Introduction

The General Medical Council (GMC) is a public body which was founded under the Medical Act 1983 [1]. Its main roles include [2];

(1) Management of the medical register in the United Kingdom (UK);

(2) Setting standards for doctors in both clinical and non-clinical domains;

(3) Education and training including undergraduate and postgraduate education;

(4) Revalidation;

(5) Investigation of concerns raised about a doctor and acting on them if necessary.

This article focuses its role as an investigator in the context of ophthalmology in the UK.

Concerns about a doctor can be raised by various parties such as a member of the public, a colleague of any discipline, a responsible officer or self-referral [3]. Other sources of referral include any employers such as the National Health Service (NHS) Trusts or Clinical Commissioning Groups and the police. Once a concern is received by the GMC, it will decide whether a further investigation is required. When an investigation is started and there is a serious concern that the doctor should not practise unrestricted, the case will be referred to the Medical Practitioners Tribunal Service (MPTS) to place temporary measures in place during the investigation in an interim orders tribunal. At the end of an investigation, there are several outcomes which include [4];

  • Advice

  • Warning—fitness to practise is not impaired but issued if the doctor’s conduct, behaviour or performance significantly deviated from the Good Medical Practice and needs to be addressed for future practice.

  • Undertaking—it is an agreement between the GMC and a doctor about limits regarding the future practice. It may include restrictions on the practice and behaviour and commitments to retrain or practise under clinical supervision. Fitness to practise is impaired.

If the GMC believes that the allegations suggest a serious failure or deviation from the standards, they will refer to the MPTS. A referral is also made if the doctor disagrees with the undertakings suggested by the GMC. The MPTS is an independent public body which runs public tribunal hearing services. The possible outcomes of these are:

  • No action

  • Warning

  • Undertaking

  • Conditions—these are sanctions which are imposed on a doctor’s medical licence following a medical practitioners tribunal hearing [5].

  • Suspension

  • Erasure

In this article, we have studied the current trends in referrals of ophthalmologists to the GMC in the UK.

Methods

We requested information from the GMC under the Freedom of Information Act 2000 [6], of all complaints of ophthalmologists irrespective of grade between 2007 and 2019. The following information was requested, and all entries were anonymised with no personal identifying information.

(1) The number of ophthalmologists referred to the GMC including those listed and not listed on the Specialist Register.

(2) Outcomes of referrals

(3) Types of allegations

Types of allegations were presented in two-time periods; 2007–2016 and 2017–2019. This is because the GMC started recording the allegation types for all complaints received from 2017 onwards including those which did not result in investigation.

We also investigated the rates of suspensions and erasure per year, utilising the data from the NHS Workforce Statistics [7], Public Health Scotland [8] and StatsWales [9]. We were able to obtain the data between 2009 and 2019 for England, Scotland and Wales. Unfortunately, the data for Northern Ireland was not publicly available therefore we have used the value of 40 from the Workforce Census by the Royal College of Ophthalmologists 2018 for all years [10].

Results

We were provided with information pertaining to the questions above in the 13 years spanning from 2007 to 2019. The information was correct as of 16 September 2020.

Number of complaints

There was a total of 1032 complaints received by the GMC in 2007–2019 concerning ophthalmologists (Table 1, Fig. 1). Annual complaints ranged from 42 to 121 cases with an average of 79 cases per year. Figure 1 is a graphical illustration of the numbers of complaints received by the GMC and their outcomes. From 2007 to 2015, there was an increase in cases by approximately threefold (Fig. 2). Following 2015, there was a general reduction in numbers to 80 cases in 2019.

Table 1 Outcomes of complaints received by the GMC for ophthalmologists 2007–2019.
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Fig. 1: Flowchart of the numbers of complaints received by the GMC and their outcomes.
figure 1

Each category is subdivided into the relevant outcomes according to the GMC’s fitness to practise procedure.

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Fig. 2: A graph showing the number of complaints received by the GMC by year from 2007 to 2019.
figure 2

The solid line represents the trend in the number of complaints over the 13-year period.

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What happened to the complaints?

Out of 1032 cases, 56 (5%) cases were still in progress. One case was from 2014, 22 cases from 2017, 12 from 2018 and 21 from 2019 (Table 1).

There was a total of 916 decided cases which underwent GMC processes in 2007–2019 (Table 1). Of these, 442 cases which were closed at triage without an investigation (43%) and 127 cases were referred to their employers without investigations (12%). A further 243 cases were concluded following investigation and no sanctions were applied (24%). Sixty-seven cases resulted in advice (6%), 28 cases in warning (3%) and 9 cases in undertaking (1%).

