Right-touch regulation

Credited as helping to improve the reputation of the Medical Council among doctors, GP Dr Rita Doyle is finishing her term as President. She spoke to Catherine Reilly about an eventful three years

Dr Rita Doyle’s term as Medical Council President began at the height of the CervicalCheck controversy. It concludes amid a major cybersecurity attack on the HSE. In between, the biggest health crisis in living memory paralysed much of the globe and placed an enormous strain on healthcare staff.

The ransomware attack was “a very cruel blow”, Dr Doyle told the Medical Independent (MI). It erupted just as healthcare staff were “beginning to think a bit of normality might be returning”.

With delayed or limited access to diagnostics and blood tests, for example, MI asked about potential regulatory implications for doctors. Dr Doyle said the Medical Council’s approach was “that all complaints are contextualised” – a position it has also voiced during the Covid-19 pandemic.

“And if you are finding yourself in a very awkward situation, just to be very clear about your documentation.” She said doctors’ notes should reference the cyberattack. The situation has compounded fears about delayed diagnoses and late presentations due to the pandemic, according to Dr Doyle. “It just couldn’t have happened at a worse time, it just couldn’t have,” reflected the Bray GP.

First woman

Appointed to the Medical Council in 2013 as the ICGP’s representative, Dr Doyle was elected Council President in July 2018, becoming the first woman to hold this role. Dr Doyle has been a particularly vocal President, partly through her presence on Twitter. She has consistently highlighted issues in doctors’ working lives that impact on patient safety – excessive working hours, understaffing, bullying, communication breakdowns between primary and secondary care.

Doctors’ health has long been an interest. For the past eight years Dr Doyle has chaired the Council’s health committee, which supports doctors to maintain their registration during illness and/or disability (including addiction issues). Doctors can be referred, or self-refer, to the health committee.

Was there any change in scale or type of presentations during the pandemic?

“At the beginning, I think a couple of doctors who had mental health issues, they just found that Covid was the tipping point, but they got to us and we were able to support them and get them back to work,” Dr Doyle told MI.

“The vast majority of doctors who come to us do get back to work, which is really good… I have a very fine committee, really stunning people who go out of their way to support these doctors, and it is something I am very proud of.

“Our numbers are now up to 50, but that is the tip of the iceberg. Our register has nigh on 25,000 doctors, so if we have only 50 sick doctors within that, either we have a very healthy population or there are a lot of sick doctors who haven’t presented to us anyway.”

Dr Doyle added that the Council also has a memorandum of understanding with the independent Practitioner Health Matters Programme.

She said the health committee can help doctors in a unique way.

“It is not a therapeutic relationship, but we direct the care of these doctors, and I think it does a really good job, and I would like to see more doctors attending. The workload is heavy enough, each review team spends an hour with the doctor and they do at least two reviews a month.

“I think the remote access has actually made it easier for doctors, they don’t have to travel into Kingram House… they [previously] came in after hours and nobody would see them, anonymity and confidentiality was absolutely sound.”

Another matter raised prominently by Dr Doyle has been communication breakdowns between primary and secondary care, and vice versa. This issue is a major patient safety risk and a source of interprofessional tensions among doctors.
“We had a consultative forum, we have a document, and it is ready,” answered Dr Doyle on this matter.

“I think the most appropriate place for this is probably Sláintecare, so I think it will probably be discussed with [Executive Director of the Sláintecare programme implementation office] Laura Magahy.

“I still feel very strongly about it. I think communication is still way below par and the transitional care – the journey of the patient from primary to secondary and back again – is the most dangerous journey the patient ever makes.”
The risks involve inadequate and delayed transfer of patient information between healthcare settings, particularly in relation to prescribing.

“There is a screaming need for more clinical pharmacists both at community and at hospital level to help do the reconciliation of medications and also the question has to be asked – is it appropriate that the most junior doctor writes the discharge letter? And I think that question needs to be asked and answered by the profession.”

The document contains recommendations on “all parts” of the patient journey, according to Dr Doyle.

Over-prescribing

In September 2019, the Council issued a statement headlined ‘Medical Council warns doctors to reduce over-prescribing of benzodiazepines, z-drugs and pregabalin or face potential investigation’. It is understood the regulator did not consider poor prescribing practice as being widespread, but a significant amount of overall complaints related to prescribing.

Nevertheless, the tone of the Council’s press release attracted some ire within the profession. Dr Doyle said the statement was a reminder to doctors to review their prescribing practice. It was also intended to provide support to those who are being pressurised to prescribe these drugs.

