Recent eLetters

Displaying 11-20 letters out of 345 published

  1. Correction to corresponding author's email address

    Please see the correct email address of the corresponding author:

    We apologise for the error.

    The authors

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    None declared

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  2. Obesity Interventions offered in Primary Care

    This article particularly caught our attention because as Psychiatrists we routinely prescribe psychotropic medications with unwanted side effect in the form of weight gain. Under the Shared Care Protocol (with General Practitioners) we often refer our patients to GPs for weight management interventions.

    Globally, there are more than 1 billion overweight adults, at least 300 million of them clinically obese. There was a marked increase in proportion of adults that were obese between 1993 and 2012 from 13.2 % to 24.4% among men and form 16.4% to 25.1% among women1. In 2012, an estimated 62% of adults (aged 16 and over) were overweight or obese and 2.4% had severe obesity. The prevalence of obesity rose form 15% in 1993 to 25% in 2012 2. . Data form Health Survey for England (HSE) show that obesity rates among adults with a long- term limiting illness or disability (LLTI) are 57% higher than adults without a LLTI. Once considered a problem only in high-income countries, overweight and obesity are now dramatically on the rise in low and middle income countries particularly in urban settings.

    Overweight and Obesity are major risk factors for a number of chronic diseases including heart disease3, diabetes4, hypertension, stroke, arthritis and cancer. The Foresight Report in 2007 estimated that direct health care costs attributed to being overweight or obese were 4.2 billion pounds , potentially rising to 6.3billion in 2015 and further up to 9.7 billion pounds by 20505. . A more recent analysis estimated that overweight and obesity cost the NHS 5.1 billion pounds per year6.

    The prescription of antipsychotic medication for chronic and enduring mental illness often leads to weight gain which is most of the times an unacceptable side effect and can also produce metabolic syndrome, irregularities in blood level of glucose and lipids7,8. It is a delicate balance to achieve between mental health recovery and these side effects. These changes invariably affect the life expectancy of patients with mental health issues9.

    To effectively tackle these unwanted side effects, patients are usually referred to dieticians and GPs for further interventions. After reading the results that these interventions are not being offered as they should or not recorded, it raises a few questions:

    1. Every one is aware that GP surgeries are struggling to give appointment to patients who need to be seen for their primary physical disease. Do GP's have the flexibility or allocated time to do any type of preventive work?

    2. GP usually see their patients in 10 minutes time slots, which is hardly sufficient to deal with the primary issue, giving prescription and writing notes. Even though they observe that the patient is overweight there is a limited opportunity to discuss, motivate or give proper advice to these patients.

    3. Earlier GP could prescribe exercise on prescription. In the recent overhauling of the benefit systems, DLA has been replaced with Personal independent Payments (PIP). Many councils have scrapped this privilege under the assumption that people can pay to attend exercise programmes from their PIP allowance. Under the current climate of financial constraints, spending money on such programmes may not take precedence over other basic needs.

    Obesity is growing at a fast rate and if not tackled it would pose an enormous economic burden on the NHS to treat various physical and mental diseases whose precursor is obesity.

    References: 1. Statistics on Obesity, Physical Activity and Diet-England,2014 (Health and Social Care information Centre)

    2. Adult Weight data Sheet Public Health England

    3. H B Hubert,M Feinleib,P M McNamara, WP Castelli: Obesity as an independent risk factor for cardiovascular diseases: a 26 yeas follow up of participant in Framingham Heart Study : Circulation 1983;67:968-977

    4. A.Astrupand N Finer :Redefining Type 2 Diabetes: Diabesity or Obesity Dependent Diabetes Mellitus?

    5. Government Office for Science , Foresight Report,tackling Obesities: Future Choices-Projet Report ,2nd Edition, ocotber 2007.

    6. P Scarborough, P Bhatnagar, K Wickramasinghe ;The economic burden of ill health due to diet, physical activity, smoking ,alcohol and obesity in UK: an update to 2006-07 costs, Journal of Public Health vol.33no.4, may 2011, pp527-535

    7. Jonathan M Meyer, Henry A Nasrallah, Joseph P McEvoy, Donald C Goff, Sonia M Davies, Miranda Chalos, Jayendera K patel, Richard S E Keefe, T Scott Stroup, jefeery A Leiberman: The Clinical Antipsychotc Trails Intervention Effectiveness (CATIE) Schizophrenia . Schizophrenia Vol 80,issue 1, December 2005 .

