Should we be complaining about the complaints system?

I stood at the kitchen counter at lunchtime opening the post, waiting for the kettle to boil; that glorious respite in a GP’s life – the half-day. I saw the postmark franking of the Medical Council but thought nothing of it as I opened it. When I saw the words ‘complaint’ and ‘Preliminary Proceedings Committee’ the shock of the unexpected came first. My next emotion was anger. 

I was so cross I danced around the kitchen mouthing expletives that shouldn’t be repeated. As I calmed down, mixed emotions followed. While angry, I realised I was also really surprised, disappointed and frustrated. I then realised I was also embarrassed. I sighed in resignation and made a cup of tea and thought: ‘here we go – six months of this now’.

Didn’t see it coming

It was a complaint I didn’t see coming. The complainant, a woman and her two children, had been patients of mine for more than 12 years. The individual was sometimes a challenge to deal with and she had a ‘fat file’ but as a practice we ‘managed’ the family and kept going. The issue with the children had run for years and while interactions had been becoming more tense, I didn’t see that things had come to this. 

The complaint was received by the Medical Council three days before their letter to me and six days before I received notification. That is some efficiency. I was advised that my complaint was going to the Preliminary Proceedings Committee eight days later and the Committee would decide if further action needed to be taken. 

I was advised to read the enclosed paperwork about their procedures and what I could expect – the sequence of events, having a case officer assigned, having an alert put on my professional competence record in the Medical Council computer and the like. 

I was to send my certificate of professional competence before their planned meeting. I re-read the dates a few times to check. It was all so quick. What if I had been out of the country? It didn’t come by registered post so could have got mislaid or lost? 

Considering the importance of the issue I thought that the schedule didn’t leave much wriggle room and what was all the rush? I accept there shouldn’t be undue delay but fairness suggests there should be more time. You wouldn’t want to be the procrastinating type opening your mail. 

‘Going into battle without all the armour’

The half-day was invaluable. I wouldn’t like to have had to go straight into a surgery. After a second cup of tea, (a Barry’s golden moment?), I kicked my CBT experience in to gear and said to myself ‘it is what it is; it doesn’t change who you are; enjoy collecting the children instead’.

I left doing anything about it until the next day (not a lot of sleep that night) and rang the Medical Protection Society at 9am. They were calm, helpful, predictable, reassuring. They asked me to email their office with the complaint, get my full CV in order and get my professional competence sent off. When printing that, I regretted that I had entered a mere 53 points for the previous year whereas I had lots more but hadn’t bothered to enter them. I know you only need 50 but in my sensitive state I felt the lack of them, as if I was going in to battle without all my armour.

The issue behind the complaint

The background to the complaint is complex but I’ve left it sketchy here for reasons of patient confidentiality. The outline of it was that our practice had refused to continue to prescribe a medication to the complainant’s two children; a medication she believed they should be on for behavioural issues. 

There was a conflict of opinion between on the one side two multidisciplinary team assessments undertaken locally stating there was no diagnosis for either child and detailing prescribing was not indicated, (assessments I agreed with) and a private assessment that said there was a diagnosis for both, and private prescriptions had been issued. 

As a practice we had historically been prescribing the medication on the basis of the private prescriptions while awaiting local assessments and had been having multiple discussions among ourselves as to what to do about it. Once the second opinion was returned I suggested we needed practice agreement on it and all the doctors met to discuss it. 

The strong argument made in favour by one of the partners was that the private prescription was as valid as any other and that we had to continue. While I was the one encouraging the ‘no prescriptions’ option, I fluctuated between the idealistic ‘Mary you have to stand up for these kids’, to the pragmatic ‘Mary put the head down and don’t create a fuss in the practice’. 

What decided it was the GP registrar saying ‘couldn’t these kids come back when they are 18 and legitimately complain that you continued to prescribe a medication when two multidisciplinary assessments clearly said don’t?’ 

This piece of wisdom made it a majority decision not to continue. The next bit, in retrospect, we didn’t handle well. 

Handling the patient

The patient had been largely attending another partner in the practice for a few months. I figured she was avoiding my ‘chats’ and I was somewhat relieved. However, that doctor was on annual leave when the second opinion arrived. We had awaited that doctor’s return to have the discussion and I had signed the requested prescriptions at the desk. I added a note to the last one requesting she meet with us to discuss same. It was a politely worded letter but not warm and fuzzy in retrospect. She requested another script and was declined in the office and advised to make an appointment.

The complaint dated the same day was handwritten and seven pages long. It detailed the complainant’s alleged difficulties with the practice – that we had all let her down, that she kept getting the prescriptions and being told it was ‘no problem’ and then we wouldn’t give them to her and this was causing stress and affecting her health. 