“We made a statement about the guidelines for benzodiazepine prescribing to encourage doctors to stick with the guidelines, and that if they persistently voided the guidelines then we would take action.

“The logic behind our statement was to support doctors in being able to say to patients, ‘No I can’t, sure look, this is what the Medical Council has said to us, I can’t do it’.

“I am very aware that the act of not prescribing is much harder than the act of prescribing. It is much quicker to sign a prescription and it takes much longer not to prescribe, I am aware of that.”

When MI spoke to Dr Doyle about the issue in October 2019, she said the High Court had recently temporarily prohibited a doctor from prescribing benzodiazepines following a process initiated by the Medical Council.
Since that time, Dr Doyle recalled at least three further cases.

“Obviously I cannot discuss specific cases, but certainly there were a couple of emergency meetings… where we applied to the High Court either to modify their prescribing or desist from prescribing addictive substances.”
The Council’s benzodiazepine working group has expanded to become an over-prescribing working group, outlined Dr Doyle.

“Of course we have now included opiates in our discussions. You know about the huge epidemic of opiate prescribing in the States and it literally spread from one side of the States to the other.

“And we are a little bit concerned that guidelines need to be more clarified, looking at what are the gold standards in medication and trying to encourage doctors to stick to the gold standards.

“There is a lot of advertising among the producers of these drugs… the oxycodone/Oxycontin in the States was the big one, but there are other versions of that with things added to it… and not necessarily more efficacious medications appearing on the market all the time.

“So we are trying to get doctors to stick to the basic guidelines and follow gold standards. There will be a bit of education coming from that group.”

Dr Doyle believes pregabalin and gabapentin should be made controlled drugs in Ireland. She said addiction to pregabalin is a “huge” issue in this country.

“They have now made them controlled drugs in the UK, and I certainly foresee that will happen here. How long it takes I don’t know, but I certainly foresee that will happen.”

Undertakings

In recent years, the High Court President has made some sharp criticisms of the Council, including on its system where doctors make ‘undertakings’ in regard to their practice (for example, in some cases the Council accepts undertakings
rather than initiating High Court proceedings to seek immediate suspension of a doctor’s registration).

In late 2019, the then High Court President Mr Justice Peter Kelly criticised the fact there was no system whereby employers/prospective employers could know a doctor had provided undertakings to the Council or to its health committee.

Mr Justice Kelly’s comments related to a case where a doctor had undertaken to the health committee in May 2016 not to practise medicine but was hired by a mental health service that was unaware of this information. Dr Doyle told MI the process has been revised such that, when undertakings are made to the Council or the health committee, the medical register notes that conditions are attached to the doctor’s practice.

“If you are an appropriate person to be asking the question, you can ring the Council and the information will be given to you,” stated Dr Doyle.

Complaints process

A major and long-awaited change is imminent as to how the Medical Council handles complaints on foot of legislative amendments. When the new procedures are operational, complaints will be first examined by the CEO/authorised officers rather than the preliminary proceedings committee (PPC). Complaints reaching a certain threshold (ie, those that concern a doctor’s fitness to practise (FTP)) will be investigated by the PPC.

“Now the work is ongoing on developing the policies and procedures associated with that,” outlined Dr Doyle.
Local processes for complaints in regard to GPs are being developed (this does not mean patients cannot still complain to the Council).

“We have more complaints about GPs than anybody else, but that is because there is more of us (GPs) and we see more patients,” noted Dr Doyle. The Council has been working with the ICGP on developing a local complaints process supported by MPS and Medisec. Dr Doyle anticipates this will be in place by Christmas.

“The legislative change should be in process long before that. The professional standards department are working very hard on developing all of that, I would see that happening before September.”

The lay majority in the FTP committee was a major feature of the Medical Practitioners Act 2007. However, some patient advocates have highlighted that the PPC is dominated by doctors (the Act prescribes that all the Council’s committees, except for the FTP committee, should comprise a majority of doctors).

Dr Doyle said she would have no “emotional or moral objection” to a lay majority in the PPC, but believed this would not be practical. She said the PPC assessed a large number of complaints and medical expertise was important in this context.

“It is to do with the technical nature of the complaint and the knowledge base. And we have obstetricians, physicians and surgeons, every different type, and they are not all members of the Council, they are external members of the Council. But you need… a degree of medical expertise, you can’t go and get an expert on every case, you’d never get the work done. You definitely do need the medical expertise, I would think.”

Interestingly, it was also Dr Doyle’s general experience that “the lay people are kinder to the doctor… doctors can be very mean to doctors, for want of a better word”.

