Complaints procedures faced by doctors risk harming patients, study suggests

Doctors who go through complaints procedures experience high rates of serious depression, anxiety and suicidal thoughts, according to a new study.

Four out of five doctors also reported changing the way they treat their patients as a result of either complaints against themselves, or observing a colleague go through a complaints process.

The authors of the research say that by causing psychological ill health and encouraging defensive practice, the processes designed to hold doctors to account are having negative consequences for patients.

The findings come from a survey of 7,926 doctors published in BMJ Open.

Professor Tom Bourne, lead author of the study from the Department of Surgery and Cancer at Imperial College London, said: “Of course it’s essential that when things go wrong, the reasons are properly investigated. But this study suggests that the regulatory system we have in the UK has unintended consequences that are not just seriously damaging for doctors, but are also likely to lead to bad outcomes for patients. We think this needs to be looked at carefully by policy makers.”

The General Medical Council regulates doctors in the UK and can stop or limit their rights to practise. In 2013 there were more than 8,500 complaints about doctors to the GMC, of which just over 3,000 went on to be investigated. About 80 doctors a year are suspended or erased from the medical register. Apart from those referred to the GMC, many other complaints are investigated through hospitals’ internal enquiries.

The study found that doctors who had recently been the subject of a complaint were twice as likely as other doctors to report moderate or severe anxiety, and twice as likely to have thoughts of self-harm. Those referred to the GMC had especially high rates of psychological illness, with 26 per cent reporting moderate to severe depression and 22 per cent moderate to severe anxiety.

“Our data suggests the impact of complaints procedures of all kinds on doctors is often disproportionate to the issue being investigated,” said Professor Bourne. “For example the vast majority of doctors referred to the GMC are found to have no case to answer, yet many doctors being investigated show high levels of serious psychological morbidity and we know this impacts on how they treat patients.”  

Many doctors admitted practicing medicine more defensively as a result of being investigated or witnessing the impact of investigations on colleagues. Eighty-four per cent reported hedging – overcautious practice such as overprescribing, referring too many patients, or ordering unnecessary tests. Forty-six per cent reported avoidance – reluctance to take on difficult patients or procedures.

“A key issue that has come out of the study is the apparent impact on patient care of these complaints processes,” said Professor Bourne. “Over prescribing or referral and avoiding complex patients or difficult operations because of a fear of complaints or the actions of the regulator is clearly not in the interests of patients, and may increase costs to the NHS. We need a new structure that is transparent, fair and has the confidence of all parties”

The study also found that:

• 20 per cent of doctors felt the complaint against them was a result of them being victimised after whistleblowing.
• 39 per cent said they felt bullied when going through the complaints process.
• 27 per cent had more than a month off work as a direct result of the complaints process.

“Our findings are a concern for all of us who want to see a culture within the NHS that is transparent and open, that recognises that honest mistakes can occur, where complaints are learnt from, and where it is safe to speak out about clinical and managerial concerns,” said Professor Bourne. “But how likely is it that doctors will have the confidence to put their hand up when regulatory processes can have such negative consequences for both them and their patients?”

Many doctors who took part in the survey felt processes could be improved through greater transparency, managerial competence, and the capacity to act against vexatious complainants.

In December, the GMC published an internal review of 28 cases of suicide by doctors while they were being investigated by the regulator. The report highlighted the need for doctors under investigation to feel ‘innocent until proven guilty’ and stated such processes may stigmatise and ‘create a culture of fear and discrimination’.

“The data from our study on over 7000 doctors has limitations, but based on the findings one must question whether a wider external review of the impact of the regulator and the complaints ‘pyramid’, beyond the narrow remit of 28 doctors who actually did commit suicide, should be carried out,” said Professor Bourne.

Reference

T. Bourne et al. ‘The impact of complaints procedures on the welfare, health and clinical practice of 7,926 doctors in the United Kingdom: a cross-sectional survey.’ BMJ Open (2015) doi 10.1136/bmjopen-2014-066687