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A significant event

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A complaint brought a thriving GP practice to the brink of collapse – not because of what it uncovered, but the way NHS England handled it. One of the GPs tells Neil Hallows how he endured 14 months of aggression and suspicion, and asks how many others may be facing the same treatment

Andrew Jones’s* practice is a good one: a training practice, well-respected by patients and colleagues, with experienced staff. Yet a complaint almost destroyed it.

Difficulties began when a GP partner resigned following a dispute about management.

Shortly afterwards the doctor referred the practice to NHS England, alleging concerns with quality of care. This resulted in a 14-month investigation that left it on the point of collapse.

 

Lack of support

The case raises fundamental issues about the support given to GPs when there are concerns about performance.

‘One investigator was highly supportive of our care, but the other had questions regarding 20 of the 30 cases they looked at’

It also highlights the duty of care owed by the NHS to those who work in the NHS, and an investigatory system that lacks transparency and safeguards. There may be many other such cases but despite a request by The Doctor, the NHS can’t or won’t provide any figures.

The referral in this case cited ‘a lack of understanding of the significant event process’. It included four cases where there had been very brief delays in sending two-week-wait cancer referrals, and another four cases where there had been short delays in copying entries from written home-visit records on to the clinical system.

 

Concerns raised

Three further clinical cases were cited:

  • the medication of a patient with diabetes was stopped (because of risk of hypoglycaemia), which then had to be reintroduced at a lower dose
  • a patient had fallen on an outstretched arm and attended with symptoms of shoulder pain. Two months later the patient attended with unrelated symptoms (of cough syncope) and mentioned persisting neck pain. Given the history of a fall, Dr Jones requested an X-ray, which showed a healing fracture dislocation of C7 facet joint, subsequently treated with a collar 
  • a pre-op clinic letter had been received three years previously noting a new diagnosis of atrial fibrillation. The diagnosis was coded, but anticoagulation wasn’t started following surgery at that time.

‘We don’t dispute that some of these cases could have been managed better,’ says Dr Jones.

‘But it was notable that, of all of these issues, only one case had been flagged up by our former partner before they sent the referral, and this had not yet been discussed with the other GPs.’

The four remaining partners responded immediately to NHS England. ‘We stated that we wished to facilitate an early review and that we would make all relevant information available. We wrote that we would carefully discuss and consider any concerns, that we were very willing to learn from the review and that we were prepared to make any necessary changes.’

Complaints are handled at a local level by NHS PAGs (performance advisory groups). According to NHS guidance, these should consist of two NHS managers, a lay member, and a clinician from the specialty.

 

Highly critical

One month later, the PAG informed the practice that a clinical investigation would be undertaken. It gave a timescale of two months to complete the process.

‘They were putting words in my mouth – they had come with an agenda’

A case investigator visited the practice the following month to view patient records, and visited again after a further six weeks to interview GPs individually.

‘We found the investigator to be hostile and confrontational, to the extent that one of our GPs was left crying at interview. In my case, they were putting words in my mouth and it seemed clear that they had come with an agenda. At that time, this appeared inexplicable,’ says Dr Jones.

It then took a further three months – now more than six months after the original complaint – for the practice to receive the investigator’s 30-page report (with a further 13 appendices). The practice was initially given three days to respond.

 

Of little use

The report was highly critical. ‘As an example, I was formally criticised in the conclusion for not recording DVLA driving guidance for my patient with cough syncope. This was despite telling the investigator that this patient didn’t drive and had never held a driving licence.’

'The practice called the Medical Protection Society. ‘We went through the report line by line with them. We drafted a response which accepted fault where it was valid, and which corrected factual errors.

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'We set out the steps that we’d taken to address any issues raised, which included carrying out audits and relevant courses. We made it very clear that we were keen to learn from any mistakes and to identify areas of improvement.

'However, on the basis of this critical report, the PAG commissioned a further investigation. This was to be a random case review, with two investigators each assessing 30 cases. The terms of reference for the investigation said: ‘The expectation is that records will be compliant with good medical practice, including NICE-compliant.’

