Bad apples? Bad barrels? Or bad cellars? Antecedents and processes of professional misconduct in UK Health and Social Care: Insights into sexual misconduct and dishonesty

This report outlines the results of a sequential mixed methods analysis, examining results from analysis of 6,714 individuals’ fitness to practise (FtP) cases from three distinct groups - doctors, nurses and midwives, and allied professionals working in the UK health and social care context. We used analysed the FtP determination documents that record the decision taken in formal hearings to identify the prevalence and differences in misconduct cases from across and within each profession. Using multi-method analysis, we: 1) identify the most prevalent forms of wrongdoing; and 2) examine in further details of sexual misconduct and two forms of dishonesty (theft and qualifications fraud) whose existence and prevalence undermines trust in professionals and confidence in institutional systems. Specifically, our analysis shows eleven frequent forms of wrongdoing, with comparative quantitative cluster analysis for each profession offering exploration of the commonalities and differences. Applying Robinson and Bennett’s (1995) taxonomy, we offer a meta-level perspective on these wrongdoings and their interconnections to reveal fundamental similarities between misconducts across these professions. Then, using quantitative analysis, we examine first arguably the most severe form of wrongdoing, sexual misconduct. We show these as self-gratifying actions which are diametrically contrary to that expected from a health professional. We analyse NHS staff survey data to show important associations in the broader culture of these locations. We then examine the most prevalent, dishonesty and theft, common to all three professions, and add further insight by specifically analysing qualifications dishonesty where the target for perpetrator action is the organisation. Our qualitative analysis involves identifying the perpetrator profession and gender differences, specifically their different target(s) and location(s) of these wrongdoings. We highlight differences in both the recording of misconduct and also the form and severity of sanctions used. Importantly, we distinguish three different types of perpetrator: first, a category of instrumentally-focused perpetrators (bad apples) operating as sole agents; the second group is characterised as follower-based action in which individuals’ wrongdoing has a clear social dimension emanating from learning and transfer from key others, and involves the normalisation of misconduct, and thus the erosion of perpetrators’ moral compasses (corrupting barrels); the final category is typified by a different set of antecedent processes, and central here is the accumulative erosion of individuals’ resources through stress or resource depletion, and therefore misconduct emerges through omission and error (depleting barrels). The latter category is not found for qualifications fraud.