PI Brief Update

GMC Good Medical Practice: Loopholes and Unreasonable Expectations - Dr Mark Burgin

26/08/24. Dr Mark Burgin explores the perverse effects of the GMC’s new Good Medical Practice guidelines by creating loopholes and unreasonable expectations of doctor behaviour.

The GMC Good Medical Practice 2024 has some areas of improvement over the 2013 iteration but there are some areas that are less good. The new guidance leaves some loopholes which the general public could be concerned about. The failure to balance the rights of the doctor and patient to make decisions comes from a fallacy.

It is assumed that there is no range of opinion that can provide all doctors with an agreed list of reasonable treatments. This means that it is left to the individual doctor to decide what options are reasonable for that patient based upon Bolam thinking. This is clearly wrong and is due to conflating reasonable treatments for the individual and reasonable treatments for the disease.

In practice any medical student can list all the reasonable treatments for a disease. They can explain the benefits and risks of those treatments. What they are not able to do is weigh up all the factors in the individual patient and choose the best treatment. Medical experts can easily list all the reasonable treatments for even rare diseases. Often experts appear to be in fundamental disagreement whereas the reality is that that there are large areas of agreement as to which treatments are reasonable.

Into this confusion there have been increasing expectations imposed in how doctors should behave. This means that medicine is becoming less and less diverse as those who unable to play the game are excluded. This in turn has led to many doctors acting rather than being authentic and some feeling that using drugs and alcohol is necessary to sustain the pretence. As long as the doctor can give the illusion that they care, no one seems interested in what is behind the paper mask.

Examples of loopholes

• As long as you feel you are competent and up to date you do not need to prove that you are to your patients or colleagues. For example, a doctor can practice for decades without formal assessment and can refuse to provide evidence that they have recent training in an area to a solicitor in a clinical negligence case.
• You do not need to record what the patient’s needs and priorities are and you can decide if a physical examination is necessary. For example, if the medical records incorrectly record the history then the doctor can argue that there was no clinical indication for an examination even if requested by the patient.
• You can decide what is an effective treatment for your patient and you do not need to discuss other reasonable or better treatments that other doctors would offer unless you are prepared to offer it yourself. See McCulloch v Forth Valley Health Board [2023] UKSC 26
• Where the treatment is time sensitive you do not need to provide it within the window of opportunity and you only have to provide it promptly if you feel it is necessary. E.g. heart attack patients may miss the opportunity to have treatment because they are in an ambulance sat outside the A and E.
• You can decide if you are offering a ‘safe’ treatment, whether a patient needs to be referred for further treatment and when you feel it is appropriate to ask for advice on a case. Bolam has been used to argue that there is no objective test of professional practice.

Examples of unreasonable expectations

• You need to engage with management approaches such as attending meetings about quality, achieving targets as an individual and as a team, cooperating with management feedback, going on training courses and completing CDP documentation. Management can appear to overrule patient’s best interests on the grounds of public interest and courts have generally found against the patient.
• You should work within your resources providing the best service and care standards according to guidelines rather than what is best for the individual patient. Doctors are often criticised if they do not follow the guidelines even where those guidelines indicate that clinical judgment should be the arbiter.
• You must not complain if a patient is rude, abusive and intolerant, you must appear kind, courteous and respectful in the face of aggressive and prejudiced behaviour and must not delay care to those who put other patient’s safety at risk. The MPTS has heard cases of doctors who have acted in self-defence or in the defence of other members of staff.
• You must not act in any way that appears to be abusive, bullying, harassing or discriminatory for instance if the colleague has made an error or if patient needs urgent care or in a way that makes people feel embarrassed and distressed and that there is a negative unsafe environment. Complaints about behaviour do not appear to consider either whether the individual was oversensitive and that healthcare by its nature involves negative and unsafe situations such as patients becoming unwell.

Conclusions

A major concern amongst doctors is the move away from clinical outcomes to management targets. Many quality initiatives from managers address important issues and doctors are slow to engage. The managers need to show change in an organisation that will often resist. Equally managers need to understand that if patients do not get better good service will not make up for this.

Professional behaviour must include the full spectrum of normal human responses. A doctor who cries when a baby dies should be praised not accused of negligence. A doctor who uses humour to help explain a difficult subject has an extraordinary talent. When a doctor makes a mistake they should expect to feel embarrassed and distressed as this helps them remember and learn. Having no complaints is a sign that the doctor is not doing enough to help their patients.

A doctor should be interested in their patients and want to help them. This will be uncomfortable and messy at times, will involve compromising and challenging. The doctor who is authentic will help more patients than the one who puts on a mask to hide their feelings. The latter will burn out rapidly and need to be replaced at great expense and loss to the profession.

For good or bad doctors still self-regulate through the GMC and it is the responsibility of every doctor to contribute to this process. This may involve writing an article about the loopholes and unreasonable expectations in the GMC good medical practice or speaking to colleagues. The doctor’s leaders need to provide a spokesperson to collect these thoughts and push for better clinical outcomes not just service and care targets.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is on the General Practitioner Specialist Register.

Dr. Burgin can be contacted on This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 website drmarkburgin.co.uk

This is part of a series of articles by Dr. Mark Burgin. The opinions expressed in this article are the author's own, not those of Law Brief Publishing Ltd, and are not necessarily commensurate with general legal or medico-legal expert consensus of opinion and/or literature. Any medical content is not exhaustive but at a level for the non-medical reader to understand.

Image ©iStockphoto.com/ericsphotography