 

Contradictory findings

The investigators first visited one month later and, after a meeting with the GPs, provided a final report after a further three months. The findings of the two investigators were very different.

‘One investigator was highly supportive of our care, but the other had questions regarding 20 of the 30 cases they looked at.’

‘The judgements in these reports are not based on a professional consensus but on the opinion of a single investigator’

This investigator stated that Dr Jones had ‘consciously gone against NICE [National Institute for Health and Care Excellence] guidance’ in one case when he had treated a frail 84-year-old patient with a cough and chest discomfort with antibiotics.

However, the guidance cited (CG69) specifies that antibiotics are appropriate if a patient had been hospitalised in the previous year or had a history of heart failure, both of which applied in this case.

 

NICE guidance misinterpreted

Dr Jones was also criticised for not following NICE guidance in the case of an older patient with fatigue (who had a history of cancer and hypothyroidism) as he had ordered blood tests immediately. The investigator stated that the NICE guidance Tiredness and Fatigue in Adults recommends delaying blood tests for a month. However, this guidance relates specifically to the management of patients with chronic fatigue syndrome.

There was even more serious criticism.

Dr Jones had seen and assessed and ordered tests for an older patient with symptoms of reduced appetite. According to the report ‘… the patient died the following day in A&E. It is my opinion that a clinician who is imminently [sic] involved in the management of a patient who dies shortly afterwards unexpectedly has a duty to perform a significant event analysis.

'I believe this contravenes the standards set out by the GMC in relation to the duty of clinicians to contribute to and comply with systems to protect patients’.

 

Unfair claims

Dr Jones states this simply wasn’t true. ‘This patient had unexpectedly fallen the next morning and had been admitted to hospital. Unfortunately, they had died of a myocardial infarction in hospital a week later, but this was unrelated to the symptoms that I had assessed them for.

‘It’s very concerning when there is a medical investigator saying that a doctor’s practice does not meet professional standards. I feared that I was going to be referred to the GMC.’

The investigator’s mistakes were basic and yet the impact was potentially devastating.

‘There were multiple errors in the report. With the help of the MPS we provided a definitive response.’

 

End to the matter

Two months later, 14 months after the original complaint, the practice received formal notice that the investigation was closed.

The concerns noted above had been dropped. The final report stated that the investigators ‘could not find any evidence of poor patient care, and there were numerous examples of good care provided.

‘Much of the damage that was caused to our practice was a result of the slowness of the process’

'Overall the care provided compared very well with that expected of GPs working in similar circumstances.'

By this point, the practice was under severe pressure. During the course of the investigation, both of the practice’s nurses had resigned and more than half of the reception and administrative staff had resigned or had been on long-term sick leave.

‘The seriousness and uncertainty of an investigation contaminates a practice, and we came perilously close to disaster. If a GP or another key member of staff had left the practice we could certainly have folded.

‘Recruiting replacement staff during the process had been impossible, as we had to disclose the ongoing investigation. We employed locums to help cover the workload, but at great expense. At times our workload was overwhelming.’

 

Enormous stress

The stress for the practice during the course of the investigation was enormous. Dr Jones says this contributed to one of the GPs developing pneumonia and requiring hospital admission.

‘Our only contact with the department was by email. There was absolutely no support from the NHS during the whole process. When we raised this with the case manager at the end they expressed surprise: “Did you not receive our support leaflet?”

‘Later we received funding from the vulnerable practice programme, which was NHS funding designed to get the most at-risk practices back from the brink of closure.’

Dr Jones had originally been criticised for not conducting a significant event analysis. But perhaps the way he and his colleagues were treated needs to be regarded as a significant event in its own right. It caused harm, certainly to his GP partner with pneumonia, and seriously destabilised a GP practice – potentially affecting the care of thousands of patients.

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Apology

The practice received an apology from NHS England and was promised that it would learn from the experience and that this would inform other investigations.

