DOCTORS NOT REASSURED BY GMC

BMJ 2022; 379 doi: https://doi.org/10.1136/bmj.o2800 

(Published 18 November 2022) Cite this as: BMJ 2022;379:o2800

1. Elisabeth Mahase

The GMC has warned that doctors may need to “depart from established procedures to care for people” during this “difficult” winter but that it will take the context of working conditions into account when dealing with any referrals it receives.1

In a letter co-signed by four UK chief medical officers, the regulator the Care Quality Commission, and England’s national medical director, the GMC said that clinicians were “likely to have concerns about both the professional practicalities and implications of working under sustained pressure” and may be “fearful that they will be referred” to the regulator.

However, it said that “in the unlikely event” a doctor is referred, the GMC will take “local realities and the need at times to adapt practice at times of significantly increased national pressure” into account. It added that it expected “employers, educational supervisors, professional bodies, national health and social care organisations to be flexible in recognition of the challenging and changing landscape” doctors will face.

The letter, which the GMC said was intended to provide “reassurance,”2 has been met by doctors with some scepticism.

London GP Azeem Majeed, head of primary care and public health at Imperial College London, told The BMJ, “I did not find the letter from the CMOs and GMC reassuring. The letter seems to imply that doctors and other NHS staff should be expecting to work in substandard conditions this winter where there will be significant threats to patient safety and the quality of healthcare.”

He continued, “Doctors who have made errors in the past while working under difficult circumstances have not been treated well by their NHS employers or the GMC and have been scapegoated for wider system failures.”

In recent years two GMC cases have caused major upset over the treatment of doctors from ethnic minority groups and those who have trained overseas: Hadiza Bawa-Garba and Manjula Arora.34

The Arora case saw the GP face a suspension of one month, later overturned, for dishonesty over her use of the word “promised” when requesting a work laptop. A review into the case, sparked by a backlash among doctors, found that the GMC was wrong to pursue Arora and missed opportunities to assess whether the allegations were serious enough to be referred to a tribunal.5

Asangaedem Akpan, a consultant geriatrician in northwest England, said, “I truly believe that our senior colleagues who have written these letters believe what they have written and are individuals with credibility and integrity. However, as a person of colour I have no confidence that I or any clinician of colour will be treated fairly or the same as a white clinician. This is because the system is institutionally racist and discriminatory, and until such a time when it is reformed so that everyone is treated the same way I do not trust the referral process to be fair.”

Data show that, when compared with white doctors, those from ethnic minorities were twice as likely to be referred to the GMC by their employers for fitness to practise concerns. The referral rate among doctors qualifying outside the UK is three times that of UK doctors.6

The Medical Defence Union (MDU) and Medical and Dental Defence Union of Scotland (MDDUS) have welcomed the letter but said that actions must match the words.

Naeem Nazem, head of the MDDUS medical division, said, “Many remain nervous about how they acted during the pandemic because they were working outside their comfort zones and about whether this is now going to make them vulnerable as things are scrutinised.

“What is needed now is more practical support to help doctors get through this winter. For example, more support for doctors from local employment liaison advisers, additional wellbeing resources and clearer information from the GMC and UK CMOs about how they are working with others to create a framework of support.”

Caroline Fryar, MDU’s director of medical services, said, “One concrete step the GMC can take is making sure the new version of Good Medical Practice reflects the realities of practice on the frontline, rather than an aspirational vision which hard pressed doctors have little control over. We want the GMC to deliver guidance that works for doctors, so they can get on and deliver for patients.”

The defence unions told The BMJ that there have already been some cases in which pandemic conditions or the care backlog have been cited, though they noted that there was usually some delay between incidents happening and cases being reported. They expected to see more such cases next year.

1. ↵General Medical Council. Winter pressures—letter to the profession. Nov 2022. https://www.gmc-uk.org/news/news-archive/winter-pressures-letter-to-the-profession.
2. ↵General Medical Council. Twitter. Nov 2022. https://twitter.com/gmcuk/status/1592554330237931522
3. ↵The Bawa-Garba case. BMJ. https://www.bmj.com/bawa-garba.
4. ↵
   1. Mahase E
   2. . Manjula Arora: GMC won’t challenge appeal and calls for sanctions to be dropped by court. BMJ2022;377:o1583. doi:10.1136/bmj.o1583 pmid:35760422FREE Full TextGoogle Scholar
5. ↵
   1. Mahase E
   2. . Manjula Arora: GMC was wrong to pursue GP over “promised” laptop, finds review. BMJ2022;379:o2619doi:10.1136/bmj.o2619.FREE Full TextGoogle Scholar
6. ↵General Medical Council. GMC targets elimination of disproportionate complaints and training inequalities. May 2021. https://www.gmc-uk.org/news/news-archive/gmc-targets-elimination-of-disproportionate-complaints-and-training-inequalities.

