries; regulation tends to stasis not change. But the health care of the future needs us to break down boundaries – to open up to new ways of working, to new relationships, to new structures. If we want to rethink quality in health care, we must rethink regulation too".
Focus on the Future
Regulators alone cannot be the whole answer to improved patient safety. However, there are some key reforms that could create a fairer environment and drive patient safety.
As we grow the workforce for the future, we must ensure we are recruiting the right people and equipping them with the right skills to thrive and prosper in the complex world of healthcare. In my experience, medical schools shy away from identifying people who are unsuitable for careers in medicine and, sadly, we often see the fall out many years later in front of fitness to practise panels. Few other jobs select candidates on academic performance alone. Doctors who enter medical school this year will be practising in the 2060s – what skills will they need by then?
The GMC sets the standards for providers of medical education and training, and they have a statutory obligation to check those standards are met. The regulator is much better known for their other statutory functions. But I would argue that a lot more potential good can be achieved through driving improvements in education and training than there can be through investigating thousands of complaints against doctors that ultimately won't meet the threshold for sanctions.
Caring for the Workforce
Steps are being taken to tackle discrimination and improve a sense of belonging in healthcare, but we need to step this work up. The system into which we bring overseas graduates needs to be far better prepared to accept them.
The mental health and wellbeing of doctors continues to be a grave concern and regulation should not add to that. The GMC has made some improvements to its processes in recent years in order to reduce the impact of investigations on doctors – including reducing the number of full investigations it carries out and creating a specialist team to work with doctors who have health concerns – but we believe there is still more to be done. Investigations must be resolved quickly and sensitively. The GMC should be able to close more investigations earlier and make the overall process faster for cases that do proceed to a hearing.
Reducing the Focus on Blame
We want regulators to be given the discretion to not take forward investigations where allegations clearly do not require action and instead focus on serious concerns where a doctor's behaviour poses a risk to patients.
The recent case involving Dr Arora, who was given a 1-month suspension over her use of the word "promised" when requesting a work laptop, is a case in point. The issues raised could have been resolved locally without the doctor's employer referring the case to the GMC and it then proceeding to a hearing.
GMC Right of Appeal
Another key reform which the Government must still act on is the removal of the GMC’s right to appeal MPTS decisions. The Government has accepted in full the recommendations of the Williams and Hamilton reviews and it was suggested that removing these powers would "help address the mistrust of the GMC amongst doctors and contribute to cultivating a culture of openness that is central to delivering improved patient safety". The Government has committed to progressing the legislative change to enable this by 2023, which is a positive step, but it must now honour the commitment.
Ultimately, as patient safety advocate James Titcombe said, the NHS has a clear choice: safety or fear - an organisation with a memory or an organisation that continues to miss opportunities to learn and improve. I know which I would prefer. Changing the focus of the regulatory system can go a long way to bringing about this change.