    8. McIntyre Roger S , McCann Sonia M, Kenenedy Sidney H ; Antipsychotic Metabolic Effects: Weight Gain, Diabetes Mellitus and Lipid Abnormalities. The Canadian Journal of Pyschiatry /La revue canadienne de psychiatrie Vol 46(3), Apr 2001, 273-281

    9. Casey Daniel E, Haupt Dan W , Newcomer John W, Henderson David C , Semyak Michael J, Davidson Michael, Lindenamyer Jean Pierre, Manoukian Steven, V Banerji, Mary Ann, Lebovitz Harold E , Hennekens Charles H : Antipsychotic induced Weight Gan and Metabolic Abnormalities: Implications for increased Mortality in patients with Schizophrenia. Journal of Clinical Psychiatry, Vol 65 (suppl 7) , 2004, 4-18.

    Conflict of Interest:

    None declared

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  3. Response to : Methadone maintenance treatment programme reduces criminal activity and improves social well-being of drug users in China: a systematic review and meta-analysis

    Dear Sir, I read this article with great interest as it resonate all the research work done in addiction psychiatry in developed countries. As Psychiatrists we come across many services user whose mental illness is complicated with various substances harmful use or dependency.

    Drug addiction is a big problem world wide especially addiction to class A substance which is difficult to overcome without expert help.It is estimated that there are 500,000 heroin addict in USA and Public Health England figures state that there are around 262,000 opiate drug user in England in 2010/11. The latest figures does show that the drug addiction is more in older group (25-35 years) rather than early teens or young adults1. Not to forget, three times or more the number of these figure , the carers and the family members effected by drug addiction problem of their loved one. Unfortunate there is a large proportion of children who are deprived of stable family homes and are ofter under the care of social services2. These children are more vulnerable to mental health problems including attachment disorder, depression, anxiety ,bullying and predisposition to substance addiction.

    The burden on any health economy due to drug addiction is massive , its impact on mental health and direct consequences on physical health, there are many other blood borne and sexually transmitted disease which are more prevalent in drug addicts e.g. Hepatitis B and C and HIV. 120 new cases of HIV ,in 2012 ,were infection acquired through injecting drugs3.There were 6,549 admissions to mental health hospital with a primary diagnosis of a drug-related mental health and behavioural disorder in 2012/134.

    To fund their drug habit , the drug users do various crimes from shoplifting, burglary, theft selling or smuggling drugs and prostitution5. This adds huge burden Criminal Justice System.The problem drug use costs society ?15.4 billion a year, of which ?13.9 billion is attributed to crime committed by drug dependent offenders5 . Government spending on drug treatment give good value for money, for every one pound , it generates 2.50 pounds worth of savings6.

    Methadone replacement treatment for opiate dependency has been practiced in developed countries for more than two decades. Research has shown that it is cost effective in the term of harm reduction .Its long half life not only helps in combating opioid withdrawal symptoms but it also reduces cravings for opioids.It reduced the euphoric effect of heroine. A number of studies have shown that Methadone maintenance treatment is associated with reduction in mortality (accidental overdoses), injection practices, blood borne infections and other sexually transmitted diseases and criminality. It also improves physical & mental health, social functioning and quality of life6. There is significant reduction in crime rate after the service user enters methadone treatment programme7,8.

    For all these above reasons it is important that Methadone treatment should be the part of a comprehensive assessment which not only for harm reduction but also encourages, as we say each contact matters, service user for detox and rehabilitation.

    References: 1. Statistics on Drug Misuse England 2013 Health and Social Care Information Centre

    2 .Parents with Drug Problems: How Treatment helps Families. The National Treatment Agency for substance misuse 2012.

    3. HIV in the United Kingdom: 2013

    4. Statistics on Drug Misuse England 2013 Health and Social Care Information Centre

    5. National Audit office (2010) Tackling problem drug use .

    6. Home Office (2009) The Drug Treatment Outcomes Research study (DTORS): Cost-effectiveness analysis. Home Office Research Report 25

    7. Change in criminal activity after entering Methadone maintenance James Bell et al. British Journal of Addiction Vol.87, Issue,2 251-258, Feb 1992.

