Good Management Practice: guidance for all doctors. About the ... local arrangements for the delivery of health services
Good Management Practice: guidance for all doctors Raising and acting on concerns about patient safety Writing References
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Good Management Practice: guidance for all doctors About the guidance How the guidance applies to you Duties of a doctor in the workplace Planning, using and managing resources Resource allocation Probity and compliance with financial governance Working with colleagues Leadership Respect for colleagues Communication within and between teams Responsibility and accountability Employment Recruitment, rewards and compensation Induction and mentoring Supervision Teaching and training Grievance, performance and health procedures Writing references Maintaining and improving performance Keeping up to date Adverse incident reporting and other quality systems Information governance Performance review and revalidation Raising and acting on concerns about patient safety Part 1 : Raising Concerns Duty to raise concerns Obstacles to reporting Steps to raise concerns Part 2: Acting on concerns Useful contacts Writing references Notes
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Good Management Practice: guidance for all doctors
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About this guidance Good Management Practice: guidance for all doctors sets out the wider responsibilities of doctors in the workplace, including in relation to employment issues including teaching and training, planning, using and managing resources, raising and acting on concerns and participating in service improvement and development. The guidance applies to all doctors – regardless of whether they are inside or outside the NHS, whether they work directly with patients or outside of clinical care, or whether they have a formal managerial role or responsibility. This guidance does not repeat the principles in Good Medical Practice that should underpin the practice of all doctors. This guidance applies across the UK and should be interpreted in the context of the relevant national and local arrangements for the delivery of health services.
How the guidance applies to you The guidance is separated into: a. the duties and principles that apply to all doctors b. the additional responsibilities that may only apply to some doctors, for example doctors with management or leadership responsibilities at a personal, team, organisation or policy level. In this guidance, the terms ‘you must’ and ‘you should’ are used in the following ways. l
‘You must’ is used for an overriding duty or principle.
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‘You should’ is used when we are providing an explanation of how you will meet the overriding duty.
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‘You should’ is also used where the duty or principle will not apply in all situations or circumstances, or where there are factors outside your control that affect whether or how you can comply with the guidance.
You continue to have responsibility for the safety and well being of patients when you undertake non-clinical duties, including when you work as a manager. You remain accountable to the GMC for your decisions and actions even when a non-doctor could perform your role. You must be prepared to explain and justify your decisions and actions. Serious or persistent failure to follow the guidance will put your registration at risk.
Duties of a doctor in the workplace 1 Doctors make an important contribution to the management of health services and the delivery of healthcare as part of a multi-disciplinary team. All doctors have some responsibilities for the use of resources; many will also lead teams or be involved in the supervision of colleagues. Recent and proposed changes in the NHS will make doctors roles in the management and delivery of health services more extensive. 2 The primary duty of all doctors is for the care and safety of patients. Whatever their role, doctors must:
a. Understand and take responsibility for the efficient use of resources for the benefit of their patients and the public.
b. Understand the importance of and demonstrate effective team working and leadership.
c. Promote a positive working environment free from discrimination, bullying and harassment.
d. Engage with colleagues and with the managers of services to maintain and improve patient care.
e. Contribute to discussions and decisions about the organisation and delivery of services.
f. Take appropriate action to raise and act on concerns about patient safety.
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Planning, using and managing resources All doctors 3 Regardless of your role or level in your organisation, you should be willing to demonstrate leadership in the management and efficient use of resources. This means that you should be prepared to contribute to discussions and decisions about:
Resource allocation
a. the allocation of resources and the setting of priorities in any organisation in which you work; and
b. the commissioning of services for the wider population of patients.
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You should be familiar with financial allocation in your organisation and the basics of financial management.
All doctors 9 Decisions about access to treatments made on a case by-case basis, without reference to agreed policy or guidelines, risk introducing elements of unfair discrimination or failure to consider properly the patient’s other legal rights. When making decisions about the use of resources you must:
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To minimise waste, improve services and promote the effective use of resources, you should take financial responsibility for the delivery of your service at a level appropriate to your role. You should understand the roles and policies of local, and where relevant, regional and national agencies involved in healthcare delivery.
Doctors with additional responsibilities 6 If you have responsibility for the management of resources, or the purchasing and delivery of health services, including through the commissioning of services, you should have a more detailed knowledge of how management processes work and how they impact on the delivery of patient care. 7
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You must make sure that you are competent and have the necessary training or advice for any financial responsibilities that are part of your role. You must make sure that those you manage have the necessary skills and advice to fulfil their roles.
