The investigation and tribunal hearing of Dr Manjula Arora generated significant anger and anxiety among the medical profession. The case raised once again the perception of a regulatory process lacking in fairness; of a system in which the stakes seem much higher if you are a black and minority ethnic doctor. The General Medical Council (GMC) acknowledged that strength of feeling, making clear it would not oppose Dr Arora’s appeal against the sanction and commissioning a review of the case to understand lessons to be learned for future cases.
- It is always best practice, in cases where there is no immediate risk to patient safety for concerns to be raised either with one of the GMC’s Employer Liaison Advisers (ELA), where available, or a responsible officer (RO). This allows for attention to be focussed on live concerns and presents an opportunity for matters to be resolved locally. On receipt of an employer referral, the GMC should ask whether efforts have been made to liaise with the RO and, if not, encourage the referrer to consult with them before taking any further action (excluding immediate patient safety concerns). They should also consider further amending their referral form to include a requirement for the referrer to discuss with the relevant RO first. To aid with this recommendation, the GMC should consider updating their triage guidance, to guide a referrer to a local first approach via an RO, if that hasn’t already happened; and before a decision is made on whether to promote a referral to investigation.
- The UK’s health services, and the GMC, should collaborate to promote a local resolution first culture; and explore whether additional training on complaints handling and investigations at a local level would be beneficial. The GMC should also encourage the Care Quality Commission to include the assessment of complaints handling as a part of their ‘well led’ inspection framework.
- Trusts and boards across the UK should consider using a digital system to share good practice in the local resolution and handling of complaints, as a means of learning and continuous improvement.
- The GMC should review their investigation plan guidance to consider whether it should be expanded to say more about the aims, priorities and scope of an investigation; and what considerations should be recorded if a concern has already been the subject of a local investigation, before being referred to the GMC.
- The GMC should do more to embed a culture of professional curiosity, where individuals in all relevant teams actively seek to add value by raising queries about the evidence provided, and where potential concerns are flagged at the earliest opportunity. To aid with this, the GMC should consider developing an escalation policy and process, to ensure that concerns about cases are raised at the right level(s) until appropriately resolved.
- The GMC should ensure that all decisions are set out in full and include reference to the seriousness of the allegation(s) and the realistic prospect test. They should include a robust analysis of all of the available evidence, rather than a summary.
- The GMC should consider whether their low level violence and dishonesty guidance gives those making decisions enough flexibility; and/ or whether supporting information should be provided to decision makers to ensure they fully understand the discretion they have in each case in order to make the right decision.
- The GMC should consider expanding their existing internal review process across all relevant teams; this should include identification of issues and good practice in case handling; and through post-case discussions, looking at successful and unsuccessful outcomes, to drive continuous improvement.
- The GMC should consider reviewing their guidance on the process for drafting sanction submissions, to ensure that submissions include the necessary evidence for informed decision making; to reflect that approval for some submissions may be withdrawn in the event only some of the allegations are proven; and to ensure that those who approve submissions are consulted in advance of a sanction hearing, in the event that only some of the allegations are proven.
- Where a referrer is also a key witness in tribunal proceedings, the GMC should provide them with full details of the allegations they are taking forward.
- When the GMC provides a witness with a redacted statement, they should draw attention to any changes that have been made, to allow an opportunity for questions or issues to be addressed in advance of the hearing.
- When the GMC instructs external counsel, they should always ask them to consider the overall merits of the case, and to raise any concerns as soon as they become aware of them. They should also ensure they have an understanding of, and commitment to, the GMC’s aim of compassionate professional healthcare regulation.
- The GMC should ensure advice from internal or external experts and/ or training is available to relevant teams on issues linked to a doctor’s communication, attitude and/ or behaviours; cultural awareness, competence and sensitivity; diversity intelligence; and eliminating bias in fitness to practise decision making.
- The GMC and MPTS should consider whether their sanctions guidance should take greater account of the changing demographics of the medical workforce. This includes whether it should demonstrate sensitivity to the interpretation of values, cross cultures, and communication, through the lens of culture competence and diversity intelligence.
- The GMC should consider how it assures itself that its decision making is fair and unbiased, and whether the systems and processes already in place are appropriate. This includes proactive monitoring for ethnicity related variations in teams and developing frameworks to review practice. Given the small numbers involved, case mix considerations, and risk of confounding, analyses should be used as a tool for internal continuous improvement and interpreted with care.
- All partners involved in developing the ‘Welcoming and Valuing International Medical Graduates: A guide to induction for IMGS recruited to the NHS’, including the GMC, should encourage induction programmes to be made available to all IMGs, including those working outside the NHS. Induction should cover patient safety, professionalism, legal and ethical aspects and inform and make IMGs new to UK aware that NHS basic indemnity does not cover legal advice and support for other processes including GMC or Coroner investigations.
- The GMC should consider whether the level of support they offer to doctors in a fitness to practice process is sufficient. They should also encourage medical defence organisations to improve the support they provide to doctors going through a fitness to practice process and extending to a period beyond the tribunal hearing; and responsible officers to ensure local pastoral support.
- The UK government should bring forward legislative reform for the regulation of healthcare professionals at the earliest opportunity. This would enable our recommendations of compassionate, supportive, fair and proportionate regulation, by allowing the GMC to dispose of appropriate fitness to practise cases consensually.