    8. Changes in offending following prescribing treatment for drug misuse.Tim Millar et al .(2008)

    Conflict of Interest:

    None declared

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  4. "Don't talk to the driver"

    Lawyers think in terms of crime, homicide with or without premeditation, fraud, legal responsibility, economic damage, indemnification and guilt. Terms medical doctors are not so familiar with. Medical doctors think in terms of patients, differential diagnosis, treatment options, cure and care. Because the primary aim of practising medicine is to help patients, we are particularly affected if something goes wrong, especially if this results in harm to our patient. Medical doctors are human beings. We may misjudge a situation, underestimate a disease's severity or be misled by the patient's history. Because unintentional inappropriate medical acts may have serious or fatal consequences, it is of paramount importance that we learn from errors and complications. The history of medicine has been written this way. Progress in medicine is based on (self)reflection each time things didn't turn out as expected. The paper by Tom Bourne et al.(1) demonstrates that complaints procedures may hinder this permanent evaluation and improvement process, and may have an adverse effect on patients' safety. The paper doesn't plead for a permissive policy of low level medical practice. On the contrary, it is acknowledged that in order to reach the medical care levels of excellence patients are entitled to, each unexpected adverse outcome should be debriefed. This paper is particularly important because scientific evidence is given that complaints procedures can have disastrous side effects on medical doctor's psychological health, and hence can change the attitude of the entire medical profession. Customers are instructed not to talk to the driver while the bus is in motion, to avoid accidents because distraction may compromise the customers' safety. Bus companies do not expect their drivers to be 'emotionally resilient' (2) enough to cope with distraction. Likewise, the primary goal of medical councils is to guarantee a safe and "distraction free" working environment for medical doctors, allowing good medical practice and ensuring patients' safety. Tom Bourne's study demonstrates complaints procedures may become a 'fatal distraction' for the medical practise. It is doubtful if the introduction of 'emotional resilience' training (2) for medical doctors is the appropriate answer.

    1. Bourne T, Wynants L, Peters M, et al. The impact of complaints procedures on the welfare, health and clinical practise of 7926 doctors in the UK: a cross-sectional survey. BMJ Open 2014;4:e006687. doi:10.1136/bmjopen-2014-006687 2. Doctors who commit suicide while under GMC fitness to practise investigation. http://www.gmc-

    Conflict of Interest:

    I have been co-author with Tom Bourne on papers about ultrasonography in gynaecology

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  5. The volume of complaints against doctors and how they are handled are not necessarily in the best interests of patients and harms doctors. New solutions are needed based on good quality evidence.

    We would like to thank Niall Dickson for his interest in our paper (1). As Dickson suggests, being the subject of an investigation in any profession is likely to be associated with stress and anxiety. Professor Terence Stephenson illustrated the scale of the problem in medicine when he stated in his recent evidence to the health select committee "I have personally been investigated twice by the GMC. Doctors recognize having complaints against them as an occupational hazard" (2). The implication being that the regulator expects most doctors to be subject to a General Medical Council (GMC) referral at some stage of their career. Set against this, whilst some distress is inevitable, we would contend that levels of moderate to severe depression of over 25%, moderate to severe anxiety of 22%, and suicidal ideation of 16% associated with being investigated by a regulator or indeed any other body is not acceptable in any profession.

    To better put this in context it is perhaps helpful to review some definitions to better understand the seriousness of this issue. Moderate depression is defined by persistent low mood or irritability and a loss of interest in usual activities. Other symptoms include slowed thinking, difficulty remembering things or making decisions, loss of energy and decreased activity levels, low self esteem, guilt and self-blame, disrupted sleep and frequent thoughts of death and suicidal thoughts. The severity of the depression refers to the number of symptoms present as well as the degree of impairment to daily functioning across several life domains, such as relationships and work (3). Such a combination of symptoms will have a baleful impact on an individual and be highly likely to impair their function as a clinician. It does not seem reasonable that such a profound impact on an individual's mental health is an acceptable cost of a regulatory process. In any event our paper and others can now leave both the GMC and others involved in complaints investigations in no doubt that their procedures may be associated with serious psychological morbidity.

    Dickson also cites a comment made by Professor Terence Stephenson to the health select committee about defensive practice, suggesting doctors are more concerned about the media and litigation than other types of investigation (2). We are not aware of any data to substantiate this view. In any event our paper concerned itself with reported defensive practice by doctors experiencing complaints processes or their views having observed others go through them. As the overall level of defensive practice was around 80%, levels of defensive practice associated with media exposure or litigation must be very high indeed. The levels of avoidance behavior reported by doctors involved in GMC processes (46%), and of doctors reporting that they had suggested invasive procedures against their professional judgment (26%), are a real concern. We would take the view that the relationship between complaints processes/regulation, the impact of defensive practice, and overall patient safety merits further research.

