In 2003 the General Medical Council commissioned a review of its procedures for dealing with doctors whose fitness to practise is impaired by ill health. The report by the Health Review Group, under the chairmanship of Dame Deirdre Hine, is a very long document. Below are a list of its contents and the text of Section 7: Conclusions and Recommendations.

Contents:

Section 1: Background, Introduction & Methodology

Section 2: The impact of the GMC's new fitness to practise procedures on doctors whose fitness to practise is impaired by ill health

Section 3: Supervising and monitoring doctors whose fitness to practise is impaired by ill health

Section 4: Sharing information

Section 5: Responding appropriately to some aspects of concerns about a doctor's health

Section 6: Other issues

Section 7: Conclusions and Recommendations

Annex A: Health Review Group Membership and Terms of Reference

Annex B: A description of the GMC's procedures for dealing with cases involving ill health

Annex C: Flow chart showing GMC's procedures for dealing with ill health

Annex D: Data on cases involving ill health (from 2003 statistics)

Annex E: Summary of proposed roles and responsibilities

Annex F: Summary of the pre-November 2004 Health procedures.

Section 7: Conclusions and Recommendations

141. The review acknowledged that the GMC's old health procedures had in many ways operated extremely effectively. The experience and expertise of the Health Screeners and members of the Health Committee had, in particular, contributed to this. The review also recognised that the GMC had made significant efforts to respond to the 1999 evaluation report.

142. The introduction of the GMC's new Fitness to Practise procedures, the fourth and fifth reports of the Shipman Inquiry and the CMO's response, and other external factors, have nonetheless meant that it has been an opportune time for the review to examine the implications of these developments and to provide comments on their relevance and possible impact on arrangements to protect the interest of patients when a doctor's ill health affects his/her ability to practise safely.

143. The HRG felt that the themes of safeguarding patients and of supporting doctors who are ill should not be seen as being mutually exclusive. Both are integral to an effective framework for dealing with concerns about ill health. However, the GMC's role as a regulator focuses on the former.

144. The HRG noted that, in many cases, the GMC's investigation into a doctor's fitness to practise would be much broader than an assessment of the doctor's health. The HRG felt that this was particularly important in those cases involving allegations of drug abuse.

Recommendation: Where the allegations involve drug abuse, the GMC's investigation should look into the broader circumstances of the abuse, including how it commenced and its impact on patient care. (Recommendation 1)

145. An underlying theme of much of the discussion of the HRG was the importance of clarity in the functions to be performed by all those involved in the assessment, supervision and monitoring of doctors and of a more structured framework. Similarly it was essential that each function should be discharged effectively by the responsible party.

146. The HRG felt that increased clarity about the roles of all those involved in the process of responding to concerns about doctors whose fitness to practise is impaired by ill health, together with a developed programme of treatment for doctors, would enable the GMC and the profession to provide an improved framework for both responding to concerns and helping affected doctors.

147. The HRG felt that it was essential to acknowledge both the GMC's role and the importance of other organisations, including those offering support to doctors affected by ill health. Whilst the HRG would confirm absolutely that the GMC's primary responsibilities relate to the protection of patients and the public, it also recognises that it is not in the public interest for competent clinicians to be removed from or restricted in their practice unless there are clear reasons for doing so. The HRG felt that it was essential that there should be effective and easily accessible arrangements for the treatment and rehabilitation of doctors. These must run in parallel and in a co-operative way with the GMC's Fitness to Practise procedures. The HRG felt that access to such services were vital in ensuring that affected doctors sought appropriate advice and treatment.

Recommendation: The Government (in partnership with the profession) should take responsibility for the treatment and rehabilitation of affected doctors, through the provision of effective and easily accessible arrangements for their treatment and rehabilitation and support. (Recommendation 2)

Supervision

148. The HRG welcomed the improvements in the arrangements for supervising doctors that had been made since the 1999 evaluation report. The HRG considers that the establishment of the Case Review Section is an important development which will be central to developing and maintaining effective arrangements for supervising doctors.

149. The HRG agreed that the GMC develop further guidance for supervision covering the matters outlined in section 3. The guidance should cover the functions of the workplace supervisor and their relationship with the medical supervisor. The treating doctor should not be appointed as the medical supervisor.

150. The HRG considered that chemical testing will remain an important element of the supervision arrangements for doctors who have had had problems involving alcohol or drugs. It recommends that the GMC should develop clear guidelines on chemical testing.

151. The HRG considered that in many cases it would be important to carry out an assessment of a doctor's fitness to practise before agreeing to lift the doctor's conditions or undertakings. The GMC should consider what kind of assessment of the doctor's performance is required.