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All doctors must make the care of patients their first concern. However, decisions about the treatment options that can be offered to patients may be affected by resource constraints.
a.
Provide the best service possible within the resources available, taking account of your responsibilities towards the wider population, funding bodies and employers.
b. Be familiar with any local and national policies that set out agreed criteria for access to a particular treatment1.
c.
Make sure that decisions about setting priorities that affect patients are fair and based on clinical need and the likely effectiveness of treatments, and are not made on grounds of age, disability, race, social status or other factors that may introduce discriminatory access to care.
d.
Be open and honest with patients (if they have capacity), or those close to them, and the rest of the healthcare team about the decision-making process and the criteria for setting priorities in individual cases.
10 If issues or disputes about the allocation of resources arise, you should discuss these with the healthcare team, with colleagues and managers to try and resolve them. You should be honest with patients when resource constraints may affect the treatment options available2.
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For example, national service frameworks and NICE and SIGN guidelines.
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Consent: patients and doctors making decisions together (2008), paragraph 9(l).
Doctors with additional responsibilities 11 If you have a management role or responsibility, you will often be required to make judgements about competing demands on available resources. When making these decisions, you must consider your primary duty for the care and safety of patients. You must take account of any local and national policies that set out agreed criteria for access to particular treatments and the allocation of resources and make sure that such policies are available to clinical staff. 12 If you are concerned that such management decisions might conflict with your primary duty to patients, you must take steps to manage or resolve any conflict, for example by:
a. seeking colleagues’ advice
b. declaring the conflict to your board or other decision-making body
c. seeking advice from external professional or regulatory bodies, if necessary.
13 You should make sure that systems are in place within your team or organisation for seeking and taking account of patients’ views on the use and allocation of resources.
Probity and compliance with financial governance All doctors 14 If you have financial or other personal interests in organisations providing health or social care or in products used in health or social care, you must follow the advice in Conflict of interests3 and in Good Medical Practice4. Doctors with additional responsibilities 15 Where you are responsible for the management and allocation of funds, you must make sure they are used for the purposes they were intended and are clearly and properly accounted for. You should also make sure that appropriate professional services, including audit, are commissioned when necessary. 16 You should make sure there are adequate systems in place to monitor financial and management information. You and those you manage should make full use of these systems including when awarding contracts and managing waiting lists and service plans.
3 www.gmc-uk.org/guidance/ethical_guidance/conflicts_of_interest.asp 4 www.gmc-uk.org/guidance/good_medical_practice.asp
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Working with colleagues Leadership All doctors 17 Most doctors work in multidisciplinary teams focused on the needs and safety of patients. The formal leader of the team is accountable for the performance of the team, but the responsibility for identifying problems, solving them and implementing the appropriate action is shared by the team as a whole5. 18 You must be willing to work with others to maintain and improve performance and change systems where this is necessary for the benefit of patients. 19 You should respect the leadership and management roles of other team members, including non-medical colleagues.
Respect for colleagues All doctors 20 It is essential for good and safe patient care that doctors work effectively with colleagues from other health and social care disciplines, both within and between teams and organisations. Whatever the make up of the teams in which you work, you must respect and value each individual’s skills and contribution. 21. You must treat your colleagues fairly and with respect. You must not bully or harass them or unfairly discriminate against them. You should challenge colleagues who do not meet this standard. 22 You must keep up to date with and adhere to your organisation’s policies in relation to employment, equality and diversity and the relevant legislation6. You must obtain expert advice on these issues if you need it.
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Doctors with additional responsibilities 23 You must promote a positive working environment free from discrimination, bullying and harassment to enable your teams to work effectively. You must tackle discrimination where it arises, actively promote equality and diversity and encourage your colleagues to do the same.
Communication within and between teams 24 Healthcare is increasingly provided by multidisciplinary teams and through multi-agency working. Such teamwork can bring benefits to patient care, but problems can arise when communication is poor or responsibilities are unclear. All doctors 25 Whatever your role in an organisation, you must make sure that you communicate relevant information clearly to colleagues in your team or in other services with whom you work to deliver patient care. You must also make sure that you communicate information to patients and those close to them in a way that they can understand and that they are told who to contact if they have questions or concerns; this is particularly important when patient care is shared between teams. 26 You should not assume that someone else in the team will pass on information necessary for patient care. You should always check if there is uncertainty about responsibility for communicating information to members of the healthcare team, other services involved in providing care, patients and those close to them. 27 You should encourage team members to co-operate and communicate effectively with each other and other teams or colleagues with whom they work. If you identify problems arising from poor communication or unclear responsibilities within your team you should take action to resolve them.
