Picking doctors to pick on

This July, the Court of Appeal heard stinging criticism of the General Medical Council (GMC) over its treatment of Dr Bawa Garba; treatment which has caused:

“very substantial consternation, verging on outrage, in the medical profession both in the United Kingdom and abroad. It has led to the Secretary of State for Health and Social Care to criticise the GMC in Parliament and to announce a formal review into various issues arising from this case”.

Mr James Laddie QC

This case must change the GMC. But how?

A starting problem is the conflict between the GMC’s duties. The Medical Act (1983) requires the GMC to protect the public by:

(1) keeping patients from harm (“Safety”)

(2) upholding confidence in the profession (“Reputation”)

(3) setting its standards (“Standards”).

[I’ll refer to these by number].

It’s an odd setup. Imagine air traffic controllers being tasked with safety and upkeep of reputation. Surely, if safety’s done well, reputation should look after itself?

In contrast, the medical profession can struggle to demonstrate safety. Data goes uncollected, unanalysed or undisclosed. Instead, the profession’s reputation is defended by law at (2).

But how can the GMC both police and promote the profession? Medical error is a leading cause of death. Candour about mistakes helps (1), but undermines (2).

The GMC struggles with this conflict. The Gosport inquiry criticised the GMC’s lack of candour about potential conflicts of interest [Chapter 6 para 6.220] and its redaction of documents relating to the inquiry into multiple deaths [Chapter 11 para 11.37].

The GMC’s competing interests are evident elsewhere too. It tasked Dame Claire Marx with independently learning the lessons of the Bawa Garba case, only for it to emerge that Dame Marx was competing to lead the GMC. It seems to seek scrutiny – but not too independently – for fear of hitting public confidence.

Rotten apples: selecting doctors to sanction

The GMC has to be seen to protect patients at (1) but has to protect reputations at (2).

One way is to imply the problems of the profession are limited to a few rotten apples. The GMC selects from amongst the doctors against which it could act. If public sentiment is harsher towards foreigners and women wearing veils, the GMC can mirror this by picking those doctors more often and pursuing them more vigorously. The public and profession are reassured that problems are chiefly with doctors who are “other”.

Picking out foreigners while keeping quieter on British failures occurs at the highest levels. Dame Marx was quoted as claiming Brexit would make the NHS safer by allowing stricter language tests on foreign doctors. Such a hypothetical risks being a dog-whistle to the English Defence League when it unsafely ignores proven and major failures (listed in next section) where the doctors responsible are Britons fluent in English.

For example, scores of women were harmed by breast surgeon Ian Paterson over many years. Other British surgeons shored up Paterson’s position, downplaying the concerns of several overseas doctors.

Too big to fail: protecting powerful doctors

When groups of powerful doctors are involved in wrongdoing, the narrative shifts. Instead of rotten apples, we’re told of doctors doing their best in difficult circumstances. Exposing them would harm faith in the profession. The GMC’s reactions slow – and failures linger unaddressed.

Examples of such delay include failures like Bristol (heart surgery), Alder Hey (organ retention), Shipman (mass murder), Mid Staffs (neglect), Ian Paterson (unsafe breast cancer ops), Roger Bainton (unsafe facial surgery), Gosport (killing by opiate), Northern Ireland (cover up and hyponatraemia deaths in children), Neil Ineson (string of sexual assaults by a doctor who had worked for the GMC as an investigator).

Moving the goalposts

The GMC sets the rules under (3). Boundaries can be redrawn and reinterpreted to pick doctors for (1) while ring-fencing others for (2).

So Dr Bawa Garba and Mr David Sellu face public GMC proceedings over the deaths of Jack Adcock and James Hughes while groups of white doctors face no such process over: the avoidable deaths of Caitlyn Parry and Sean Akdemir; the threats to use the GMC as a weapon against a whistleblower and a journalist.

The GMC also allows Alder Hey Hospital to resist full disclosure of its death rates for fundoplication with vagotomy and pyloroplasty (FVP) – even after the surgeon responsible has altered documentary evidence to a GMC investigation, given multiple false accounts when caught and has refused to disclose the emailed electronic originals to determine which if any is true. The GMC could order disclosure in this matter but chooses not to. So for that surgeon and his unit, the goalposts have been moved, avoiding embarrassment to the profession. In the meantime, children having FVP appear to die sooner.

What can be reformed?

The GMC should protect patients, not the profession.

A first reform would use the modern opportunities to open up data. Better information can help the profession thrive by managing patients, instead of reputation.

For example, routinely videoing surgery would allow inspection of each surgeon’s work, just as it does for footballers. Surgeons could be peer-rated on performance before reputation.

More generally, open data would allow the GMC to start scrutinising safety. The Medical Act (1983) should then shed (2)  – the need to defend faith in the profession.

Conclusion

Bawa Garba highlights a systemic problem for the GMC. Conflict between its duties means it has too often picked on individual doctors while allowing groups of powerful doctors to evade scrutiny and even operate above the law.

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