When the GMC comes for you

I can tell you from real professional experience across the last 15 years that:

1. most (approx 75%) doctors do not read carefully GMC guidance on a regular basis
2. 90-odd percent in my estimate will not have read a case from the GMC’s tribunal called the MPT in the previous  6 months. 
3. most doctors I’ve met believe the GMC are living in cloud cuckoo land and divorced from reality.

Caution: I said the above was my experience and I am being 100% honest in my estimates on that. I do not know if my estimates apply to a total population of all doctors in the UK.

I read parts of three key guidance documents (of 34) almost every day over the last 8 months. Over the last 5 years on average I would have read their guidance once per week. But wait.. hold on. This does not mean I love or favour the GMC!! I just find that their guidance is easily readable, makes sense and is very applicable to my everyday medical practice. 

Introduction

In this post I focus on the case of Prof Justin Stebbing, drawing all information from the public domain. Why this case? Well first off, I do not know Prof Stebbing from proverbial Adam, nor his patients or anyone directly or indirectly connected with him. My interest was sparked by the scale and depth of the issues found at fault across two MPTS determinations: 2021 and 2022. In thumbnail summary those were: consent issues, prognosis and treatment, poor communication with colleagues (and collaborative working), maintaining professional boundaries and dishonesty. 

According the MPT decision in 2022, “Professor Stebbing’s initial MPT hearing took place on various dates throughout 2020 and 2021. The hearing lasted around 170 days. The hearing concluded on 20 December 2021 (‘The 2021 Tribunal’).” The 2021 decision was 261,943 words spread across 610 pages (single sides of A4) . The 2022 MPT stated, “The 2021 Tribunal was of the view that it was inconceivable, as a consultant of oncology, that Professor Stebbing did not understand the concept of consent at the time of the relevant events. Whilst the 2021 Tribunal recognised that he was often treating patients facing complex or difficult to treat cancers with poor prognoses, and who were resource unconstrained, it considered that the consent process was a basic and fundamental one that did not change according to the complexity of the cancer or any other variable.“

Essential reading: “Saviour or Sinner?” Why the case of Justin Stebbing matters (Journal of Medical Ethics 13/11/2022)

Itemised list of breaches

The following is a bare bones summary. 

Clinical Care and Communication Failures

1. Failure in Providing Good Clinical Care (Paragraph 6): Allegations related to failure to provide good clinical care to 12 patients, particularly those at the end of life.
2. Poor Communication (Paragraph 6): Admitted and found proved allegations of poor communication.

Consent

3. Informed Consent Failures (Paragraph 9): Specific issues with obtaining informed consent from patients.

Professional Boundaries and Record Keeping

4. Not Maintaining Professional Boundaries (Paragraph 21): Allegations of failure to maintain professional boundaries, although later remediated.
5. Record Keeping Failures (Paragraph 6): Failures in maintaining adequate patient records. Professor Stebbing admitted to most of the allegations relating to his failure to provide good clinical care to 12 patients. These allegations were associated with record keeping failures, indicating lapses in maintaining comprehensive and accurate patient records. These record keeping failures were grouped with other issues such as poor communication, consent issues, not maintaining professional boundaries, and allegations of dishonesty​

Dishonesty

6. Dishonesty in Practice (Paragraphs 7, 17): Admitted three allegations of dishonesty; a fourth was found proved by the Tribunal, related to practice conditions.
7. Specific Instances of Dishonesty (Paragraph 22): Dishonest conduct involving unauthorised chemotherapy prescription, seeking retrospective authorisation, and altering information in a multi-disciplinary meeting form. Additionally, falsely signing off a BUPA application form for funding a cancer drug/regimen.

Deeper on Consent issues

1. Basic and Fundamental Nature of Consent Process (Paragraph 14): The tribunal highlighted that the consent process is basic and fundamental and does not change based on the complexity of cancer or any other variable. Professor Stebbing often treated patients with complex or difficult-to-treat cancers, but this did not alter the fundamental requirements of informed consent.
2. Inability to Articulate Failure in Obtaining Informed Consent (Paragraph 14): Professor Stebbing was unable to clearly articulate why he had not obtained informed consent for specific patients, despite understanding the mechanics of obtaining consent.
3. Fitness to Practice Impaired by Misconduct in Respect to Consent (Paragraph 15): The 2021 Tribunal determined that Professor Stebbing’s fitness to practice was impaired due to misconduct related to the issue of consent, posing an ongoing risk to patient safety.
4. Failings in Consent Process (Paragraph 63): The Tribunal acknowledged that Professor Stebbing’s failings in the consent process were basic and fundamental but also recognised that these failings were capable of being remediated.

5. Fundamental Core Principles and ‘No Treatment’ Option (Paragraph 38): In relation to consent, particularly focusing on the ‘no treatment’ option, Professor Stebbing reflected and understood that providing no treatment could be an effective option. This reflection was part of his broader understanding of fundamental core principles in patient care.

Vulnerability of patients

• Paragraph 64: The Tribunal identified the particular vulnerability of some of Professor Stebbing’s patients as one of the only aggravating factors. This implies that the Tribunal gave considerable weight to the vulnerable state of the patients while assessing the case and determining appropriate actions​.
• Paragraph 65: The Tribunal’s conclusions at the impairment stage included considerations of Professor Stebbing’s insight in respect of prognosis and treatment, informed consent (including end-of-life care), and dishonesty. The concern about the risk of repetition, which could raise patient safety concerns, indicates that the vulnerability of patients was a significant factor in their deliberations​.

Learning points and summary

The key learning points for all doctors emerging from the case of Professor Justin Stebbing, as determined by the Medical Practitioners Tribunal, can be summarised as follows:

1. Importance of Informed Consent: The case underscores the critical necessity of obtaining informed consent, regardless of patient circumstances or the complexity of the condition being treated. Doctors must ensure that they clearly articulate and document the process of obtaining informed consent, emphasising patient understanding and agreement.
2. Maintaining Professional Boundaries: The case highlights the importance of maintaining professional boundaries with patients. This includes recognising and respecting the limits of professional relationships and ensuring that patient care is not compromised by personal involvement.
3. Accurate and Comprehensive Record Keeping: The case demonstrates the need for diligent record-keeping practices. Accurate and comprehensive documentation of patient care, treatment plans, and communications is essential for maintaining high standards of medical practice and patient safety.
4. Clear and Effective Communication: Effective communication with both patients and colleagues is fundamental. The case illustrates the potential consequences of poor communication, particularly in collaborative working environments and in conveying critical information about patient care.
5. Upholding Ethical Standards and Honesty: The case reiterates the importance of honesty and ethical conduct in medical practice. It shows the severe professional repercussions that can follow from dishonest actions, including the manipulation of records or unauthorised treatments.
6. Professional Insight and Remediation: The case emphasises the value of developing insight into one’s professional conduct, especially after incidents of misconduct. The ability to reflect on, understand, and rectify professional shortcomings is crucial for personal growth and the maintenance of public trust in the medical profession.
7. Patient Safety and Vulnerability: The case points out the need for special consideration and care for vulnerable patients. The vulnerability of patients, especially those with severe or terminal conditions, should be a primary consideration in treatment and care decisions.
8. Legal and Ethical Obligations: The case serves as a reminder of the legal and ethical obligations inherent in medical practice. Adhering to these obligations not only protects patients but also preserves the integrity and public trust in the medical profession.

But note carefully the time and resources available to the MPT when it deliberates on a case. In case you missed it doing the usual speed-read the 2021 decision was 261,943 words spread across 610 pages (single sides of A4) for a hearing that lasted 170 days. Smoke that in your pipe!