- David Oliver, consultant in geriatrics and acute general medicine
Follow David on Twitter @mancunianmedic
On 22 August the General Medical Council (GMC) published its updated and expanded Good Medical Practice guidance for doctors, after extensive consultation.1 The initial reaction largely centred on the explicit duty of “kindness” placed on doctors—what it meant and how it could be regulated. For me, however, the most important paragraphs lie elsewhere, in the section “Responding to safety risks.”
Paragraph 75 says that doctors “must raise their concern” if patients are at risk from “inadequate premises, equipment or other resources, policies or systems.” Paragraph 76 says that doctors in formal management and leadership roles “must take active steps to create an environment in which people can talk about errors and concerns safely. This includes making sure that any concerns raised with you are dealt with promptly and adequately.”
The word “must” is important here because, as the GMC states, this means a “legal or ethical duty you’re expected to meet (or be able to justify why you didn’t).”
These paragraphs sit alongside the professional duty of candour and transparency when things go wrong, set out in 20162; with “freedom to speak up” legislation and guardians3; and with GMC guidance issued in the wake of the Hadiza Bawa-Garba case about the need for doctors who find themselves in unsafe working conditions to raise concerns formally when they come on shift,4 rather than refusing to work. Combining this with the GMC guidance on Raising and Acting on Concerns about Patient Safety5 gives us quite a powerful armoury.
Clinicians have highlighted unsafe staffing, unmanageable workloads, loss of capacity, and dangerous clinical practice—not least in various recent maternity care scandals and, going further back, the Mid Staffordshire scandal.6 In some cases the people raising the concerns have had their careers threatened or ruined.
Well, the GMC guidance gives us some ammunition in this battle—and theoretically some protective equipment. It also notionally forces clinically registered staff in management roles to listen and act. And if the current talk of non-clinical managers being registered and regulated comes to anything, there will be an onus on them too. The well documented serious problems in the NHS right now, along with underinvestment in equipment and facilities, mean that most clinical staff, in most services, on most days, face serious risks to patient care and staff wellbeing.
It’s time for an “I’m Spartacus” moment. If every week all clinical staff, in all services, raise the risks posed by staffing gaps, excessive workloads, inadequate facilities, and unsupportive or bullying management, we will force the hand of line managers either to act or to admit that there’s nothing they can do and that conditions are dangerous. Or it will force them to deny or minimise these concerns, giving a clear paper trail of their intransigence or inaction. This may put clinicians off taking such management roles—but that too is good, as it will make central agencies realise why such responsibilities are now toxic.
This kind of action will liberate staff to go public because, if everyone is doing so, it will be hard for trust managers or professional regulators to discipline, suspend, sack, or silence them all. And it will force those at trust board level or at NHS England or the Care Quality Commission—and ultimately in government—either to act or to admit that care is routinely unsafe and dangerous and that working conditions are causing ever more staff to burn out and leave. And woe betide the GMC if it refuses to protect clinical staff who are adhering to their own “must” directive or clinician-managers for failing to adhere to their own reciprocal “must” obligations.
It’s time to fight back.