Recommendations: The roles and responsibilities of all those involved in the processes for responding to doctors whose fitness to practise is impaired by ill health should be defined in line with Annex E. (Recommendation 3)

The GMC should develop and update detailed guidance for the Workplace Supervisor and the Medical Supervisor, setting out their roles and responsibilities. (Recommendation 4)

The treating doctor should not be appointed as either the Workplace Supervisor or the Medical Supervisor nor should the Medical Supervisor or Workplace Supervisor become involved in offering or providing treatment. (Recommendation 5)

Conditions and undertakings must be workable and open to monitoring. They must be manifestly aimed at patient protection. Where necessary, conditions and undertakings should be drafted with input from a specialist adviser in the doctor's area of medical practice. (Recommendation 6)

The GMC should develop clearer guidance on unannounced chemical testing, including testing at the doctor's place of work. Unannounced chemical testing must be a component of the supervision arrangements where the impairment concerns alcohol or drug addiction or misuse. (Recommendation 7)

Sharing information

152. The HRG welcomed the development of the GMC's policies on sharing fitness to practise information and the steps being taken to put these policies into operation.

153. The HRG recognised that there were circumstances where it was appropriate to share information about undertakings and conditions relating to a doctors health with parties connected with the doctor's practise. The review felt it was essential that the GMC should develop a clear policy on the criteria for sharing such information.

Recommendation: The GMC should develop a clear policy on the circumstances in which it should share conditions and undertakings that relate to a doctor's health with the doctor's workplace supervisor, medical supervisor and treating doctor and, where appropriate, the doctor's employer. (Recommendation 8)

Developing Guidance

154. The HRG recommends that the GMC's procedures for managing cases involving ill health could be further strengthened by developing additional guidance for all those involved in the procedures including employers, case examiners, and supervisors.

Recommendation: The GMC should consider developing and/or updating guidance on the following matters:

a. Guidance for employers on the threshold for referring cases involving ill health to the GMC;

b. Guidance for employers about their requirements and responsibilities for sharing concerns and information about doctors whose fitness to practise may be impaired;

c. Guidance for GMC staff on managing cases involving both health and performance concerns, and in particular assessing the performance of doctors who are ill;

d. Operational guidance on drafting appropriate workable and enforceable conditions and undertakings for handling specific medical conditions relating to the doctor's employment and performance;

e. Detailed guidance on the circumstances in which a doctor should be restricted from practising entirely because of their physical or mental condition. (Recommendation 9)

Erasure and suspension

155. The HRG agreed that that there would be some cases where it was clear that remediation of the doctor was no longer a viable option. The HRG felt that it was important that these cases were managed in such a way that the GMC made it clear that there was no realistic prospect of the doctor returning to work. The consensus within the HRG, however, was that indefinite suspension of the doctor was preferable to erasure.

Recommendation: Where a doctor's fitness to practise is impaired by ill health and it has become apparent that it is not possible to remediate the doctor and that it is not possible to agree practical undertakings or conditions, steps should be taken to remove the doctor from practice on a long-term basis through indefinite suspension.(Recommendation 10)

Summary of Recommendations:

1. Where the allegations involve drug abuse, the GMC's investigation should look into the broader circumstances of the abuse, including how it commenced and its impact on patient care.

2. The Government (in partnership with the profession) should take responsibility for the treatment and rehabilitation of affected doctors, through the provision of effective and easily accessible arrangements for their treatment and rehabilitation and support.

3. The roles and responsibilities of all those involved in the processes for responding to doctors whose fitness to practise is impaired by ill health should be defined in line with Annex E.

4. The GMC should develop and update detailed guidance for the Workplace Supervisor and the Medical Supervisor, setting out their roles and responsibilities.

5. The treating doctor should not be appointed as either the Workplace Supervisor or the Medical Supervisor nor should the Medical Supervisor or Workplace Supervisor become involved in offering or providing treatment.

6. Conditions and undertakings must be workable and open to monitoring. They must be manifestly aimed at patient protection. Where necessary, conditions and undertakings should be drafted with input from a specialist adviser in the doctor's area of medical practice.

7. The GMC should develop clearer guidance on unannounced chemical testing, including testing at the doctor's place of work. Unannounced chemical testing must be a component of the supervision arrangements where the impairment concerns alcohol or drug addiction or misuse.

8. The GMC should develop a clear policy on the circumstances in which it should share conditions and undertakings that relate to a doctor's health with the doctor's Workplace Supervisor, Medical Supervisor and treating doctor and, where appropriate, the doctor's employer.

9. The GMC should consider developing guidance on the following matters:

a. Guidance for employers on the threshold for referring cases involving ill health to the GMC;
b. Guidance for employers about their requirements and responsibilities for sharing concerns and information about doctors whose fitness to practise may be impaired;
c. Guidance for GMC staff on managing cases involving both health and performance concerns, and in particular assessing the performance of doctors who are ill;
d. Operational guidance on drafting appropriate workable and enforceable conditions and undertakings for handling specific medical conditions relating to the doctor's employment and performance;
e. Detailed guidance on the circumstances in which a doctor should be restricted from practising entirely because of their physical or mental condition.

10. Where a doctor's fitness to practise is impaired by ill health and it has become apparent that it is not possible to remediate the doctor and that it is not possible to agree practical undertakings or conditions, steps should be taken to remove the doctor from practice on a long-term basis through indefinite suspension.