Stephen Bolsin, whose fame or infamy (depending on your point of view) arose from his part in the Bristol case, recorded his trials and tribulations in Bristol at a lecture in Sydney. Every member of the audience was given a whistle before the event and invited to blow it as soon as he or she felt that the situation required further action to be taken.
No-one blew their whistle. This may mean they felt there was nothing that required 'whistleblowing', or it may demonstrate how difficult it is to decide when to put your head above the parapet.
A small number of underperforming doctors have attracted a great deal of publicity, not just to themselves but to the profession at large. Ledward, Neale and Shipman deserve their reputation, but, in the process, damaged the profession and public confidence in professional regulation.
A doctor's duty to protect all patients is set out in Good Medical Practice – the General Medical Council's required code of professional behaviour.1 It states quite bluntly:
'You must protect patients when you believe that a doctor's or other colleague's health, conduct or performance is a threat to them.'
The next paragraph sounds a note of caution and then gives more detailed advice:
'Before taking action you should do your best to find out the facts. Then, if necessary, you must follow your employer's procedures or tell an appropriate person from the employing authority, such as the director of public health, medical director, nursing director or chief executive, or an officer ofyour local medical committee, or a regulatory body. Your comments about colleagues must be honest. If you are not sure what to do, ask an experienced colleague or contact the GMC for advice. The safety of patients must come first at all times.'
How does this work in practice?
Suppose, for example, that you suspect that one of your partners has taken to drink or drugs. How do you establish the facts? And which facts should you be attempting to establish?
The key question here must be:
Is patient care being jeopardised?
Problems may come to light as a result of complaints, but the fact that no complaints have been received does not mean that there is no problem.
Where patients shuttle between the partners in a practice, issues may be noticed, but where a personal list system is in operation, opportunities for that sort of informal peer review will be sparse.
Critical event reporting is another way of picking up performance problems, but doctors who realise that they are vulnerable to criticism are often adept at covering their tracks.
Despite all the talk of a blame-free culture being a key ingredient of clinical governance, there is still a remarkable amount of finger-pointing going on. Unless or until something happens, a doctor's underperformance may not become apparent.
Presuming that a problem has been identified, the next question is:
Collecting objective evidence of the amount that someone drinks is tricky, but various aspects of behaviour are likely to raise suspicions if drink is at the root of the problem.
Is it time to blow the whistle?
What should you do now? Most doctors would be reticent to run off to the health authority or LMC behind their colleague's back, preferring to see if there are ways in which they can help short of reporting 'the facts' outside the practice.
Assuming that the doctor has sufficient insight to acknowledge that there is a problem, the next difficulty is in monitoring and enforcing any agreement on his or her conduct.
It may be agreed that the partner should take a period of sick leave and abide by certain conditions on his return. But what happens if there is a minor transgression? And who is competent to supervise the partner's practice and conduct?
While an in-house approach may work, it puts pressure on the partnership and the partners are unlikely to have the necessary time, skill and detachment to do the situation justice. This, in turn, leaves them vulnerable to criticism by the GMC and others.
Equally, being hypercritical can land doctors in trouble. This is what Good Medical Practice has to say about that:
'You must always treat your colleagues fairly. In accordance with the law, you must not discriminate against colleagues, including doctors applying for posts, on grounds of their sex, race or disability. And you must not allow your views of colleagues' lifestyle, culture, belief, race, colour, gender, sexuality, or age to prejudice your professional relationship with them.
'You must not make any patient doubt a colleague's knowledge or skills by making unnecessary or unsustainable comments about them.'
It is probably better in these situations to seek help from the local medical committee (LMC), health authority, or even the GMC, to ensure an appropriate degree of objectivity and, secondly, to provide a more robust framework to support the doctor's rehabilitation.
Where there is a health problem, LMCs, health authorities and the GMC are generally helpful and supportive provided that the doctor is cooperative.
But it is not just health issues that may give rise to concern. Misconduct and bad practice can also put patients at risk. Other issues that may give cause for concern include:
- Irresponsible prescribing
- Poor notekeeping
- Repeated failure to assess patients thoroughly
- Sloppy administration
- Doggedly sticking to out-of-date management techniques.
The advent of protocols and guidelines, the use of clinical audit, and the introduction of annual appraisal should make identification of such problems easier and provide a means of addressing some issues.
However, where there is a major issue, it cannot wait for the next annual appraisal, and saving up a problem to hit the doctor with during appraisal is exactly how it should not be done.
Tackling the problem
Problems should be addressed as and when they arise. Most can be discussed relatively informally, with agreement on how best to manage the clinical situation under review. But if the doctor is determined not to acknowledge the problem or it is too major to be tackled in this way, something more must be done.
Action that may be taken includes discussion with the clinical governance lead, the medical advisers at the health authority or the GMC, preferably with the doctor concerned forewarned, albeit that agreement or acquiescence are unlikely to be forthcoming.
In summary, doctors have a duty to act if they consider patients to be at risk through the conduct, ill health or poor performance of a colleague.
The doctor's cooperation should be sought wherever possible to remedy the underlying problem, returning the doctor to safe practice where possible. Provided that the doctor cooperates, the problem can usually be dealt with locally. But where the problem cannot be resolved locally or issues are very serious, the matter should be referred to the GMC. This may not be an easy step to take, but patient care must always come first.
- Good Medical Practice. 2nd edn. London: GMC, July 1998.