However, in the box that asks you to state what the complaint is she said I was rude and enclosed the letter I had attached to the last prescription. It was of course irrelevant that I wasn’t rude and the letter was polite. 

She also stated in the body of the complaint that I stopped the other doctors prescribing the medication, but this wasn’t the actual complaint made.

Why target me for the complaint?

So why did I get the complaint? Why me as opposed to all of us or the doctor largely writing the prescriptions who was then going to stop? I imagine because she saw me as the protagonist and the motivator, and to be fair to her she was right. 

Issues relating to the practice probably precipitated the complaint in a more general sense and we have since looked at the issues involved as a significant event review. 

The issues were that as a practice we see-sawed between mixed messages for nearly three years while awaiting assessments and second opinions. The children’s mother was being given prescriptions without a problem from some doctors and others including me were creating hassle for her by asking her to attend for discussion of the scripts every three months. 

From her point of view I think she would say that she had thought I was on her side. I had provided care to her and her children through some turbulent times and I had been sympathetic to her difficulties with the children’s behaviour (I was probably more supportive than honest) and that then I stopped being supportive and I think didn’t really work that through with her enough to keep her onside. When she started attending one of the other doctors I just saw that as an advantage for me rather than a ‘red flag’ as to why.

Answering the complaint

When it came to answering the complaint it was fine to know all this detail about the case and have a strong sense of the rights and wrongs of it but that wasn’t going to ‘butter the parsnips‘ at the Medical Council. The MPS put me in contact with a solicitors’ firm in Dublin and so began a most tortuous process of preparing my reply. 

The Medical Council wrote again, to tell me that the Preliminary Proceedings Committee had met and wanted more information by the end of that month. The solicitor asked for a delay and they gave us another three weeks. The MPS and the solicitor took the view that as the case involved children we needed to reply to it as if preparing for a fitness to practise inquiry. Better to do it properly the first time they said. 

I sent all the notes. I went to Dublin and spent five hours in the solicitor’s office being grilled about it all. We went through page after page of patient notes and correspondence, hundreds of consultation entries. The solicitor and MPS legal advisor were very pleasant but professional and thorough. I constantly had to explain myself and justify my actions, all from the perspective of how a lay person on the Medical Council might look at it. 

What I thought were good notes seemed patchy at best. I was exhausted after it. Thankfully the solicitor was to write the reply and I was to proofread and agree it – all 23 pages. I did little else for the next month as we tick-tacked by email with details of prescriptions and what this or that task or entry had meant. 

It got emailed the day of the deadline and I felt it was as good as it could be. The Medical Council didn’t acknowledge receipt. I waited a week and rang the MPS. They reassured me that the Medical Council often doesn’t acknowledge. 

Four weeks later I got a letter stating the committee hadn’t got to it at their meeting and it would now be deferred until the new year. The date hovered in my mind but I largely ignored it. Then came the letter that there was no case to answer. Almost six months to the day. 

Relief and frustration

I was relieved of course, but also back to feeling more frustrated than anything else. What a palaver for such an issue! How much of my own and everybody’s time did it take? How much did it cost? I’d guess close on €10,000 in fees between both sides. 

Why don’t we have an appropriate local complaints procedure rather than the ‘sledgehammer’ of the Medical Council? Patients have the right to complain (fair enough), but what about a doctors’ charter detailing our needs and expectations?

It’s a year since the whole process finished and I mull on it quite a bit. It sure wiped any smugness from me about never having had a complaint against me. I do believe that I was complained about for doing the right thing but I felt ‘marked’ for many months. 

Telling other GPs has been an important part of processing the experience. I have had great support and heard so many other stories of people’s experiences and realise if we don’t talk about it little will change in how we deal with it.

One of the issues I haven’t yet managed to sort is the fear of it happening again. I know it has made me more cautious and more defensive. I refer more and am less inclined to take on the ‘big’ patient issues, having become more risk averse. 

Maybe that will mellow but I know it is still ‘cramping my style’, something I notice as I pause over difficult patient decisions. I know it doesn’t do patients any favours in the bigger picture, but I can’t change that. 

Resources on Complaints Procedure

For further reading on the complaints procedure, please visit medicalcouncil.ie/Information-for-Doctors/Complaints/

For the publication ‘Listening to complaints, learning for good professional practice’ which was referred to in the article ‘Looking at the ‘who’ and ‘why’ of complaints’ in the December issue of Forum (2015; 32(12): 22-23) go to: www.medicalcouncil.ie/News-and-Publications/Reports/Listening-to-Complaints-Executive-Summary.pdf