Further evaluation of the annual proportion of cases that concluded without investigations showed that there was a significant change in outcomes between 2007 and 2019, and is illustrated in Fig. 3. In earlier years 2007–2009, the majority of these cases were referred to the doctor’s employer but increasingly this decreased with time and in 2019, the majority of cases were closed at triage with only less than 5% being referred to the employer. In 2007, 14% of cases were closed at triage and 52% of cases were referred to the employer. The most significant change in proportions was observed in 2010 where the proportion of cases closed at triage and those referred to the employer were 57% and 14% respectively. The latest figures in 2019 showed that the reversal of the initial pattern persisted, and the rates were such that 49% of cases were closed at triage and only 4% were referred to the employer.

Fig. 3: A graph showing numbers of cases concluded without investigation by year.
figure 3

The solid grey line represents the percentages of cases closed at triage. The solid blue line represents the percentages of cases referred to employer.

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We have outcomes of 60 cases (6%) which were referred to the MPTS in 2007–2019 (Fig. 1). Of those referred to the MPTS, no sanctions were applied in 12 cases (1%), 5 cases received warning (<1%), 4 cases conditions (<1%), 28 cases in suspension (3%) and 11 cases in erasure (1%).

Types of allegations

We were provided with the types of allegations for GMC investigations in 2007–2019. The GMC started to record allegations against complaints which do not proceed to investigations from 2017 therefore we have excluded data between 2017 and 2019. We found that each complaint had more than one domain therefore more than one domain was counted per complaint. This is reflected in the percentages presented in our results.

The most prominent domains for GMC investigations are Clinical care (33%), Knowledge, Skills and Performance (33%), Maintaining Trust (24%), and Communication, Partnership and Teamwork (20%). With regards to the outcomes of MTPS hearings, the three commonest categories were (1) Maintaining Trust (44%), (2) Knowledge, skills and performance (34%), (3) Clinical care (23%), Communication, partnership and teamwork (23%) and Probity (23%).

Approximate rate of referrals and outcomes

We have calculated the annual incidences of suspension and erasure for ophthalmologists per year in the UK between 2009 and 2019 (Fig. 4).

  • On average, there are 79 complaints per year against ophthalmologists reported to the GMC.

  • The average annual incidence of complaints was 30.54 per 1000 ophthalmologists (range 18.7–42.4).

  • The average annual incidence of serious outcomes where fitness to practise is impaired (suspension or erasure) was 1.1 per 1000 ophthalmologists (range 0.8–2.0).

Fig. 4: A table and a graph showing annual incidencs of complaints, suspension, and erasure per 1000 ophthalmologists in 2009–2017 in the UK.
figure 4

The solid line in the graph represents the trend in the combined annual incidence of suspension and erasure per 1,000 ophthalmologists.

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We were unable to obtain the number of ophthalmologists per year for Northern Ireland except for 2018 (40) [10]. Therefore, we had to impute values for Northern Ireland for all other years. Given that the total numbers of ophthalmologists range from 2516 to 2979, we believe that it would not have any significant impact on the results. We have also excluded years 2018 and 2019 in calculating incidences due to the number of cases pending.

Discussions

Referral to the GMC is a highly stressful time for doctors. Moderate and severe depression have been reported to be more common in doctors subject to complaints or GMC referral process as well as thoughts of self-harm or suicidal ideation [11, 12]. Most doctors reported more defensive practice following such processes [11, 12]. A review was commissioned by the GMC on the suicide of doctors while under GMC investigations, which was published in 2014, with recommendations including “Doctors under investigation should feel they are treated as ‘innocent until proven guilty’” [13]. Support mechanisms are important in times of difficulty and there are several options available. The British Medical Association doctors support service was commissioned by the GMC in 2015 to provide free, confidential support for doctors going through fitness to practise procedures [14]. Medical indemnity bodies can also provide support, for example, the Medical Defence Union recently launched a new member peer support network in 2020 [15]. Practitioner health programme is a confidential NHS service for doctors and dentists which provides support for all types of health problems and the GMC may recommend a doctor to approach the programme if appropriate [16].

