Standing by his decision

GMC chief executive Charlie Massey’s attempt to have a paediatric trainee struck off sent shock waves through the profession that still reverberate today. On the eve of a resignation vote, Keith Cooper asks if he can regain doctors’ trust

Charlie Massey’s office appears entirely transparent. You can’t miss the glass as you’re led in and the door’s left open for our interview.

It opens on to banks of desks, where staff sit, in rows, as in Guess Who? that family game where you compete to pick a mystery person, by a process of elimination. He’s on show, in earshot and wants to be, it seems.

We’re here to talk about his handling of the case of Hadiza Bawa–Garba, a paediatric trainee whose erasure from the medical register, earlier this year, sent shock waves through the medical profession. It left doctors fearful of making mistakes, mistrustful of the GMC.

He admits the case has caused ‘anxiety and distress’ since January, when he appealled a decision by the MPTS (Medical Practitioners Tribunal Service) to suspend Dr Bawa–Garba for a year.

Mr Massey wanted her struck off instead. The high court agreed and he’s stuck to his decision. ‘I’ve said on the record that I don’t feel I had any choice about the decision,’ he says. ‘I remain of that view, given the legal advice that I had.’

Questions were raised about his decision after details of the PSA’s (Professional Standards Authority) own case review surfaced. It said the GMC’s arguments to erase Dr Bawa–Garba from the register were ‘without merit’. The GMC had not been ‘privy’ to the PSA’s advice, Mr Massey says.

Pressure from the profession

There’s good reason to bring this all up again.

He is facing calls to resign at this week’s annual representative meeting, the BMA’s policymaking body. Also, a Government-ordered policy review of gross negligence manslaughter in healthcare, endorsed by health and social care secretary Jeremy Hunt, has recommended the GMC be stripped of its power to appeal MPTS decisions.

And next month, the GMC will find itself defending his decision again, in front of judges from the court of appeal. Does he have any regrets about appealing?

‘I would not have wanted the impact as it has happened,’ he says. ‘But that doesn’t mean my decision was wrong. There’s real anger and a need to address the concerns that are out there and the confidence in the GMC. That is something I regret.’

However, you pose the question, he insists his decision to appeal, to push for erasure was the appropriate one.

Given what you know now, would you have done things differently?

‘I don’t believe I had any choice but to take the decision I did… We have always been clear that this is going to be a journey,’ he says.

‘I don’t believe anything we do is going to transform people’s views overnight. But we are a professional regulator. Our job is to make tough and unpopular decisions. It’s really important that we feel able and robust enough to do that well.’

The GMC has been ‘listening very carefully’ and wants to ‘take the opportunities to learn from the case’. It has ‘kicked off a number of streams of work’ prompted by conversations with doctors.

He points to recent calls by BMA council chair Chaand Nagpaul for a ‘dramatic shift’ from the ‘culture of blame’ in the NHS, so doctors and the wider health service can learn from mistakes and prevent tragedies occurring.

The tragedy in the Bawa–Garba case is the death, aged six, of Jack Adcock in 2011. As has been widely reported, Dr Bawa–Garba was convicted in 2014 of gross negligence manslaughter.

The high court judge who considered the GMC’s appeal for Dr Bawa–Garba to be struck off described the failures in Jack’s care as being ‘not simply honest errors or mere negligence, but were truly exceptionally bad’.

Expanding issue

The case has sparked intense concern about the extent to which wider issues, such as work pressure and her ethnicity, played a role in how the case was handled, as well as the weight given to wider system failings.

Dr Nagpaul recently pointed to a 2013 report by Don Berwick, a patient safety expert, which said that NHS staff were ‘not to blame’ in most tragedies. ‘It’s systems, environment and constraints they face that lead to patient safety problems,’ the report states.

‘Five years on, what lessons have we learnt?,’ Dr Nagpaul asked doctors at the BMA annual representative meeting on Monday.