    Dickson is right to point out that the GMC is only one part of a system that deals with complaints that we have called the "complaints pyramid". Our paper shows that significant psychological distress is associated with all types of complaint process, as is defensive practice in response to complaints. In 2013-14 in England there were over 175,000 written complaints with more than 52,000 directed towards medical staff (4). Given the vast workload that must be involved in dealing with these and the distress to staff associated with them, it would seem important that complaints processes are reviewed across the board. In his letter Dickson touches on changes in the operations of the GMC that will fundamentally change the relationship between the regulator and doctors, many of which are contained within a recent consultation document (5). Serious concerns have been raised about many of these proposals (6), in particular in the context of this discussion, the stated desire of the GMC to investigate and/or impose sanctions without regard to the personal impact these may have on doctors.

    Our study summarises what doctors who took part thought would improve things. In order of importance these were: complete transparency about any communications and documentation, those responsible for handling complaints should have a full and up to date knowledge of correct procedure, action should be taken against complainants in the event that a complaint has been shown to be vexatious, if a doctor is exonerated there should be a mechanism to recover costs, there should be a strict time limit within which complaints must be submitted and that multiple complaints to different authorities should not be permitted, and finally a complaints process must have a statutory limit to the time taken to carry out any investigation. These can all be reviewed in supplementary online table 5 in our paper (1). When considering the balance that is required between investigating complaints appropriately whilst having a fair open system for doctors, none of the proposals listed above seem either unreasonable or undeliverable.

    A major problem with clinical complaints is that the GMC deals with individuals and is not equipped to deal with the cause of most clinical errors - the system in place on the day the error took place. Accordingly whilst the GMC sets out to protect the public, the reality is that it can only address one part of what is often a larger problem. An example might be the current controversy over A&E waiting times. There seems to be a consensus that there are issues relating to volumes of patients and staffing. Accordingly doctors in these hard pressed A&E departments are working under pressure, they may be cutting corners to cope, or simply not have the time to do things properly, it is likely they will fail to communicate as well as they would like with patients. They will be the individuals reported to the GMC when something goes wrong, not trust managers or people in the department of health. The only fair way to investigate complaints in this situation it to look at the overall set of circumstances a doctor has been placed in, if anything is going to be learnt from what has gone wrong. It is therefore axiomatic that the GMC is not the right body to be examining such clinical complaints. These should be investigated locally or by another external body with a much broader remit. The proposal outlined by the chair of the public administration select committee in the UK is based on a review by Macrae and Vincent (7), and seems a good starting point for this discussion. The principal proposals for such an investigative body are that it should be:

    * Independent and impartial. No executive, regulatory, commissioning or performance management functions.

    * Transparent. Clear, timely, open communication of findings of investigations, recommendations and monitoring of implementation.

    * Established as permanent body able to investigate and follow up recommendations over years.

    * Collaborative and cooperative. Working in partnership with those being investigated.

    * Authority to access all sites, organisations, staff and information across the healthcare system.

    * Non-punitive. Separated from assignment of blame or liability and legally protected.

    * Accountable.

    Further to these proposals based on the feedback received in our study we would also suggest that when investigating complaints:

    * It is clearly set out what is and is not within the remit of investigation locally, by a national clinical complaints body and what should be looked at by the GMC. There should be no double or triple jeopardy as exists currently with the potential for doctors or clinical errors to be investigated serially or in parallel by different bodies.

    * Enforce a strict time limit that is permitted for any complaints process and resource it appropriately.

    * The source of any vexatious complaints should be investigated and disciplinary action taken in the event of it being a staff member or redress in the courts if from a patient as there is no public interest defense in the event of a complaint being shown to be vexatious.

    Currently as alluded to above, in the UK we have the public administration select committee taking evidence on the handling of complaints. The health select committee has just had its accountability hearing with the GMC where complaints were discussed. Lord Robert Frances is leading a review of whistleblowing in relation to complaints, and the GMC has also asked Sir Anthony Hooper to report on whistleblowing in a separate piece of work. In every clinical environment we see information about how to complain, and entering "NHS complaints" into a Google search leads to a plethora of sponsored sites from solicitors. The GMC is asking for more powers. In parallel to this we have seen the introduction of revalidation. We have also seen the rise in patient "opinion" as a major part of how services are rated, despite emerging evidence that levels of patient satisfaction are not necessarily associated with the quality of their care (8,9). Furthermore turning each hospital interaction into a "customer service experience" requiring feedback may be intrusive in itself (10). Given this extraordinary level of activity, it is surely reasonable to ask where the evidence is from good quality appropriately analysed studies to show all these interventions are leading to improvements in patient care? In clinical medicine we are expected to practice evidence-based medicine, we carry out systematic reviews based on standardized measures of evidence quality (11). We defer to the opinion of the National Institute for Health and Care Excellence (NICE) on the cost effectiveness and efficacy of interventions. Perhaps it is now time for NICE to start reviewing regulatory interventions and for us to demand evidence of value and patient benefit from properly conducted pilot trials before they are implemented more widely?