But it is difficult to see how much learning will go on when NHS England either does not know or will not reveal the annual number of investigations. It initially told us that it collected ‘centrally aggregate[d] information in relation to both GP practice and GP performer performance concerns’. However, a request for the overall number of local performance investigations received no response.

This is in sharp contrast to the GMC, which publishes annual data on fitness-to-practise investigations. Without such data for NHS investigations it is impossible to establish if there are regional differences, for example, or to determine if there is a disproportionate number of investigations for different groups of doctors.

 

Opinion

The role of the medical investigator needs serious consideration, says Dr Jones.

‘Investigators not only collect evidence, but provide their own judgements based upon the evidence. Their opinions will typically be accepted unequivocally by PAGs, whose lay and managerial majority have absolutely no clinical experience. Ultimately, the judgements in these reports are not based on a professional consensus, but on the opinion of a single investigator.

‘Local medical committees will be able to offer help and support during a difficult time’

‘The preparation for this role is two days of training, without any testing or assessment of participants. With such a powerful and responsible role, it would seem vital to assure competence. With individual investigators there is also an inherent risk of bias or conflict of interest.

‘While our investigation was still ongoing the first investigator posted on social media, mentioning circumstances highly relevant to our case, that doctors like us should be “struck off and disbarred”. We believe this indicates that this individual was biased against our practice.’

PAGs operate on a civil standard of proof, which is the balance of probabilities. Therefore, a single critical report can result in referral to the next disciplinary level, the PLDP (Performers List Decision making Panel), which has powers to suspend doctors or refer them to the GMC. While there is a right of appeal against PLDP decisions, there is no right to appeal those made by a PAG.

 

Slow process

Dr Jones says ‘much of the damage that was caused to our practice was a result of the slowness of the process. PAG panels typically meet monthly, which causes unavoidable delays’.

Richard Vautrey, GPC chair 2017

BMA GPs committee chair Richard Vautrey (pictured) says: ‘All doctors make mistakes which is why it is important for all teams to have mechanisms in place, within a supportive environment, to reflect on what has happened and try to make improvements in future care as a result of the shared learning. External investigations can be needed when serious incidents occur, but these can be extremely stressful for the clinicians involved and therefore need to be done professionally, sensitively and as quickly as possible.

‘Practices should inform their local medical committees if this is happening as they will be able to offer help and support during what is often a difficult time.

'There also needs to be a much better understanding of the serious consequences on team morale and recruitment and retention an external investigation can have and that if done inappropriately it can cause more harm than good, and makes it less likely in the future that individuals or teams would be prepared to highlight mistakes for fear of the consequences.’

 

Unrealistic standards

Every concern reported to a clinical commissioning group must be forwarded to PAGs for consideration. Dr Jones says panels then have absolutely no discretion to look into or resolve concerns informally. PAGs must either order a formal investigation or take no action. However, even if no investigation occurs, all reported concerns are recorded and stored. GPs will not necessarily ever be informed that these have been received.

‘A critical problem is the standards to which practices are held’

A critical problem is the standards to which practices are held. Every practice should aspire to high standards of care. However, NICE guidance is not a baseline to judge minimum acceptable standards of practice.

At the conference of England local medical committees later this month, the agenda has a motion calling for effective independent oversight and review of NHS England performance management procedures in primary care.

This includes performance investigations and the functions of PAGs and PLDPs.

 

Rare outcome

At the UK LMCs conference in March, GPs agreed unanimously that the assessment of GPs’ and practices’ performance may be based on unreasonably high standards and called for ‘real-world’ benchmarks of practice.

NHS England either does not have or will not reveal any data about investigations, but Dr Jones feels his practice is ‘unusual’ having survived it and in receiving an apology.

Dr Jones warns anyone facing the same situation that they are in for a prolonged and stressful experience. He says his practice had just enough resilience to get through.

* Names have been changed

If you are a BMA member and have a query or concern about your pay, contract, terms and conditions or any aspect of your working life, you can contact the BMA on 0300 123 1233

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