Medical Leadership Competency Framework – the definition of shared leadership.
6 For example, you must be familiar with employment and related legislation, including the Equality Act 2010 www.legislation.gov.uk/ukpga/2010/15. 8
Doctors with additional responsibilities 28 You should provide necessary and timely information to those you manage to enable them to undertake their roles effectively. You should also pass on any relevant information to senior managers and make sure that arrangements are in place for relevant information to be passed on to the team promptly.
Doctors with additional responsibilities 33 Where you are responsible for leading or managing a team you must make sure that staff are clear about their individual and team roles and objectives, their personal and collective responsibilities for patient and public safety, and for honestly recording and discussing problems. 34 You should:
29 You must be satisfied that systems to communicate information about patient care are in place.
a. contribute to the establishment and maintenance of systems to identify and manage risks in the team’s area of responsibility
Responsibility and accountability
30 Whether you have a management role or not, your primary duty is to patients. Their care and safety must be your first concern. You also have a duty to the health of the wider community, your profession, your colleagues, and the organisation in which you work.
b. make sure that all team members have an opportunity to contribute to discussions and that they understand and accept the decisions taken
c. make sure that each patient’s care is properly co-ordinated and managed.
All doctors 31 You should establish clearly with your employer the scope of your role and the responsibilities it involves, including non-clinical responsibilities. 32 You should raise any issues of ambiguity or uncertainty about responsibilities, including in multi-disciplinary or multi agency teams in order to clarify:
a. lines of accountability for the care provided to individual patients
b. who should take on leadership roles or line management responsibilities
c. where responsibility lies for the quality and standard of care provided by the team.
35 You are accountable to the GMC for your own conduct and any medical advice you give, including while you serve as a board member of a hospital or other corporate body. If you are concerned that a board decision would put patients or the health of the wider community at risk of serious harm, you must ask for your objections to be formally recorded and you should consider taking further action in line with our guidance in Raising and acting on concerns about patient safety (see page 16).
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Employment 36 If you are involved in any aspects of employment of staff such as recruiting, promoting or rewarding staff, including sitting on appointment or reward committees, you must abide by your organisation’s policies and procedures, and observe the principles of fairness, equality and diversity.
Recruitment, rewards and compensation All doctors 37 You must always be open and honest about your experience, qualifications and current employment status when applying for posts. 38 When applying for and accepting posts, you must follow the guidance in Good Medical Practice and in Taking up and ending appointments7 bearing in mind how your decisions may affect patient safety. Doctors with additional responsibilities 39 If you have specific responsibility for recruitment, promotion or other staff rewards or compensation, you must make sure that the process is accessible and transparent, and that decisions are based on objective criteria. 40 You must make sure you, and anyone you appoint to take part in these activities, have the necessary skills and competence and the opportunity to undertake appropriate training including in relation to equality, diversity and non discrimination in employment matters.
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Induction and mentoring All doctors 41 Understanding the systems in place and how an organisation operates helps to make sure that doctors can deliver safe, effective, and efficient care to patients as soon as they start a new job. Induction and mentoring schemes and access to other support mechanisms are important ways that this can be achieved. While important for all doctors, this may be particularly important for doctors if they are new to clinical practice, have trained outside the UK8 or are taking on a role in a new area or at a higher level. 42 You must take part in the induction programme offered by your employer when you join an organisation or move into a new role. You should also contribute to the induction of colleagues when asked. Doctors with additional responsibilities 43 You must make sure that any new doctor or other healthcare professional you manage is offered a relevant induction programme. You must also make sure that staff who are new to an organisation or are moving into a new role have access to an appropriate mentoring arrangement, where relevant, depending on the nature of their clinical practice and their responsibilities. 44 You must be willing to take on a mentoring role, either formal or informal, for more junior doctors or other healthcare professionals. 45 If you have agreed to act as a mentor you must make sure that you can fulfil your obligations. You must establish clearly the objectives and purpose of the mentoring and the scope of your role as a mentor and be readily available to provide advice, support and practical mentoring, when required.
www.gmc-uk.org/guidance/ethical_guidance.asp
8 Non UK qualified doctors and Good Medical Practice: The experience of working in a different professional framework, www.gmc-uk.org/Executive_Summary_2_09_AS.pdf_25402925.pdf. 10
Supervision
Teaching and training
All doctors 46 You must recognise and work within the limits of your competence and you must make sure, to the best of your ability, that you are appropriately supervised for any task you perform. You must be willing to seek advice and support from colleagues when necessary.
