Witness to Harm-Holding to Account. Improving patient, family and colleague experiences of Fitness to Practise proceedings: A mixedmethods study

Abstract

Background: In the United Kingdom, over 2.5 million health and social care professionals are registered by 13 statutory professional regulators. When professional conduct falls below standard, registered professionals may face an investigation into matters such as their conduct, health or competence via fitness to practise processes. Very serious cases are heard in public by an independent adjudication panel. The public, the largest source of concerns, may be asked by the regulator to be cross-examined in a hearing where their evidence may be crucial. Witness cross-examination is known to be distressing in the criminal context, where the victim is questioned about the harm they experienced and how they faced the alleged perpetrator. In fitness to practise, retelling stories could be similarly retraumatising. Our research focuses on the public (and colleagues) who raise concerns, including that they have been harmed by a professional, and examines their experience of engaging with fitness to practise processes. Design and methods: The study employed multiple qualitative methods. Public website materials were analysed using thematic content analysis, accessibility and readability algorithms and a useability survey about submitting a complaint (n = 11). The views of the public and those with personal experience of fitness to practise validated our analysis of the web content (n = 15). Sociolegal analysis was conducted of the United Kingdom’s social work/ social care regulators’ conceptualisations of witness vulnerability and special measures. Twenty-seven registrants’ employers were approached, and 25 were interviewed about organisational support for registrants, patients and service users. Data collection via regulators (n = 285) with small numbers via social media included surveys, (n = 64 in total) across 9 regulators, interviews (n = 47) across 10 regulators, ethnographic observation of hearings (n = 22) with 81 days of observation across 9 regulators, and documentary analysis of hearings determinations and witness statements across 13 regulators (n = 207). Project recommendations were coproduced through six formative workshops involving public members, legal, health and social care professionals, regulatory staff and lawyers and academics. Analytic methods included institutional ethnography, thematic analysis and narrative portraits. Results: The website information for the public was often too much or too little, in inaccessible formats, and requiring high literacy and digital skills. The social care regulators’ conceptions of vulnerability largely relied on inherent factors (e.g. disability), or misconduct categories, rather than being situationally sensitive to witnesses’ diverse needs. The experience of those who had been harmed was found to be profoundly distressing for most participants at each stage of the fitness to practise process: having to retell their story, uncertainty about when and where they would need to respond, and taking part in a legalistic and adversarial process where their evidence, and credibility, were questioned. Findings informed 20 recommendations. Project resources are available for all stakeholders. Conclusions: This project provides globally unique evidence of the experiences of the public involved in health and care professional regulation. It recommends improvement of professional regulation through public-focused information, compassionate and trauma-informed communications and support, and for independent cross-regulator evaluation. Public and stakeholder involvement and engagement: Our research was informed throughout by people who had personal experience of fitness to practise, regulators, employers, lawyers and professional bodies.