Doctors' discipline 'must be reformed': Patients suffer through poor procedures, NHS chief says

PATIENTS are suffering because of the difficulties of disciplining or dismissing incompetent doctors, a senior NHS executive said yesterday.

Professor Liam Donaldson, general manager of the Northern and Yorkshire regional health authority, who as Director of Public Health has been involved in disciplining almost 50 consultants in the region in the past five years, said a new solution must be found.

And he warned that under the new-style NHS, where individual trusts are responsible for discipline, rather than a regional doctor operating at one remove, the temptation to turn a blind eye to difficult or dangerous doctors is likely to be greater.

Handling such cases was 'difficult, distasteful, time consuming and acrimonious work', he warned, writing in the British Medical Journal. 'The temptation to avert one's gaze from these problems is at times very great.'

The disciplinary procedures were so 'legalistic, time-consuming, expensive and intimidating to those who might wish to report a problem' that 'I have no doubt many employers do look away when they should not'.

'I fear for the position of the NHS trust medical directors. They are taking on this work for the first time, but they will be dealing with their peers who work in the same institution. They will not be at an appropriate distance to sustain objectivity, as were their predecessors, the regional health authority medical officers and chairpeople.'

Professor Donaldson, providing the most detailed account yet of the difficulties, lists 49 cases - 6 per cent of a consultant and specialist workforce which averaged 850 - with which he had to deal over the five years to 1991. Problems ranged from gross rudeness, sexually suggestive examinations of patients which stopped short of assault, doing private practice in NHS time, having outdated skills or inadequate knowledge which produced high rates of complications after surgery, and dishonesty.

Yet the disciplinary procedures - which ranged from formal tribunals to a review process by other doctors - were so cumbersome and difficult to operate that they were simply 'inadequate', Dr Donaldson said.

Twenty-five of the 49 doctors were either retired, or left the region - in some cases to be employed elsewhere. Twenty-one remained after counselling or under supervision. But the need for patients, relatives or hospital staff to provide evidence at formal tribunals made many reluctant or even afraid to pursue complaints, particularly over sexual behaviour.

Fellow doctors, while complaining informally, tended to close ranks formally. And assembling evidence sufficiently strong to sustain an action for professional misconduct or incompetence often proved difficult. Even the 21 consultants who failed to fulfil their contracts proved hard to tackle because the contract was not sufficiently explicit, he said.

Suspending doctors was no answer, as it produced stigma and confrontation, while early retirement was not an easy route, as it was often only reached 'after months or sometimes years of difficulty'.

Dr Donaldson's comments follow almost a decade's criticism of the disciplinary procedures, by doctors and managers.

'A solution must be found which introduces greater flexibility, less confrontation and more openness, as well as striking an appropriate balance between professional self-regulation and employer-based mechanisms for dealing with problem doctors,' Dr Donaldson said.