All doctors 49 The skills of being a doctor can be learned only by specific on the job training in the work placements begun at medical school and continuing through the early postgraduate years. Every doctor who comes into contact with trainee doctors, medical students and other healthcare professionals in training should act as a positive role model in their behaviours towards patients, colleagues and others.
Doctors with additional responsibilities 47 You must make sure that the people you manage have appropriate supervision, whether through close personal supervision (for junior doctors, for example) or through a managed system with clear reporting structures. 48 If you are responsible for supervising staff, regardless of your role, you must understand the extent of your supervisory responsibilities, give clear instructions about what is expected and be available to answer questions or provide assistance where necessary. You must support any colleagues you supervise or manage to develop their roles and responsibilities through appropriate delegation of tasks and responsibilities. You must be satisfied that staff you supervise have the necessary knowledge, skills and training to undertake their roles.
50 If you are formally involved in teaching in the workplace, for example teaching trainee doctors on placements, you must develop the skills, attitudes and practices of a competent teacher. This includes respecting cultural diversity and making reasonable adjustments for those with a disability without compromising patient safety or educational outcomes. Doctors with additional responsibilities 51 Where you are responsible for the delivery of teaching and training in your organisation, you must make sure that:
a. Only people with the appropriate knowledge, skills and attitudes conduct teaching and training for which you are responsible.
b.
There are enough staff members from appropriate disciplines, and with the necessary skills and experience, to deliver teaching and training and to support the learning and development of trainees and students.
c.
Systems are in place to identify the educational and training needs of students, trainees and staff, including locums, so that the best use is made of the time and resources available for keeping knowledge and skills up to date.
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d.
An appropriate environment for training is provided, including through the implementation of reasonable adjustments to meet individual trainees’ needs in line with the Equality Act 20109.
e.
You should provide opportunities for those you manage to keep up to date and develop their skills as teachers and trainers and make sure that there are systems in place for regular feedback and appraisal of these skills.
Grievance, performance and health procedures Grievance All doctors 52 You should understand the difference between a personal grievance or complaint about your own employment situation and a concern about a risk, malpractice or wrong doing that affects others, particularly where patients or the public are at risk of harm. You should make sure you use the correct procedure to make your complaint or raise your concerns10. 53 If you have a personal grievance or complaint that you cannot resolve informally, you should follow your organisation’s grievance procedure. If you have a concern about patient safety, you must follow the guidance in Raising and acting on concerns about patient safety ( see page 16). Doctors with additional responsibilities 54 You should make sure that any staff you manage are aware of the organisation’s grievance procedure and know how to raise grievances through the appropriate process.
9 Gateways to the Professions, Advising medical schools: encouraging disabled students www.gmc-uk.org/static/documents/content/Disability_guidance.pdf 10 For further information see Speak up for a healthy NHS (www.pcaw.co.uk/policy/policy_pdfs/SpeakupNHS.pdf)
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Performance and health All doctors 55 You should be prepared to help, support and respond constructively to signs that colleagues have health problems. In particular you should be aware of early signs that colleagues may have mental health problems such as depression, and alcohol and drug dependence. You should encourage colleagues to seek help and support for any health condition and you must not unfairly discriminate against colleagues because of an issue related to their health or disability.
60 You must make sure that you respond appropriately to requests for reasonable adjustments for staff with a disability or health condition in line with the Equality Act 2010.
Writing references 61 If you have been asked to, or have agreed to, write a reference for a colleague you must follow the guidance in Writing references (see page 22) .
56 You should, as far as possible, support colleagues who are experiencing performance problems, bearing in mind your duty to raise concerns where you believe a colleague may not be fit to practise or may otherwise pose a risk of serious harm to patients ( see page 16). Doctors with additional responsibilities 57 You must make sure that there are clear and effective procedures for responding to concerns about colleagues’ conduct, performance or health and that staff are aware of these procedures. 58 You should be prepared to discuss constructively and sympathetically any work problems that the people you manage may have. You must deal supportively and, where possible, openly, with problems in the conduct, performance or health of people you manage. 59 You must make sure that people you manage have access to support for any health or performance problems they have. You must make sure that people are not unfairly discriminated against on the grounds of their health or disability.