Views And Reviews Primary Colour

https://www.bmj.com/content/377/bmj.o1353

BMJ 2022; 377 doi: https://doi.org/10.1136/bmj.o1353 (Published 31 May 2022) Cite this as: BMJ 2022;377:o1353

1. Helen Salisbury, GP

Author affiliations

1. helen.salisbury@phc.ox.ac.uk
   Follow Helen on Twitter: @HelenRSalisbury

There has been much disquiet in GP circles about the treatment of Manjula Arora, firstly by her employers and then by the General Medical Council and the Medical Practitioners Tribunal Service.1 How this dispute about whether or not Arora had been promised a new laptop reached the GMC is a mystery to most of us. What is clear is that, in any functioning organisation, the issue would have been swiftly resolved at local level.

The tribunal’s report is distressing to read. It really is difficult to work out how the misinterpretation—or even slight exaggeration—of an email about office equipment could be construed as an impairment of Arora’s fitness to practise, meriting a one month suspension from the medical register.2 The ruling specifically states that she “did not have dishonest intent” and “did not set out to mislead” in telling her IT department that she’d been “promised” a new laptop. There’s absolutely no suggestion that patients’ health, or the reputation of the profession, was at risk in this entirely private spat between a doctor and her employer. Unless something important has been omitted from this report, the conclusions make no sense.

Trust is essential in medical practice, and it’s important to justify the confidence patients put in us by maintaining scrupulous standards of honesty. Most medical courses start with an examination of the GMC’s document Good Medical Practice, so that students understand the expectations of them in both their work and their private lives. The standards to which we’re held are high (in marked contrast to, for example, politicians), but I think that very few people can or should be 100% honest all of the time.3

Sometimes a lie feels justifiable, such as the decision to err on the side of optimism when discussing prognosis with a newly diagnosed cancer patient (to misquote T S Eliot: “Humankind cannot bear too much reality”). Other lies are less acceptable, such as blaming your lateness on the traffic when in reality you lost your keys or had an argument with your partner—but they’re very common and usually slip under the radar unless they affect patient care. We should strive to be open and honest in all of our dealings with patients and colleagues, but we should also recognise that doctors are human and will, on occasion, fail to meet our profession’s exacting standards.

The task that we entrust to the GMC is to determine whether a particular failing is serious and constitutes a threat to patients or their trust in the profession. All registered doctors are obliged to pay the organisation a significant sum each year, and in return we deserve a system that’s fair, sensible, and proportionate. Unfortunately, this case has brought the GMC into disrepute: apart from incredulity at the judgment (“They’ve spent my money on this?”), it also smacks of racism. It comes as no surprise to observers that the doctor at the centre of this case is a woman from an ethnic minority, like Hadiza Bawa-Garba before her. In fact, ethnic minority doctors are twice as likely as others to be referred to the GMC, and doctors who trained overseas are three times as likely.4 As one commentator on Twitter has observed,5 when dealing with the GMC, doctors should be aware of the extra hazard of “practising while brown.”

• Competing interests: See www.bmj.com/about-bmj/freelance-contributors
• Provenance and peer review: Commissioned; not externally peer reviewed.

1. ↵
   1. Mahase E
   2. . Doctors express “grave concerns” at GMC action after GP is suspended over laptop claim. BMJ2022;377:o1324. doi:10.1136/bmj.o1324. pmid:35613730FREE Full TextGoogle Scholar
2. ↵Medical Practitioners Tribunal Service. Record of determinations: Mrs Manjula Arora. 3-12 May 2022. https://www.mpts-uk.org/-/media/mpts-rod-files/mrs-manjula-arora-12-may-2022.pdf
3. ↵
   1. Sokol D
   2. . A cautionary tale for potentially dishonest doctors. BMJ2022;377:o1298. doi:10.1136/bmj.o1298. pmid:35606013FREE Full TextGoogle Scholar
4. ↵
   1. Mahase E
   2. . GMC to review Manjula Arora case after backlash from doctors. BMJ2022;377:o1350. doi:10.1136/bmj.o1350. pmid:35623645FREE Full TextGoogle Scholar
5. ↵DocInTheHeed. Twitter. 22 May 2022. https://twitter.com/HeedDoc/status/1528317154176561152?t=Eb086p6XgDF4sXFSfcZszg&s=19

 https://www.manchestereveningnews.co.uk/news/greater-manchester-news/family-gp-doctor-nhs-banned-24071124

The tribunal has been slammed as 'reflecting an oppressive and punitive culture in the NHS driven by top-down targets'

A family GP has been suspended for ''over-egging'' a request she made for a new NHS work laptop to help her treat patients. Dr Manjula Arora, 58, was reported to the General Medical Council (GMC) after she wrongly told IT officials she had been ''promised'' the device by her boss when, in fact, he ''noted her interest'' in getting one.

Dr Arora, who was working in Manchester as a locum practitioner for out-of-hours provider Mastercall, was subjected to a 15-month inquiry following her remark. It culminated in her facing an eight day disciplinary hearing and being found guilty of dishonesty, serious professional misconduct and ''impaired'' ability to practise medicine.

