Review of ‘Good Medical Practice’ by the General Medical Council

The General Medical Council (GMC) provides its core guidance on the standards of patient care and professional behaviour, which it expects of all medical professionals registered with it, in the form of a booklet called ‘Good medical practice’. The booklet was last updated a decade ago in 2013 and is currently undergoing review. The proposed changes follow a period of consultation undertaken by the GMC between April and July 2022. 

In the preamble, the GMC explains the purpose of Good medical practice: “Good medical practice and its explanatory guidance represent a shared agreement of what good practice looks like for both patients and medical professionals”. 

It goes on to say that “For patients and the public – Good medical practice puts the patient at the centre of care. It supports safe, high-quality care and fair outcomes for all patients” and “For the medical professionals we regulate – Good medical practice is a framework to help medical professionals provide safe, high-quality care in the interests of patients”. 

The central themes of the new booklet appear to be an expectation of high-quality care and a more patient-centred approach. 

The new version will add an explanation that Good medical practice is not a set of rules and that doctors should use their judgment on how to apply professional standards in practice. 

As the GMC notes, “This means [doctors] will use their knowledge, skills and experience, informed by these standards and other sources of guidance and advice, to practise ethically and in the interests of patients”.  

The new guidance will go on to explain that use of the word “must” is for an overriding duty or principle that will usually apply and “should” is used where the principle may not apply in all circumstances, although it is also used to explain how to meet an overriding duty. 

The new version will also explain that the GMC will act “where there is a risk to patients or public confidence in medical professionals, or where it is necessary to maintain professional standards”, rather than the previous ‘threshold’ statement where only serious or persistent failure to follow the guidance would put a doctor’s registration at risk.  

This does appear to be a slightly different test and potentially broadens the ambit, although the GMC explains they have proposed the change “…because we think it would be reassuring to medical professionals and helpful to patients and the public to explain more fully when we might take action to protect the public”. Perhaps this reflects high-profile cases such as that of Ian Paterson. 

It is proposed that there will now be 4 domains, which I shall mention below. Within these domains, there are various proposed amendments that are of potential interest from a clinical negligence perspective. 

In the past, I have sometimes found the booklet can be a helpful adjunct when considering the duties of doctors generally and in the context of the standard legal tests for negligence; it can also be of assistance with respect to the duties of medicolegal experts.  

Domain 1: Working with Colleagues

The first domain relates to working with colleagues. There will be greater emphasis on effective teamwork amongst doctors and collaboration between colleagues, including “taking responsibility for continuity and coordination of care, maintaining and improving quality of care, and responding to risks”. 

This is particularly important where there is multidisciplinary care, and treatment is being shared between teams and care providers. 

It is not especially unusual to have a case of shared care in which each involved healthcare provider fails to take responsibility for a patient’s care, perhaps assuming the other will, and, as a result, the patient falls between two stools and their care suffers – I have just such a claim at the moment. 

The section on delegation will be widened to encompass the delegation of tasks and duties such as supervision. The section is proposed to read: “When you delegate tasks or duties, you must be satisfied that the person you are delegating to has the appropriate qualifications, skills and experience to carry them out, and that they will be appropriately supervised and supported if necessary” [underlined text is text changed in the new version]. 

This is an important section because it is not particularly uncommon in ‘consent’ cases for delegation to an unsuitable junior to have taken place, especially with respect to consent for a procedure or operation. 

The paragraph on recording work will be slightly reworded, stating: “Formal records of your work (including patients’ medical records) must be clear, accurate, and legible. You must make records at the same time as the events you are recording, or as soon as possible afterwards”.  

Again, even with the advent of electronic records, we still find frequent examples of poor, inaccurate or incomprehensible record-keeping despite the GMC’s guidance. The requirement to make contemporaneous records is an overriding one.  

Additionally, the paragraph on what clinical records should contain and how to record decisions made is proposed to be amended to include, “decisions made and actions agreed (including decisions to take no action), and who has made the decisions and agreed the actions” and “the information given to patients and relevant others”. These changes would appear to reflect the Montgomery judgment in 2015 and the approach to decision-making and consent. 

Domain 2: Partnership with Patients

There is a particular focus on doctors working in partnership with patients, which is the second domain. From a negligence point of view, this is especially relevant post-Montgomery. 