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Maintaining and improving performance Keeping up to date All doctors 62 You must keep your skills and knowledge up to date in all areas of your work, whether in a clinical or non clinical setting. 63 You must keep up to date with, and observe, the laws and statutory codes of practice relevant to your particular responsibilities and location11, seeking expert advice when you need it. You must be familiar with the relevant guidelines and developments that affect your work and use them to inform your practice. 64 You should regularly reflect on your own performance and your contribution to any teams in which you work. You should seek and be prepared to act on feedback you receive from colleagues and patients, including through the formal appraisal process (see paragraphs 81 to 83) and through patient complaints and comments. 65 You must follow the guidance on maintaining and improving your performance in Good Medical Practice12. Doctors with additional responsibilities 66 You should do your best to make sure that the individuals and teams you manage (both doctors and other healthcare professionals) are aware of and follow the guidance issued by relevant professional and regulatory bodies and that they are able to fulfil their professional duties so that standards of practice and care are maintained and improved. 67 Leading by example, you should advocate and encourage a culture that allows all staff to contribute and give constructive feedback on individual and team performance.
Adverse incident reporting and other quality systems 68. Early identification of problems or issues in the performance of individuals, teams or services is essential to ensuring patient safety. All doctors 69 You must participate in regular reviews and audit of the standards and performance of any team you work in, taking steps to remedy any deficiencies. 70 Early, routine notification of adverse incidents or near misses can allow issues to be addressed, problems rectified and lessons learned. You should be familiar with, and use, the clinical governance and risk management structures and processes within the organisations for which you work or to which you are contracted. You must also be familiar with, and use, the systems in place in your organisation for early reporting of near misses and adverse incidents. 71 You must follow the guidance in Good Medical Practice and Raising and acting on concerns about patient safety when you have reason to believe that systems, policies, procedures or colleagues are, or may be, placing patients at risk of harm. Doctors with additional responsibilities 72 If you have a management role or responsibilities, you must make sure that effective systems are in place to give early warning of any failure, or potential failure, in the clinical performance of individuals or teams, and that such failures are addressed quickly and effectively. 73 If you are managing or leading a team, you should make sure that systems, including benchmarking, are in place to monitor, review and improve the quality of the team’s work. You should make sure that teams you manage are appropriately supported and developed and are clear about their objectives. 74 If you manage a team that is not functioning well, you must take steps to put it right and seek help when needed.
11 For example, you must be familiar with the Equality Act 2010, Data Protection Act 1998 and relevant employment legislation. 12 www.gmc-uk.org/guidance/good_medical_practice/maintaining_good_medical_practice_performance.asp.
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Information governance All doctors 75 You must keep accurate and legible patient records following the advice in Good Medical Practice. You should make sure that non clinical records you keep, including financial records are clear, accurate and up to date. 76 You must follow the guidance in Confidentiality on protecting information and disclosing information for patient care or secondary purposes. 77 You should be familiar with and follow the confidentiality, data protection and record management policies and procedures where you work and know where to get advice on these issues. Doctors with additional responsibilities 78 If you are responsible for the management of patient records or other patient information, you must follow the specific guidance for managers on protecting information set out in our guidance, Confidentiality13.
82 You must take part in appraisal and you must make sure that your appraisal covers your whole practice, including any non-clinical roles you undertake. 83 If you hold a licence to practise you must take part in revalidation. Doctors with additional responsibilities 84 You should make sure that staff you manage, including doctors in sessional and other non-training posts, have sufficient time to prepare for their appraisals or performance review and that they have the opportunity to complete them fully and on time. 85 You must be honest and objective when appraising or assessing colleagues’ performance. The safety of patients and the public could be put at risk if you make false, exaggerated or incomplete comments about another professional’s competence or experience. 86 You should facilitate and support staff you manage to complete learning and development activities identified by appraisal or performance review.
79 You must make sure that any other records you are responsible for, including financial or management records, or records relating to complaints are kept securely and are clear, accurate and up to date.
87 You should make sure that you, and any staff you manage who are responsible for appraising and assessing colleagues, have the necessary knowledge and skills and receive regular feedback.
80 You must make sure that records you are responsible for are made, stored, transferred and disposed of in accordance with the Data Protection Act and other relevant legislation.
88 If you are responsible for the design and delivery of services, you should make sure that there is an appropriate appraisal or performance review process in place and that staff understand and follow it. You should also make sure that there are mechanisms for dealing with any problems that appraisals bring to light. If the appraisal process includes clinical academic staff you should make sure it complies with the Follett principles14.