    An example of such an intervention might be resilience training. This possibility was raised at the recent health select committee GMC accountability hearing as a possible solution to doctors suffering mental ill health associated with complaints processes (2). Probably the largest example of resilience training is the comprehensive soldier and family fitness program in the United States army, also known as CSF2. However the value of this training in the military is questioned by some authors (12), and it was recently stated in JAMA that the CSF2 has shown only small effects in preventing PTSD and depression despite the department of defense investing over $125 million in expanding the program (13). On the other hand there are some emerging data on the benefits of mindfulness and self-compassion on other aspects of doctors behaviour (14,15), and whilst such programs are unlikely to be harmful, it is premature to estimate how efficacious they will be in preventing depression and anxiety in the context of complaints. In any event, whilst resilience training tends to focus on building an individuals coping and stress management reservoir, resilience should be a multi-faceted construct that depends on having a positive work environment and flexible working conditions as well as good leadership.

    It is important to acknowledge that the position of the GMC is very difficult. Understandably following such extreme and rare events as the Shipman case, there were calls for more regulation. In parallel to this our paper and others demonstrate that doctors respond to fears about the fairness and outcomes of all types or complaints processes, including those of the GMC, by practicing defensively themselves. We would suggest that neither of these behaviors are in the best interest of patients and perhaps now is the time to take a step back and break this cycle by reviewing how complaints are best managed in the NHS. In order to do this all parties should remember two key points from the Berwick report (16). Firstly "fear is toxic to both safety and improvement", and secondly "supervisory and regulatory systems should be simple and clear, avoid diffusion of responsibility, and be respectful of the goodwill and sound intention of the vast majority of staff".

    Tom Bourne, Maria Jalmbrant, Dirk Timmerman, Ben Van Calster


    1. Bourne T, Wynants L, Peters M, et al. The impact of complaints procedures on the welfare, health and clinical practise of 7926 doctors in the UK: a cross-sectional survey. BMJ Open. 2015 Jan 15;5(1):e006687. doi: 10.1136/bmjopen-2014-006687.

    2. GMC Annual Accountability Hearing, Health Select Committee, January 6, 2015. -committee/2015-accountability-hearing-with-the-general-medical- council/oral/17274.html Last accessed 26th January 2015

    3. Diagnostic and Statistical Manual of Mental Disorders (DSM-5?), Fifth Edition 2013. American Psychiatric Association?

    4. Health and Social care Information Centre. Data on Written Complaints in the NHS - 2013-14 [NS]. Publication date: August 28, 2014 Last accessed 26th January 2015

    5. GMC consultation: Reviewing how we deal with concerns about doctors - A public consultation on changes to our sanctions guidance and on the role of apologies and warnings. (last accessed 28th September 2014)

    6. Jalmbrant M. The GMC consultation on regulation suggests the regulator has ambitions to be a punitive body based on "maintaining public confidence", whilst the proposed regulatory changes may harm doctors and patient care. BMJ 2014; 349 doi: (Published 25 September 2014)

    7. Macrae C, Vincent C. Learning from failure: the need for independent safety investigation in healthcare. J R Soc Med. 2014 Nov;107(11):439-43. doi: 10.1177/0141076814555939.

    8. Lee DS, Tu JV, Chong A, Alter DA. Patient satisfaction and its relationship with quality and outcomes of care after acute myocardial infarction. Circulation. 2008 Nov 4;118(19):1938-45.

    9. Lyu H1, Wick EC, Housman M, Freischlag JA, Makary MA. Patient satisfaction as a possible indicator of quality surgical care. JAMA Surg. 2013 Apr;148(4):362-7. doi: 10.1001/2013.jamasurg.270.

    10. A&E helped us through a miscarriage. Then we got a feedback text text Accessed 29th January 2015

    11. Whiting PF1, Weswood ME, Rutjes AW, Reitsma JB, Bossuyt PN, Kleijnen J. Evaluation of QUADAS, a tool for the quality assessment of diagnostic accuracy studies. BMC Med Res Methodol. 2006 Mar 6;6:9.

