England to consider shake-up of medical regulation

London

Andrew Cole

England’s chief medical officer, Liam Donaldson, has recommended a radical shake-up of the way doctors’ performance is assessed and a substantial reduction in the powers of their regulatory body, the General Medical Council.

The long anticipated review of medical regulation contains 44 recommendations, including lowering the burden of proof in misconduct cases; a rigorous system of revalidation for all doctors; and the devolution of many of the GMC’s powers to local hospital level.

The report, prompted by the murder of an estimated 250 patients by the GP Harold Shipman and a subsequent inquiry that was highly critical of the GMC (BMJ 2005;330:10), will now go out for consultation until November. But many of the central recommendations have already been attacked by doctors’ organisations.

Professor Donaldson said that doctors’ revalidation must be robust enough to ensure patient safety and trust. But this was not happening. "At present a senior doctor can go through a 30 year career without undergoing a single assessment of their fitness to practise, whereas an airline pilot would face over 100 checks in a similar timescale."

He proposed a new twin track system of revalidation based on clear standards of performance that would be written into every doctor’s contract. In future, all doctors would be subject to "relicensure," probably every five years, and specialists and GPs would have to be recertified at regular intervals.

These assessments would be based on a new, more objective form of appraisal, said Professor Donaldson. Appraisal was a good idea but "it is very patchy and lacks rigour." The onus would now be on doctors to prove their competence rather than for the regulator to demonstrate incompetence.

Under the proposals the GMC would lose many of its powers. In particular it would no longer act as prosecutor, judge, and jury in fitness to practise cases. Instead it would be responsible solely for assessment and investigation, and an independent tribunal would determine guilt or innocence.

The burden of proof would be lowered from the criminal one of beyond all reasonable doubt to the civil standard of balance of probability. This would eliminate the dangerous gap between the NHS and medical regulation, where a doctor could be judged not good enough to be trusted by patients or colleagues yet not bad enough for action by the regulator.

The GMC would also lose its educational role, with responsibility for setting the medical undergraduate curriculum and approving medical schools, with these moving instead to the Postgraduate Medical Education and Training Board.

Members of the new GMC would be independently appointed by the public Appointments Commission rather than elected, with its president being elected by these appointees. Ultimately it would be accountable to parliament and would be scrutinised each year by a committee of MPs.

The report also proposes a network of GMC affiliates at local hospital, primary care trust, and private sector level, who would be trained by the council to investigate local complaints and help with generic revalidation. These affiliates would be practising doctors of high standing, working in conjunction with public and patient representatives.

Other recommendations include:

• A substantial role for royal colleges in assessing specialist practice

• All medical students to have student registration with the GMC

• Locums to be subject to scrutiny by GMC affiliates

The reforms are likely to cost between an extra £70m (€102m; $128m) and £78m a year, with doctors expected to pick up £18m of the bill.

The GMC has already signalled that it will fight the move to strip it of its educational role. Its president, Professor Graeme Catto, said that the proposal in the report had no explanation. It was difficult to understand why education was being passed to an organisation that only dealt with doctors until their mid-30s.

He also disputed Professor Donaldson’s claim that there was a global move to dispersing regulatory functions rather than keeping them under one roof. "My view is that many countries are moving to bring together the four statutory components we have and not too many are trying to divest the regulator of these."

The BMA claimed the shift in the balance of proof for misconduct cases could "open the door to miscarriages of justice which will devastate the lives of doctors and their families." It also suggested that abolishing elected members of the GMC would alienate most doctors and would erode the concept of professionally led regulation.

Professor Donaldson’s report, Good Doctors, Safer Patients, can be found at www.dh.gov.uk/cmo.