Performance review and revalidation All doctors 81 You should be familiar with the individual performance review process in all organisations in which you work.
89 If you are a Responsible Officer within a designated organisation, you will have additional responsibilities as set out in the relevant regulations15 and you must have regard to any guidance produced by the departments of health16 or your organisation.
13 Paragraph 15, Confidentiality www.gmc-uk.org/guidance/ethical_guidance/confidentiality_12_16_protecting_information.asp 14 www.academicmedicine.ac.uk/uploads/folletreview.pdf 15 Medical Profession (Responsible Officers) Regulations 2010 (which cover England, Wales and Scotland) or the Medical Profession (Responsible Officers) Regulations (Northern Ireland) 2010) 16 Department of Health (England) The Role of Responsible Officer – Closing the gap in Medical Regulation – Responsible Officer Guidance’ www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_119418.pdf. At the time of printing, no additional guidance had been published by the departments of health in Northern Ireland, Scotland or Wales
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Raising and acting on concerns about patient safety
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In our core guidance for doctors, Good Medical Practice, we advise that:
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You must protect patients from risk of harm posed by another colleague’s conduct, performance or health. The safety of patients must come first at all times. If you have concerns that a colleague may not be fit to practise, you must take appropriate steps without delay, so that the concerns are investigated and patients protected where necessary. This means you must give an honest explanation of your concerns to an appropriate person from your employing or contracting body, and follow their procedures. If you have good reason to think that patient safety is or may be seriously compromised by inadequate premises, equipment, or other resources, policies or systems, you should put the matter right if that is possible. In all other cases you should draw the matter to the attention of your employing or contracting body. If they do not take adequate action, you should take independent advice on how to take the matter further. You must record your concerns and the steps you have taken to try to resolve them.
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This supplementary guidance is intended to provide more detail about how to comply with these principles. The guidance is separated into two parts:
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Part 1 is intended to help you to raise any concerns that you might have that patients might be at risk, and to advise on the help and support available to you. Part 2 is intended to help you to understand your responsibilities when colleagues or others raise concerns with you and how those concerns should be handled.
While the guidance provides suggestions about what to do and who to approach, it cannot be exhaustive. You will therefore need to use your judgement to apply the principles to your particular circumstances. If you are unsure of how they apply to your situation, then you should seek advice.
We also produce Good management practice: guidance for all doctors, which states that all doctors must take appropriate action to raise and act on concerns about patient safety.
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Part 1 : Raising Concerns Duty to raise concerns
Obstacles to reporting
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You may be reluctant to report concerns for a variety of reasons – for example because you fear that this may cause problems for colleagues, adversely affect working relationships, have a negative impact on your career or result in a complaint about you.
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If you are hesitating about reporting a concern for these reasons, you should bear in mind that:
a. Your duty to put patients’ interests first and act to protect them must override personal and professional loyalties.
b.
The law provides legal protection against victimisation or dismissal for individuals who disclose information in order to raise genuine concerns and expose malpractice in the workplace1.
c.
You do not need to wait for proof – you will be able to justify raising a concern if you do so honestly, on the basis of reasonable belief and through appropriate channels – even if you are mistaken.
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All doctors have a duty to raise concerns where they believe that patient safety is being compromised by the practice of colleagues or the systems, policies and procedures in the organisations in which you work. They also have a responsibility to encourage and support a culture in which staff can raise concerns openly and safely.
For further information see the Public Interest Disclosure Act (www.legislation.gov.uk/ukpga/1998/23 ), the NHS Constitution (www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Documents/nhs-constitution- interactive-version-march-2010.pdf) or Public Concern at Work (www.pcaw.org.uk).
Steps to raise concerns 8
If you have reason to believe that patients are, or may be, at risk of death or serious harm for any reason, you should report your concern to the appropriate person or organisation immediately. Do not delay doing so because you yourself are not in a position to put the matter right.
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Wherever possible, you should raise your concern with your manager or an appropriate officer of your employing/contracting body – such as the consultant in charge of the team, the Medical Director or a practice partner – in the first instance. If your concern is about a partner then it may be appropriate in that instance to raise it outside the practice - for example with the Medical Director or Clinical Governance Lead responsible for your organisation. If you are a doctor in training then it may be appropriate to raise your concerns with a named person in the Deanery, for example the postgraduate dean or director of postgraduate general practice education2. You should follow any procedure where you work for reporting adverse incidents and concerns.