Yesterday, May 25, a row broke out after Dr Arora - who qualified 35 years ago and who is described as a woman with ''strong moral principles'' - was banned from treating patients for a month. The Medical Practitioners Tribunal Service said suspension would ''send a message that her misconduct, albeit relating to a single fleeting moment of dishonesty was not acceptable.''

But Professor Sam Shah, who worked as Director of Digital Development at NHS England said: "This case reflects an oppressive and punitive culture in the NHS driven by top-down targets in an underfunded and poorly designed system. Remote working to get the best out of the workforce was encouraged for the last two years and allegedly championed in urgent care. It is disappointing that this case turns on a laptop.''

The saga began in December 2019 after Dr Arora who lives in Hale Barns, near Altrincham, exchanged emails with Stockport -based Mastercall's Medical Director about getting a work laptop to assist with her duties.

In his response on Christmas Eve, the boss who was referred to as Dr B at the hearing told her: “We don’t have any laptops at present, but I will note your interest when the next roll out happens. Technology is advancing, we may soon be able to allow clinicians to use their own computers, watch this space.”

But trouble came on 30 December, 2019, when Dr Arora spoke to an IT Support Analyst at Mastercall and referred to her email exchange about the laptop with Dr B. She told the analyst: ''He said the next time it’s available he’ll give it to me, so you have laptops and I thought it’s best that I take one because I don’t want too many people to be involved, just him and you directly. It’s [Dr B] who has promised it. Will you be able to speak to him directly, we talked about the laptop.''

Dr Arora, whose husband is a consultant surgeon, was referred for investigation in February 2020 after Dr B learned of her discussion with the analyst. For the GMC, lawyer Carl Hargan said the word ''promise'' was “a world away” from Dr B’s actual words'', adding: ''What Dr Arora was trying to do was obvious in that she was trying to get a computer.

''The analyst thought Dr B had authorised one and that he could therefore give her one. No other clinician had ever approached him in the way that Dr Arora had done.''

Mr Hargan said Dr B's email was “entirely unambiguous”, and could not “in any way, shape or form” amount to him ''promising'' her a laptop and he went on: ''Dr Arora has brought the medical profession into disrepute and her integrity cannot be relied upon.'

In evidence to the Manchester hearing Dr B said Dr Arora was not “at the top of the list” for requests and said his Christmas Eve message was a “holding email”. He said he “didn’t want to give negative messages ahead of the busiest time of the year” although he said Dr Arora would not necessarily be refused a laptop.

Dr Arora said in a statement: ''I accept that I perhaps interpreted [Dr B’s] words ‘note your interest’ as something more definite than he actually meant.

''I think the word 'promised’ was not appropriate and maybe it was not the word I should have used, but I thought he wanted to give it to me. It’s the connotation that I had taken from it. I said he has promised it because I took it to mean he intended to give me a laptop”.

Dr Arora's lawyer, Mr Alan Jenkins, said: ''Dr Arora had not set out hoping to gain anything that she would not have gained anyway. It was not an operative deception and that any dishonesty was the result of a slight exaggeration.

''She interpreted Dr B's email as a “thumbs up” and her position is that if she had been told she was not going to get a laptop we wouldn’t be here now.''

He added: ''Whilst Dr Arora has perhaps ‘over-egged’ her claim that Dr B had promised her a laptop, she is not a dishonest person, just someone who merely said a single dishonest thing. She does not pose a risk to the public.''

In suspending Dr Arora, MPTS chairman Mr Peter Schofield said: ''The tribunal had regard to her good character, and to the testimonials it had received on her behalf. It accepted, in general terms, that she was not a dishonest person.

''But with specific reference to her use of the word ‘promised’, the tribunal concluded that it was more likely than not that Dr Arora exaggerated the position in order to reinforce her request for a laptop. As she herself accepted, it was not appropriate to use that word and she should not have said what she did. Ordinary, decent people would consider her use of the word ‘promised’ as dishonest.

''The tribunal concluded that a short period of suspension this period of suspension would send an appropriate message to the medical profession and to the wider public that Dr Arora’s misconduct, albeit relating to a single fleeting moment of dishonesty and not a planned deception, was not acceptable and that this period of suspension would adequately reflect the seriousness of her behaviour.''

Dr Chandra Kanneganti, President of the British International Doctors Association, said: "This is an exaggerated response, just because of wording used to obtain a laptop for work purposes and more importantly the unsafe nature of workloads the doctors and most GPs have to face most days. BIDA will fully support Dr Arora if she is planning to appeal this disproportionate response."

"It is not just a travesty of justice or a waste of time and energy of the GMC, but much worse is the demoralising impact on the doctors and wider medical professionals," added Dr Ramesh Mehta President of the British Association of Physicians of Indian Origin.

"We have known that some of the GMC representatives are bent on punishing doctors whatever the facts of the case. We have raised this issue with the GMC."