Ethical guide

A major review of the Council’s ethical guide is ongoing. The regulator has informed MI this process will conclude in 2023. Dr Gabriel Scally’s scoping inquiry into CervicalCheck, published in September 2018, recommended the Council update its ethical guide to ensure open disclosure was more clearly set out as a professional duty. However, this section has not yet been changed.

“No it is not, and there is still a lot of negotiation about the open disclosure,” Dr Doyle told this newspaper.
As recently reported by MI, draft legislation sets out mandatory disclosure of serious patient safety incidents. However, there have been concerns expressed by doctors about what they consider as the “bureaucratic” nature of the processes and unclear delineation between expected and unexpected complications.

As of mid-May, a revised draft HSE national open disclosure policy was due to be circulated for consultation.
Dr Doyle indicated the pandemic had stymied work on this issue. However, she added: “If you go back to CervicalCheck, the patient’s information belongs to the patient and I think open and honest and frank disclosure is absolutely appropriate and if you make a mistake, to put your hand up and say, ‘look I am really sorry this is what happened and this is what I am going to do so it doesn’t happen again’. We all make mistakes; we are all human.”

Social media

The ethical guide’s section on doctor’s use of social media will also be analysed. Asked if most doctors used social media appropriately, Dr Doyle said “my general impression is yes”.

“The vast majority of doctors behave in a very professional and correct manner. Of course, we hear more about the ones who stray than about the ones who don’t stray. But, it is my personal experience that most of the time that they do behave in a very professional manner and there are guidelines in the ethical guide on how to behave on social media.

“I would say if you identify yourself as a doctor on social media, then you have a responsibility – the same responsibility to be ethically correct as you would have if you were talking to somebody. The ethical principles must stay there; mud-slinging and nasty stuff is not appropriate.”

MI referred to a phenomenon whereby some doctors are promoting products on social media as part of commercial
relationships. This would be “a conflict of interests”, according to Dr Doyle. “That is a no-no… if you identify as a doctor you must behave in the same way as if the patient was sitting in front of you.”

The ethical guide’s last update occurred in 2019 following the enactment of abortion legislation. The next divisive issue for the profession could be assisted death and the potential role of doctors. Dr Doyle said the Council has not yet made any submissions on the Dying with Dignity Bill 2020. “We will watch what goes on and comment when we need to. We will have to stick with our very clear ethical guide.”

When asked, Dr Doyle said her personal view did not matter. “I believe, in general, the vast majority of patients can be looked after with great dignity and with good palliative care.” Dr Doyle was the first female President of the Council and will be succeeded on 1 June by another woman – Paediatric Intensivist Dr Suzanne Crowe.

Recent discussions on social media highlighted the fact that female GPs must find, and in some cases finance, their own maternity cover. What further improvements are required to ensure female doctors can continue to progress their careers?

“I am laughing because I am that old I had no maternity leave. Neither paid or unpaid,” responded Dr Doyle.

“I would have been back to work six days after my youngest child was born. So that is appalling. It is a bit better today, but actually women should be treated like everybody else in the workforce, they are entitled to their statutory maternity leave and yes, the HSE should be providing cover for [female GPs on maternity leave].

“Because we are not HSE employees they have always held us at an arm’s distance, we are independent contractors, so as far as they are concerned you can die as long as you provide the cover, and that is wrong, it just has to change, full stop. The HSE has shown no interest in GP health and that has to change – that is not a Medical Council issue, that is a GP issue.

“But yes, women in the medical workforce should be treated exactly the same as women in all workforces, they should get their proper maternity leave and their cover should be arranged, full stop.”

According to Dr Doyle, the “powers that be never took any recognition about the feminisation of medicine”.

Covid-19

During the Covid-19 pandemic, Dr Doyle reflected that the Council had undertaken a “huge amount” of good work, including the swift re-registration of hundreds of doctors onto the medical register.

“Good work in supporting doctors, good work in keeping the channels of communication wide open, good work like working with the Department of Health, HSE and the Pharmaceutical Society to enable the electronic transfer of prescriptions…,” commented Dr Doyle.

Overall, Dr Doyle said she was “very proud” of the response of the Council, its staff and executive during this major public health crisis.

“We issued statements over the period of time. I think and hope the profession believed that we had their back, that we knew they were in very difficult situations, and that if complaints were made that they would be contextualised.”

The Council President reflects that it has been “a very challenging” three years at the helm.

“It has been a privilege, I have learned an enormous amount, I have worked with some stunning people.… I have had moments of panic, but I have enjoyed it. I just hope I did a half decent job.”