10 You should be clear, honest and objective about the reason for your concern. Acknowledge any personal grievance that may arise from the situation, but focus on the issue of patient safety. 11 You should keep a record of your concerns and any steps that you have taken to resolve them. 12 You should contact a regulatory body such as the GMC, or another external body with authority to investigate the issue (such as those listed at the end of this guidance) in the following circumstances:
a. If you cannot raise the issue with the responsible person or body locally because you believe them to be part of the problem.
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b.
If there is an immediate risk to patients from a colleague and an external body needs to be alerted straight away (though in such cases you should also, at the same time or immediately afterwards, make the employing/contracting body aware of your concerns and the action you have taken).
c.
If you have raised your concern through local channels but are not satisfied that the responsible person or body has taken adequate action.
Making a concern public 13 If you:
a.
have done all you can to resolve any concern by raising it within the organisation in which you work/to which you are contracted, or with the appropriate external body; and
b. have reasonable grounds to believe that patients are still at risk of harm.
You may consider making your concerns public, provided that patient confidentiality is not breached. You should seek advice (see below) before making a decision of this kind.
Help and advice 14 If you are unsure whether, or how, to raise your concern, you should seek advice from:
a. a senior member of staff or other impartial colleague
b. your medical defence body, your Royal College or a professional association such as the BMA
c. the GMC (or, if your concern relates to a colleague in another profession, the appropriate regulatory body)
d.
Public Concern at Work – a charity which provides free, confidential legal advice to people concerned about wrongdoing at work who are not sure whether or how to raise their concern.
www.gmc-uk.org/education/postgraduate/responses_to_concerns.asp
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Part 2: Acting on concerns 15 Concerns about patient safety can come from a number of sources, such as patients’ complaints, colleagues’ concerns, critical incident reports and clinical audit. Concerns may be about inadequate premises, equipment, or other resources, policies or systems or the conduct, health or performance of staff or of multidisciplinary teams. If you receive such information you have a responsibility to act on it promptly and professionally. You can do this by putting the matter right if that is possible, investigating and resolving concerns locally or by referring serious or repeated incidents or complaints to senior management or regulatory authorities.
18 If you are responsible for investigating incidents or complaints you should make sure that:
16 If you are responsible for clinical governance or have wider managerial responsibilities in your organisation, you must make sure that there are systems are in place to allow concerns to be raised and for incidents, concerns and complaints to be investigated promptly and fully. 17 Where you have a management role or responsibility, you must make sure that:
a. Clinical staff understand their duty to be open and honest about incidents or complaints with both patients and managers.
b.
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Appropriate adverse event and critical incident reports are made within the organisation and to other bodies, such as the National Patient Safety Agency3.
b. You have a working knowledge of the relevant law and procedures under which investigations and related proceedings are conducted.
c. Staff members who raise concerns are protected from unwarranted criticism or actions4.
d. The person or people being investigated are treated fairly.
e. Recommendations that arise from investigations are implemented or referred to senior management.
19 Where you are responsible for investigating incidents or complaints, you must make sure that patients who make a complaint receive a prompt, open, constructive and honest response. You must also make sure that patients who suffer harm receive an explanation and, where appropriate, an apology.
All other staff are encouraged to raise genuine concerns they have about the safety of patients, including any risks that may be posed by colleagues or teams.
Note: the National Patient Safety Agency are one of the bodies which the Government has announced will be abolished under the Arms Length Bodies Review. We understand that the National Reporting and Learning System function of NPSA will become the responsibility of the NHS Commissioning Board and that the National Clinical Assessment Service will continue to function independently. We will continue to monitor developments in this area and make sure that the final published guidance includes links to the appropriate bodies.
4 ‘Speak up for a Healthy NHS: How to implement and review whistleblowing arrangements in your organisation’, www.pcaw.co.uk/policy/policy_pdfs/SpeakupNHS.pdf 20
Useful contacts Advice and help Public Concern at Work www.pcaw.co.uk 020 7404 6609 British Medical Association www.bma.org.uk 020 7387 4499 Medical and Dental Defence Union of Scotland www.mddus.co.uk 0845 270 2034 Medical Defence Union Limited www.the-mdu.com 020 7202 1500 Medical Protection Society www.mps.org.uk 020 7637 0541
Regulatory/investigatory bodies General Dental Council www.gdc-uk.org 020 7887 3800 General Medical Council www.gmc-uk.org 0161 923 6602 Care Quality Commission www.cqc.org.uk 03000 616161 Health Professions Council www.hpc-uk.org 020 7582 0866 National Patient Safety Agency www.npsa.nhs.uk 020 7927 9500 Nursing and Midwifery Council www.nmc-uk.org 020 7637 7181 General Pharmaceutical Council www.pharmacyregulation.org 020 3365 3400
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Writing references
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1
In our core guidance for doctors, Good Medical Practice we advise that:
l
l
l
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Employers need to be confident that they can rely on the information in references, particularly when they are employing healthcare professionals. Candidates also need to be confident that references written about them are accurate and reliable. A reference that presents an inaccurate picture of a prospective employee, could lead either to the appointment of an unsuitable candidate or the most suitable not being appointed. In some cases this will put patients at risk of serious harm and it may undermine trust in the profession.