‘After a young child tragically, died, and an internal inquiry by the hospital trust reported 23 recommendations and 79 action points, is it right that the spotlight was fixated on a trainee doctor having just returned from maternity leave, instead of also holding to account the pressurised under-resourced, under-staffed and unsupported environment she was forced to work under?’

Mr Massey says the GMC’s response to the Dr Bawa–Garba case will change the way it investigates errors, including patient deaths. ‘It would be odd for us, as the regulator which urges the profession to reflect, to not reflect ourselves on our learning.’

One of the most ‘profound’ lessons he has learned is the need to consider ‘human factors’ in its work. This means of investigating errors, widely used by airlines, examines the role of environment, organisational, and human factors in accidents, rather than simply pinning blame on individuals.

Human factors experts warn that doctors could be deterred from reporting mistakes for fear of the consequences of doing so. ‘In the wake of Dr Bawa–Garba, who the hell feels safe?’ one human factors expert Trevor Dale, has said.

Mr Massey is looking at ‘whether and how’ it can apply human factors techniques to three areas of its work. The first in how it trains its investigators. He wants investigators to be able to ‘take an informed view about the systemic issues that may sit alongside any areas where an individual may have made a mistake’.

He wants the GMC to use human factors experts as witnesses in its investigation process. ‘Historically, we have only used doctors as experts,’ he adds.

Finally, he’s considering training responsible officers in human factors skills. These are the senior doctors the GMC works with, who often decide when to refer colleagues for investigations. ‘We want to help them to bring more of a human factors approach to their work.’

‘Crunch point’

All this extra focus on ‘systemic’ issues, beyond personal culpability, begs an obvious question, of course: has there been sufficient focus on all this in previous probes?

Mr Massey says it has taken ‘system context’ into account and offers the following evidence: ‘We’ve reduced by over a half, the number of investigations where there has been a single clinical incident, even where a patient may tragically have died’.

‘But there’s scope to build in more human factors in a deeper way.’

The GMC is also playing a part in pointing out pressures in the NHS, he says. Last year, he spoke of a ‘crunch point in the medical workforce’ and the ‘insufficient action is being taken to address it’. He works with government agencies, such as the Care Quality Commission, Health Education England and NHS Improvement to pinpoint and ease arising pressures.

It has commissioned several reviews. One, by two respected academics, Roger Kline and Doyin Atewologun will examine why some groups of doctors, those from black and minority ethnic backgrounds, are referred to the GMC more than others and to look at its own practices.

Another, by Dame Clare Marx, a former president of the Royal College of Surgeons, will look at how cases of gross negligence manslaughter and culpable homicide (in Scotland) are initiated and investigated.

The GMC has made a number of commitments to the BMA, including a pledge to doctors never to demand their reflective statements if investigating concerns about them. It even lobbied the Government (unsuccessfully), in its evidence to the Williams Review, for the reflections to have full legal protection, a measure also backed by the BMA.

But he admits that there’s a limit to what the GMC can do on its own to ease anxiety in the profession, fomented by the Dr Bawa–Garba case.

‘The GMC is part of a wider system in terms of the wider anxieties that came out of this case. We’re not responsible for the criminal justice system or workforce planning. We’re not responsible for how employers make doctors feel confident that when they can raise concerns, they will be acted upon.’

He believes the direction he set for the GMC, one he set out in our interview last year, is the ‘right one’ and that ‘everything that has come out of this case reinforces the direction of travel… we want to move to a place where the GMC spends the bulk of its resources supporting doctors rather than investigating. Ensuring it understands what’s driving mistakes and takes actions to avoid these mistakes happening.’ He considers himself the ‘right person’ for the job.

Towards the end of the interview, after being asked again if he will consider his position, Mr Massey concedes there nothing he can say ‘to change people’s opinion about the GMC’. He believes ‘actions speak louder than words’ and hopes doctors will give him the chance to prove it.

Those actions will need to be extraordinarily effective if the GMC is to regain the trust of the profession.