In this guest blog as part of our series looking at fitness to practise from different perspectives, Sarah Seddon tells about her personal experience as a patient going through the fitness to practise process and outlines her thoughts on the key considerations that she believes regulators should take into account to help 'humanise' the process.
“There must be a better way to determine fitness to practise”. This thought kept replaying in my mind during my time as a witness. Fitness to practise was not what I’d expected. As I was cross-examined on the stillbirth of my son, it felt like what I can only describe as a novel version of The Hunger Games. The ‘rules’ were constantly changing, I was terrified, traumatised, belittled and disrespected yet had no choice but to keep going. The process appeared to be set up to destroy people one by one whilst the audience watched. I had done nothing wrong (except to trust the advice of my midwife) yet this was the reality of fitness to practise for me as a patient. It made me question myself, my values, my reality and my purpose.
What I had wanted (and naively expected) from fitness to practise was transparency, honesty, compassion and fairness. I had hoped to feel respected, protected and supported. I thought the facts would be clearly established and an unambiguous decision made on the registrant’s current fitness to practise in everyone’s best interest.
There must be a better way
I was known as ‘Woman A’. To me, this embodies the entire impersonal, inhumane world of fitness to practise. I wasn’t a person with needs, thoughts and feelings; I wasn’t a bereaved mum; I wasn’t a professional anymore but simply a piece of evidence.
I was on a ‘conveyor-belt’ which zig-zagged for two years along an inflexible, imperfect pathway. But this conveyor belt wasn’t particularly reliable and broke down a lot. Sometimes pieces fell off or formed the wrong configuration, producing a final product that wasn’t fit for purpose.
Numerous people were in charge of the conveyor-belt at different times but they didn’t always try to fix errors or communicate what had happened during their shift. They couldn’t see the end of the belt from where they stood, so didn’t really concern themselves with the ‘finished product’. Some staff didn’t notice when vital parts had fallen off. Others noticed but didn’t appreciate the importance of the individual parts.
In my opinion, the conveyor-belt of fitness to practise should be taken apart and rebuilt from scratch. I have a unique viewpoint as I’ve actually ridden along it but as I’m just a spare part, I don’t have a voice. Focusing solely on the end product means you can do what you like to those parts on the conveyor belt – manipulate them, chop bits off or even crush them in order to get your optimal result. If things do go wrong, the damaged parts can be discarded – a bit of wastage is always to be expected…
I don’t deny that the end product of fitness to practise is important – but how you get to that point matters immensely when you are dealing with real people. Legal requirements are mandatory but there are many ways to implement these in a truly person-centred manner, leading to the optimal outcome for everyone involved.
What makes a good fitness to practise process?
I can answer that in one word: “compassion”. For everyone involved – patients, families, registrants, employers and staff. If you can get this right, I honestly believe that everything else will follow.
Healthcare is all about the patient. In addition to the specialist knowledge and skills required to be a safe, effective practitioner, each individual patient must be treated with humanity. Healthcare is nothing without compassion so it must be regulated with compassion.
How can a regulator hold their registrants to account on a set of ethical, person-centred standards if they are not prepared to ensure that their staff are also working to the same standards? Regulators risk damaging people further by the current adversarial, lengthy, traumatic, ambiguous processes which go against everything they are supposed to stand for. These processes certainly don’t promote patient safety in the long run as they discourage registrants from being open and honest when things go wrong and discourage the public from engaging with investigations.
It’s impossible to determine a ‘one size fits all’ fitness to practise process – an excellent process should be flexible to meet the needs of the people and the circumstances in each individual case and to fully take contextual factors into account. I truly believe that if the regulators routinely ask themselves the questions below, then they will be able to deliver an outstanding, person-centred process which will inspire confidence in both professionals and patients and will set a world-wide example for regulatory reform.
Five considerations for regulators to apply to fitness to practise processes
- Every patient and registrant is a real person – not a compound on a conveyor belt and (probably) not a criminal so do you give people respect, allow them to make choices and provide support? Fitness to practise is a grenade thrown into someone’s life and words matter, timings matter, promises matter. Support should be an integral part of any investigative process and not separated out as a ‘nice to have’. Treat people how you would like your loved ones to be treated – it can be very traumatic when things go wrong in healthcare.
- Organisational culture matters – do staff have the time, the training, the awareness, the support and the drive to be compassionate?
- Is key information always clearly transferred, ideally via a single point of contact? Is there a choice in how communication happens and are deadlines met and issues explained?
- Are processes in place to (really) listen to all stakeholders? Don’t discourage communication between the registrant and the patient (unless for a specific reason). Early communication or mediation can help with remediation, help families and registrants to move forwards with their lives and could allow cases to be closed sooner.
- Do both registrants and families fully understand your role?
- Do you obtain qualitative feedback to assess impact on people’s lives rather than focusing on arbitrary quantitative targets?
Transparency and fairness
- Don’t ask people why they want to know something but instead consider if there is any reason they shouldn’t be informed? Don’t be afraid to say sorry. Always be willing to explain the reasons behind decisions, actions or inactions…and if you can’t explain them then could/should that process be reviewed?
- Think about what you are asking people to do and would you be happy if that was your child, your husband, your parent or sibling?
- The evidence of the family is vital and should be treated with equal value to other evidence sources. The people who experienced the care are the only people who can truly give an insight into what that care delivered to them at that specific point in time. Care by its very nature is emotional and emotional impact is valuable evidence.
- Is this really the only way of doing things? Can several processes take place at the same time? Does it have to go through multiple teams rather than one? Waiting is damaging and costly for all. The more stages there are, the more chance of things getting lost, the more convoluted things become and the more relationships break down. Are your processes achieving the aims they set out to achieve? And how do you assess this?
- Processes must be co-produced – people who have been through your processes have the best insight into both your areas of excellence and your biggest weaknesses.
- Is patient safety truly at the heart of everything you are doing? Not just in terms of fitness to practise outcomes for the general public but in terms of what you are doing to the real people along your pathway?
- Are you doing all you can to eliminate fear? This is arguably the most difficult but the most important part of ensuring a just culture where people can be open about mistakes so that timely, heartfelt apologies can be encouraged and learning and remediation can happen effectively allowing registrants to excel in their vocation and feel supported whilst patients know that they have been heard and action has been taken in the best interest of everyone involved.
I challenge all 10 regulators to adopt these five considerations and apply them to every stage of your fitness to practise processes. You (or a loved-one) are all going to be patients one day and a health professional will probably have an enormous impact on your life. As regulators, you have both the responsibility and privilege of ensuring that this impact is a positive one. By implementing person-centred regulation I believe that you can achieve this aim.
Sarah Seddon is a Specialist Clinical Pharmacist at Sherwood Forest Hospitals NHS Foundation Trust in Nottinghamshire. She became interested in fitness to practise after being called as a witness in the fitness to practise hearing of her midwife, following her son's stillbirth in 2017. She now sits on the Public Support Steering Group for the Nursing and Midwifery Council and is passionate about person-centred regulation. You can read Sarah’s personal experience as witness in a fitness to practise hearing in her recent blog for the Pharmaceutical Journal. If you want to find out more you can also follow Sarah on Twitter: @sarahjseddon
Read more about our ideas for reforming fitness to practise or our blogs on this subject. You can find links to them here.
Find out more about our power to appeal final fitness to practise decisions. Or watch a short animation which explains more about why we appeal some final fitness to practise decisions.