6
You should usually provide a reference if you are the person best placed to do so. When providing a reference you should state the basis upon which you are making your assessment of the candidate, such as how long you have known the candidate and in what capacity.
7
When assessing whether information is relevant you should consider whether its inclusion, or omission, could mislead an employer3 about either a specific issue, or the overall suitability of a candidate. If you agree to provide a reference you must do the following.
a. Only provide comments which you are able to substantiate.
b. Provide comments which are objective, fair and unambiguous.
c. Do not base comments on your personal views4 about a candidate which have no bearing on the candidate’s suitability.
You must do your best to make sure that any documents you write or sign are not false or misleading. This means that you must take reasonable steps to verify the information in the documents and that you must not deliberately leave out relevant information. (Paragraph 65)
In Management for Doctors we also say that:
2
You must provide only honest, justifiable and accurate comments when giving references for, or writing reports about, colleagues. When providing references you must do so promptly and include all information that is relevant to your colleague’s competence, performance or conduct. (Paragraph 19)
opportunity to verify the information supplied in an application. References should, therefore, be written 2 in a way that is fair to both the candidate and the prospective employer.
You must be honest and objective when appraising or assessing colleagues’ performance and when providing references. The safety of patients and the public could be at risk if you make false, exaggerated or incomplete comments about another professional’s competence or experience. (Paragraph 39)
This supplementary guidance is intended to provide more detail about how to comply with these principles. It also explains to candidates what they can expect to be included in any references written about them. Serious or persistent failures to follow this guidance will put your registration at risk.
Prospective employers use references to obtain information about a candidate’s qualifications, employment history and assist in the assessment of their suitability for the post in question1. They also provide both employers and candidates with an
1
If you have general concerns about a candidate’s fitness to practise, whether in relation to their conduct, performance or health, you should follow the advice at paragraphs 43-45 of Good Medical Practice.
2
Spring v Guardian Assurance plc and others [1994]
3 Kidd v Axa Equity & Law Life Assurance Society plc, Allied Dunbar Assurance plc [2000] 4 This includes your views about a colleague’s age, colour, culture, disability, ethnic or national origin, gender, lifestyle, marital or parental status, race, religion or beliefs, sex, sexual orientation or social or economic status. 23
8
You should include all information you are aware of that is relevant to a candidate’s professional competence and be prepared to provide evidence to support this, where appropriate.
9
You should provide information about a candidate’s conduct, including matters that might affect patient trust in the individual candidate or the public’s trust in the profession as a whole.
10 You should draw attention to any other issues that could put patients at risk. This may include information relating to unresolved, outstanding or past complaints, where you judge that this is relevant to the candidate’s suitability. You should take reasonable steps to verify the information you provide. Where this is not practical, or the information is incomplete, you should make this clear.
11 Personal information about a candidate, for example in relation to their health, should not usually be included in a reference. However a situation may arise where you are aware of confidential information about a candidate, which will have a direct bearing on their suitability for the particular post in question. In such circumstances you should seek consent to disclose the information. If this is impractical, or consent is withheld, you should consider whether the benefits, to individual patients or the public, of disclosing would outweigh the possible harm to the individual candidate. For example, including health information may be justified where that is necessary to protect patients from risk of serious harm. Further guidance on disclosures in the public interest can be found in 22-27 of Confidentiality: Protecting and Providing Information.5 12 If a candidate asks for a copy of the reference, you should usually provide them with one, though you are not required to do so.6 13 If you are unsure about whether to include information in a reference you should consider seeking advice from your medical defence body or a professional association such as the British Medical Association.
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You should also consider the impact of the Data Protection Act 1998 on the disclosure of sensitive personal data. Further advice can be sought from the Information Commissioner
6
See Data Protection Good Practice Note: Subject access and employment references, Information Commissioners Office, 2005 (pdf)
Notes
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