During the consultation process, feedback was provided to the GMC that there should be greater focus on patients’ needs, rights and expectations. 

Whilst the one page summary of the key principles in the guidance is to be amended to change “duties” of doctors to “behaviours”, most of the core principles will not change and it will remain necessary for doctors still to “listen to, support and work in partnership with patients, to help them to make informed decisions about their care” and to “provide a good standard of practice and care, and be honest and open when things go wrong”.  

A new duty is intended to be added, drawn from the principle 4 in the GMC’s booklet ‘Decision making and consent’, that doctors “must try to find out what matters to patients so that you can share relevant information about the benefits and harms of proposed options and reasonable alternatives, including the option to take no action”.  

Again, this appears to reflect Montgomery, as do some of the proposed amendments to the section on partnerships with patients that was in the 2013 edition, namely: “All patients have the right to be involved in decisions about their treatment and care”, patients need to be provided with “clear, accurate and up-to-date information, based on the best available evidence, about the potential benefits and risks of harm of available options, including the option to take no action” and “[Doctors] should check [a patient’s] understanding of the information they have been given, and make sure they have the time and support to make informed decisions if they are able to (in line with our guidance Decision making and consent)”. 

These are all cornerstones of the post-Montgomery consenting process and echo the Supreme Court’s judgment and subsequent judgments which have applied Montgomery e.g. the option of taking no action. 

A new duty is to be added in line with the GMC’s ‘Good practice in prescribing and managing medicines and devices’ to reflect the change in practice following Covid: “Whether you provide clinical care in a face-to-face setting, or through remote consultations via telephone, video-link, or online services, you must provide safe and effective care”. 

The section on when things go wrong will be amended to add that when a patient under a doctor’s care has suffered harm or distress, the doctor should “offer an apology (apologising does not mean that you are admitting legal liability for what has happened)”, emphasising that apologising does not mean accepting legal liability. 

This is to encourage apologies by doctors who have made a mistake and is to be welcomed, as in my experience many claimants are aggrieved at how poor the response often is to concerns they have raised, whether raised in the form of a formal complaint or just informally. Defensiveness creates distrust and suspicion and, in my experience, is more likely to lead to consideration of a legal claim. 

Domain 3: Professional Capabilities

The third domain will concentrate on how doctors need to keep up to date and develop as clinicians. The guidance will describe these as “the fundamental capabilities that underpin a professional’s ability to achieve the standards set out in domains 1 and 2”.  

The domain is similar to the previous edition in 2013 and focuses on how doctors can maintain competence, develop, support others and demonstrate leadership. 

Domain 4: Maintaining Trust   

The fourth domain focuses on patients being able to trust their medical professionals, including doctors being honest and trustworthy, knowing the limits of their knowledge (an important factor in some clinical negligence cases when doctors attempt something beyond their skillset or expertise), not giving misleading information and maintaining patient confidentiality.  

For medico-legal experts, the previous paragraphs (71 and 72) about being honest and trustworthy when writing reports, giving evidence to court or other tribunals, ensuring information is correct in any documents the doctor writes or signs and not leaving out relevant information (e.g. including a medicolegal report) have been merged, but the duties will remain the same. 

The paragraph on insurance in the 2013 version is to be slightly amended. It will now state: “You must ensure that you have insurance and indemnity that covers the full scope of your practice. You should keep your level of cover under regular review”.  

The GMC explains that ‘full scope of practice’ is meant to cover all activities wherever these take place (including care across borders). 

There is no reference, as far as I can see, to the vexed issue of discretionary indemnity cover and certain indemnifiers not providing cover in certain circumstances (such as a failure of notification by the indemnified doctor), which can leave some injured patients without redress; this is perhaps a missed opportunity to tackle what is an unacceptable, ongoing problem. 

Nevertheless, whilst there may still be further amendments to be made following additional feedback, broadly the direction of the proposals is largely to be welcomed, as they seem to be appropriately reflective of relatively recent changes in the legal landscape, the impact of the pandemic, how patients access care nowadays and how medical professionals are having to adapt and adjust to an ever-changing environment.  

It is expected that the new version of Good medical practice will be published later in 2023.