In this article, we aim to find out the current trends on the referrals and serious outcomes concerning ophthalmologists. The NHS constitution for England states that patients have the right to complain about NHS services [17]. We found that 43% of all complaints were closed at triage stage with no further investigation. On inspection, the GMC finds approximately a half of these cases as inappropriate and dismisses such cases at an early stage. Unfortunately, some complaints may be generated in the sector of healthcare due to an undesirable clinical outcome such as blindness which may have been inevitable. This may cause considerable unnecessary stress for the healthcare professionals, patients and relatives involved. This would highlight the need for further evaluation of the complaints process in the future. It is interesting to note that from 2007 to 2019, there was a reversal in the trend of cases closed at triage and referred to the employer from 2010. We do not have the details of the nature of complaints received by the GMC. We could infer from these findings of a change in practice within the GMC to more frequently close cases at an earlier triage stage than to refer these on to the employer. It is also noted in a review published in 2014 commissioned by the GMC that a large number of complaints were closed because the initial concern raised could not be identified [18]. A further 25% resulted in no sanctions following GMC investigations and MPTS hearings. We noted that this outcome was less likely if the case was referred to the MPTS hearing, reflecting the gravity of concern raised. Despite this, the rates of serious outcomes have remained stable. It appears that the GMC is more effectively prioritising the complaints of more serious concerns.

The GMC categorises each allegation into its own series of domains taken from the Good Medical Practice published by the GMC. The majority of allegations appears to be related to the domains of Clinical Care, Communication, Partnership and Teamwork, Knowledge, Skills and Performance and Maintaining Trust. These represent the core values of a medical professional as outlined in the GMC Good Medical Practice guidelines and highlights the importance of a good understanding and awareness of these. In particular, communication skills have been shown to have a clear correlation with the likelihood of receiving complaints [19]. A survey commissioned by the Medical Protection Society also found that the poor communication was the most common reason why a patient may complain about a doctor [20]. A further study is warranted to explore the types of allegations of serious outcomes in depth to identify any recurring patterns.

Our results showed that the average rate of complaints against ophthalmologists was 3% per year. In this study, we have not asked for information on the numbers of complaints received by the GMC in other specialties. However, a comparison can be made to a publication by the GMC on “The state of medical education and practice in the UK” publication in 2017 [21]. It showed that over a period of 5 years between 2012 and 2016, about 3% of all doctors were complained about each year including a small number which received complaints in more than 1 year. This is comparable to our results concerning ophthalmologists only. Furthermore, the total number of complaints between 2011 and 2016 received by the GMC was 50,478, compared to 542 for ophthalmologists in the same time period (1.1%). It is also interesting to see the rates of complaints according to speciality in the report. This showed that general practice had the highest reported number of complaints. For specialist doctors (those on the specialist register), the highest rates of complaint were for occupational medicine, psychiatry and obstetrics and gynaecology whilst the lowest was that for pathology, anaesthesia and intensive care medicine and public health. Although an annual rate of complaints of 3% of ophthalmologists is surprisingly higher than expected, it is important to consider this in context of figures concerning all doctors across all fields.

The observations in this study showed an increase in the number of complaints throughout the study period. This increase is applicable to the total number of complaints received by the GMC irrespective of specialty [22]. Similar trends are also observed in other countries such as New Zealand [23], Australia [24] and Canada [25]. A review was commissioned by the GMC to investigation the reasons behind the rising number of complaints to the GMC against doctors [18]. It found that the increase in complaints has been consistent across the UK, not due to spikes in certain regions. The GMC’s public relation strategy has increased its public profile and along with a negative press coverage on doctors in the last few years, it may have influenced the complaint-making behaviour although they could not find a direct link between them. Other relevant factors include that patients have become better informed regarding medical treatment with higher expectations and increased use of social media has facilitated easy access to the experiences of other people for comparison. Despite this increasing number of complaints, we found that the incidences of serious outcomes have remained stable with the overall proportion of less than 4% in a 13-year period. This represents that only 1 in 20 complaints are of a nature to have significant impact on the ophthalmologists’ working practice. These findings suggest that the rising number of complaints may be due to the changes in public behaviour rather than implying worse performance of ophthalmologists. These figures should provide some reassurance that the majority of ophthalmologists practising in the UK are adhering to the Good Medical Practice guidelines.

In summary, we have noted an overall increase in the number of complaints to the GMC for ophthalmologists from 2007 to 2015 but since then there has been a gradual reduction. Despite this, we have not seen an increase in incidence of serious outcomes throughout the periods investigated.

SUMMARY

What was known before

  • Little was known before regarding the trends of serious outcomes following referral to the GMC, specifically for ophthalmologists practising in the UK.

What this study adds

  • This study gives an overview of the referrals made to the GMC regarding ophthalmologists, including the annual incidences of serious outcomes between 2009 and 2019.