The IMPACT study how complaints impact on the welfare and prac;ce of doctors Department of Primary Care and Public Health Lunch?me Seminar Tom Bourne Imperial College London and KU Leuven
Employer/Hospital Serious incident inves?ga?on (SUI) Employer/Hospital Internal Enquiry GMC/Regulator Na?onal Ombudsman Doctor Criminal Court Police Media Exposure Civil Court/Li?ga?on DEATH BY A 1000 ARROWS Serial or parallel processes
Mul?ple Jeopardy Prolonged Time Scale Guilty un?l proved innocent Contrary to Natural Jus?ce
James Halcrow age 34
Referrals to the GMC: Increasing numbers Incredibly non-specific a very blunt instrument
Background In England 2013-2014 175,000 formal wri`en complaints (3300/week or 479/day)
What about all doctors and all complaints processes? What about the health of doctors who do not commit suicide? Does this complaints culture alter how doctor s prac?ce? Does it lead to be`er care and protect pa?ents? Doctors can be subject to: internal inves?ga?ons (formally and informal), an SUI, or be reported by anyone even to the GMC These may be parallel or sequen?al events
IMPACT study all types of complaint What is the impact of complaints and inves?ga?ons on the psychological and physical welfare of doctors? How do complaints impact on how doctors treat pa?ents. Do they lead to defensive prac?ce or improve care What is the impact by complaint type: informal, formal, serious clinical incident review (SUI), regulator (GMC)
IMPACT study: par?cipants 95,600 invites 10,930 responses (11.4%) 7,900 completed the survey (8.3%) The sample was broadly representa?ve of all UK doctors in terms of gender, specialty, and place of qualifica?on.
IMPACT study: design Three groups depending on when complaint occurred: Ongoing or recent complaint (within last 6 months) Past complaint, looked at physical and mental health at the?me - recall No complaint but had observed processes in others
Used Validated Instruments ANXIETY: Generalised Anxiety Disorder scale-gad DEPRESSION: Pa?ent Health Ques?onnaire-PHQ DEFENSIVE PRACTICE - New scale measuring two factors: HEDGING including over referral/prescribing/inves?ga?ng/admilng to hospital when unnecessary AVOIDANCE including not performing high-risk procedures, stopping certain ac?vi?es e.g. surgery, avoiding complex pa?ents, abandoning procedures early SINGLE ITEM QUESTIONS: Stress related illness Suicidal idea?on Altude to complaints Par;cipants were guaranteed that their responses were anonymous and untraceable
PHQ-9 & GAD-7 Results depression, anxiety, suicidal idea?on current feelings
Results recalling how they felt (past) and how they feel (current)
Defini?ons of depression Persistent sadness or low mood and/or loss of interests or pleasure Fa?gue or low energy At least one of these, most days, most of the?me for at least 2 weeks disturbed sleep poor concentra?on or indecisiveness low self-confidence poor or increased appe?te suicidal thoughts or acts agita?on or slowing of movements guilt or self-blame Moderate: 5 to 6 symptoms Severe: 7 or more with or without psychosis Assessed using the Pa?ent Health Ques?onnaire-PHQ
Results by complaint process (current)
20% felt vic?mised aoer whistle blowing 38% experienced bullying going through an inves?ga?ve process 27% took one month or more off work following a complaint It destroyed me. I had a profound & las?ng depressive illness which I am s?ll struggling with I seriously considered suicide and fear I might well take it as an op?on in the future. I felt completely humiliated and was having daily thoughts of suicide
Bear in mind: There was an 11.4% response rate (but 7926 doctors responded). It must also be remembered that doctors most trauma?sed by the complaints may be unable to take part in the survey avoidance No complaints group had observed colleagues going through procedures Those no longer on the register (changed profession, erased, died) would not have been contacted
The Purpose of all this is to improve pa?ent care and protect pa?ents Where is the evidence?
How do doctors change how they treat pa?ents?
The unintended consequence of medical regula?on and complaints processes
Are there process issues in rela?on to inves?ga?ons that influence response and behavior?
Are the views of doctors consistent with validated Instruments?
The whole experience was the worst?me in my life even including being told that I had cancer. I felt vic?mised, isolated and that no one even bothered to listen to what I had to say. I had 3 young children and a single parent and frequently felt like harming myself. My children and I had no money so I struggled to pay bills and the mortgage. I felt on the poverty line I found it terrifying I felt very frightened and it felt out of control. This is the worst thing that has ever happened to me When the le`er came I was on a weeks annual leave at home and almost took my own life. It felt like it destroyed me as a person, not only in my working role. I have recovered to some extent but it will always scar me.
I felt I was raped by the system and completely let down. Every aspect of my life was turned over - and I teetered on the edge of financial meltdown. If it was not for the support of some fantas?c friends and very good independent legal advice I would probably have commi`ed suicide at one point. The result was I lost my job and was completely demoralized. I was off work for a year to recover. However it should never have come to that. It has taken me years to get over the experience - and I have to s?ll work hard not to feel angry and "live in the now
As a result of the nega?ve media coverage my son was physically assaulted by a class mate at university as he got academic scholarships and was told that his mother: got all the benefits that this country offered whilst in reality your f..king Mother is a f..king Killer of babies I also got my second episode of breast cancer during this period.
Need to look at the Open Ques?ons in a non-selec?ve way Q1 Try to summarise as best you can your experience of the complaints process and how it made you feel Q2 What were the most stressful aspects of the complaint? Q3 What would you improve in the complaints system?
What did people say about their experiences?
What has to happen? Recognise that fear is toxic to pa;ent safety and physician health Recognize the need for change. There is no jus?fica?on for doctors being made sick by poor processes Abandon blame as a tool Clinicians must be supported by clinicians support your own colleagues do not let them be isolated Supervisory and regulatory systems should be simple, clear and transparent currently not fit for purpose Inves?ga?ons must have fixed?mescales There must be rapid resolu?on for vexa?ous complaints and consequences for vexa?ous or dysfunc?onal complaints by staff Those inves?ga?ng complaints must be competent, up to date and fully understand process
THE FOLLOWING MATERIAL WILL NOT BE IN THE LECTURE BUT MAY BE OF INTEREST TO THE READER AND POINT THEM TO FURTHER READING
Paid by the GMC Reviewed 114 deaths whilst under UK regulators (GMC) inves?ga?on from 2005 to 2013
Clearly contrary to natural jus;ce Doctors are guilty un?l proved innocent Process is not compassionate Protracted?mescale S?gma?sing Culture of fear and discrimina?on
Are our results an anomaly?
Francis Report - freedom to speak up
Francis Report freedom to speak up