    12. Brown, Nicholas JL. "A Critical Examination of the US Army's Comprehensive Soldier Fitness Program." (2014).

    13. Slomski A. IOM: Military psychological interventions lack evidence. JAMA. 2014 Apr 16;311(15):1487-8. doi: 10.1001/jama.2014.3537.

    14. Raab K Mindfulness, self-compassion, and empathy among health care professionals: a review of the literature. J Health Care Chaplain. 2014;20(3):95-108.

    15. Pidgeon AM1, Ford L, Klaassen F. Evaluating the effectiveness of enhancing resilience in human service professionals using a retreat-based Mindfulness with Metta Training Program: a randomised control trial. Psychol Health Med. 2014;19(3):355- 64.

    16. Berwick review into patient safety. A promise to learn - a commitment to act: improving the safety of patients in England. Department of Health. safety Last accessed 25th January 2015

    Conflict of Interest:

    None declared

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  6. The impact of complaints procedures on the welfare, health and clinical practise of 7926 doctors in the UK: a cross-sectional survey

    Dear Sir,

    I read this article with great interest and applaud the efforts of the authors to highlight what would seem obvious mental health consequences of such traumatic events as investigations can be for doctors, yet the consequences can be so easily overseen.

    As Psychiatrists we come across individuals in our practice traumatised by various significant life events which have consequences on their mental health both in the short and long term.

    For a doctor who undergoes any investigation be it informal or formal, by employers or regulating bodies like the GMC, the process can be life changing and can have long ranging impacts not only on the individual but also their near and dear ones.

    The reasons for the manner in which a matter is dealt with can be multi factorial, but the fact remains that the individual has to endure and cope with whatever follows.

    The tendency for practical ex communication of the individual in the event of and during an investigation can only magnify the severity of the impact on the individual's mental health.

    The ignominy and stigmatisation that subsequently follows can contribute to isolation and potentially even lead to maladaptive coping strategies such as alcohol or substance misuse.

    The potential for contemplating self-harm and potentially even suicide or death is a fact which is reflected in various statistics quoted in the paper.

    The manner in which issues like this are highlighted therefore need to be considered in great depth and through great reflection.

    The support systems made available to doctors who are undergoing investigations, may also possibly need to identify ways of reinforcing existing support networks and acknowledging the impact on the individuals family, who may also potentially need supporting. More so in those cases where the individual may not have any extended family in this country , as the numbers highlight, there are many who may be single and from countries apart from the UK.

    Cases often attract media attention, often splashed onto the internet as newsworthy, but remain on the internet even when the matter is closed. This can be detrimental on the individual and their families for posterity as there may be no way of having these so called 'newsworthy' items removed from the domain of the overly accessible internet led media of modern global age.

    It is commendable that the GMC is acknowledging and taking steps to sensitively deal with the matters especially in the manner of communications to doctors under investigation , but that still does not and cannot possibly take away the stress the doctor under investigation must endure .

    The consequences and potential impact on the individuals mental health has to be given due relevance and importance , as these situations can be hypothetically equated to conditions which could lead to anxiety related conditions even with shades of Post-Traumatic Stress Disorder and major mood disorders. These enduring mental health conditions unless appropriately addressed can potentially outlast the investigation.

    Which unless acknowledged and treated appropriately, could, have an impact not only on subsequent medical practice but also on in a holistic sense, on the remainder of the individual's lifetime.

    Conflict of Interest:

    None declared

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  7. Choice of years can influence calculated mortality

    It has been recently observed that mortality in general and for cardio-vascular conditions specifically follows a pattern of high and low years (1-2). Had this study used 1999 as the base year the calculated reduction would have bee higher. Likewise had they used 2003 as the end point the calculated reduction would have been lower.

    Would be interesting to see the calculations using discrete years.

    1. Jones R. A new type of infectious outbreak? SMU Medical Journal 2015; 2(1): 19-25.

    2. Jones R. Recurring Outbreaks of an Infection Apparently Targeting Immune Function, and Consequent Unprecedented Growth in Medical Admission and Costs in the United Kingdom: A Review. British Journal of Medicine and Medical Research 2015; 6(8): 735-770.

    Conflict of Interest:

    None declared

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  8. Re:Niall Dickson, Chief Executive of the General Medical Council

    That Mr Dickson's has responded to Bourne's paper is highly significant and possibly the first clear acknowledgement from a senior GMC figure that its processes are associated with stress and anxiety, and that there is "much still for us [the GMC] still to do".

    It seems to me and others that we owe it to all involved in this debate to move forward in a positive way that will both ensure patient safety and carry the confidence of the profession. This would without doubt as a prerequisite require some form of public or judicial inquiry into the effect of GMC processes on doctors, their practice and health, and on their deaths and suicides whilst under investigation. Further, to examine the unintended consequences on patient care of an adversarial, expensive, protracted quasi-criminal investigative system that was designed in 1858 to investigate Professional Conduct.

    And finally, in this vexed time of CQC and GMC hyper-activity, to take a measured approach to how we would want healthcare in its broadest sense to be investigated and regulated in the future. This would be most successfully achieved if doctors looked forward with the anticipation of learning and improving following adverse events and complaints, rather than for fear of losing their professional reputations and livelihoods.

    Conflict of Interest:

    I have an interest in medical regulation, have been a formal and informal mentor to those undergoing disciplinary processes, past LNC Chair

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  9. Niall Dickson, Chief Executive of the General Medical Council

    Anyone who has been the subject of an investigation in any profession will testify to the stress and anxiety that it engenders. This was underlined in the study by Bourne et al in BMJ Open, which looked at the responses from nearly 8000 doctors who had been investigated by various organisations, the vast majority by local NHS bodies.

    Unsurprisingly the study found that among the 374 doctors who responded to the survey who had been referred to the GMC (1), levels of stress were higher - a referral to the national regulator is often more serious and, of course, carries with it the additional (albeit extremely small) risk that their livelihood could be taken away.

    Some distress is therefore inevitable, but the onus is on us to do whatever we can to reduce the fear and upset doctors experience, without in any way compromising our duty to investigate thoroughly in order to protect patient safety. This has become even more important in recent years as the number of doctors referred to the GMC has risen year after year - we saw a 64% rise between 2010 and 2013. (2) It is of course part of a wider trend which has seen big increases in complaints against health, and indeed other professionals, not just in this country but around the world. (3) But it does merit a response.

    Most of the complaints we receive are closed without a doctor ever facing action and only a small proportion lead to a sanction. (4) The increase in referrals though, makes it more important than ever that we resolve complaints as quickly as possible, sorting out those which are serious and which need our attention, explain our processes and decisions clearly and provide support for doctors during what will always be a very difficult time.

    That is why, over the last few years, we have committed ourselves to fundamental reform of our procedures with the aims of doing everything we can to demonstrate the system is fair, speed up the process at every stage and provide support in various ways for both doctors and patients who find themselves involved in our investigations.

    As a result, we established the autonomous Medical Practitioners Tribunal Service (MPTS) in 2012 under the leadership of a former deputy High Court judge which is now responsible for all the hearings and is separate from the GMC's investigation arm.(5)

    The new service has already cut the time lost to legal argument at this stage and, subject to parliamentary approval of changes of the Medical Act, will soon have more powers to prevent delays. (6) It has also begun to offer more support to unrepresented doctors. (7)

    Since 2012 the GMC itself has funded a confidential advice service run by the BMA which provides emotional support for any doctor who is being investigated by us. The response to the Doctors for Doctors service has been overwhelmingly positive and an independent evaluation which we will be publishing soon found that the service delivered real benefits to the doctors who used it. As one doctor noted:

    'It helped more than I could ever have imagined.'

    We have had a similar reaction to another key reform in this area. We have begun to pilot meetings with doctors towards the end of our investigations with the aim of seeing if we can we can agree a resolution that will protect the public and the reputation of the profession, but which could avoid the need for a hearing altogether. (8) This has the dual advantage of speeding up the process and reducing the stress for all involved. Under the current law we can only do this with some cases (the most serious must go to a hearing) but again the response has been extremely positive.

    Alongside these changes, we have been improving the tone of our communications with doctors - we need to make sure everything we send out is clear, straightforward and sensitive. We have been working with doctors who have been through our procedures and we are acting on this feedback (9) not least in updating doctors about the progress of our investigation.

    We have also revolutionised the way we engage at a local level, communicating with employers and doctors through face-to-face meetings and not just via correspondence. Our Employer Liaison Service (ELS) in particular has created strong links with employers and now supports Responsible Officers in managing concerns locally, helping to make sure that doctors are only referred to us when it is necessary.

    The Bourne study suggests that complaints may foster defensive medicine that is not in the interests of patients - clearly anyone who has been referred to the GMC may be more cautious while the issue is being investigated, but as the Chair of the GMC Professor Terence Stephenson indicated in his response to the Health Select Committee earlier this month, medicine has perhaps become more defensive and this is likely to have been caused more by fear of litigation, complaints to employers and being vilified, often unfairly, in the media, rather than fear of being referred to the GMC. (10)

    Most serious complaints that are upheld in our procedures are about conduct and health, rather than clinical decisions (11) and it is worth remembering that we will only take action when there have been serious or persistent breaches to our guidance - the vast majority of one off clinical mistakes are not matters we will pursue.

    So there is much we have done and there is much still for us still to do in this area - for example we have agreed to undertake a comprehensive review of how we handle vulnerable doctors following the report we commissioned into doctors who commit suicide in our procedures. (12)

    At the same time, creating a quick and simple complaints process that puts patients first, and is fair to those who are complained about, must be a matter for the health system as a whole. It is not something that professional regulation can achieve alone, indeed as the BMJ Open paper acknowledges, we are just one part of a much larger picture.


    1 Bourne T, Wynants L, Peters M, et al. The impact of complaints procedures on the welfare, health and clinical practise of 7926 doctors in the UK: a cross-sectional survey. BMJ Open 2014;4:e006687. doi:10.1136/bmjopen-2014-006687

    2 GMC: The State of Medical Education and Practice in the UK 2014 pp64

    3 GMC: The State of Medical Education and Practice in the UK 2013 pp44

    4 GMC: The State of Medical Education and Practice in the UK 2014 pp63

    5 The Medical Practitioners Tribunal Service (MPTS) website

    6 Department of Health Consultation Response report - January 2015.

    7 Medical Practitioners Tribunal Service (MPTS) information for unrepresented doctors:

    8 GMC Resolving complaints about doctors faster pilot leaflet

    9 GMC report: Exploring the experience of doctors and complainants who have been through the GMC's complaints and fitness to practise procedures

    10 GMC Annual Accountability Hearing, Health Select Committee, January 6, 2015

    11 GMC: The State of Medical Education and Practice in the UK 2014 pp 70

    12 Report commissioned by the GMC: Doctors who commit suicide while under GMC fitness to practise investigations, December 2014

    Conflict of Interest:

    None declared

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  10. GMC overinvestigation and poor handling of sick doctors

    Dear Authors, Congratulations for the great work. For a long time, doctors have been put in the dock for minor offences, including some non-offences, like illnesses mostly mental health and alcohol etc substance misuse related.

    The procedures applied by the GMC, after a complaint, Interim conditions or suspensions are placed by the panels, which convene upto six times in the first eighteen months period. At the end of this period, many doctors are being offered 'Voluntary Undertakings'(most doctors do not refuse for fear of referral to the Fitness To Practice). This pathways is highly questionable on moral and ethical grounds, as the doctor is persuaded to accept when there has been no findings of fact made against him.

    If and when the conditions and Undertakings make the doctor unemployable, the deskilled doctor cannot find support for retraining.

    Warnings by the GMC for minor dismeanours are affecting career and work prospects of doctors, which in some cases cause irreversible damage.

    The GMC has to use Occupational health procedures in sick doctors affairs instead of using the Fitness To Practice procedures, which are causing untold suffering and in some tragic cases, deaths.

    The deaths are only a tip of the iceberg, as most of the damage cannot be quantified, as it is manifested in loss of work of the doctors, emigration, burnout, early retirement.

    There needs steps taken by the Government to stem this unnecessary steady erosion of morale and the work force. I suggest

    1. A work force and planning body, independent of the NHS and the GMC 2. GMC to assess the impact of the procedures, more thoroughly, especially on the subgroups of Mentally/physically ill doctors and Ethnic and foreign gradute doctors 3. Use Occupational health supportive route in the sick/vulnerable doctors instead of the disciplinary route. 4. GMC to give 'advisory' letters instead of 'warnings'. 5. Government,NHS and the GMC to launch a fund for retraining of the deskilled doctors. 6. Fitness To Practice procedures to be used only in exceptional circumstances, unlike now. 7. Investigation into the lack of legal representation in upto half of the GMC hearings. 8. Making the GMC procedures accountable with compensation for the loss of earnings and careers of the doctors who are exonerated after prolonged, in some cases upto half a decade or more.

    Conflict of Interest:

    Been through the GMC procedures.

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