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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Response to 'Regulation and revalidation of doctors'
- Professor Sir Graeme Catto, submitted by Jo Wren, Media Relations Manager (21 July 2006)
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Donaldson: dangers and opportunities
- Brian D Keighley (22 July 2006)
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The Emperor's lack clothes
- Adam J Pringle (22 July 2006)
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locus of confidence
- Adrian K Midgley (23 July 2006)
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Motives
- ben dean (23 July 2006)
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We must protest!
- David M Lewis (26 July 2006)
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Case not proven
- Martin Toal (26 July 2006)
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Threat to the Profession
- Peter Gooderham (26 July 2006)
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Competence of doctors from mainland Europe
- Shahid. S Baig (26 July 2006)
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Is it fit for the purpose for which it was designed?
- Michael G Peckitt (26 July 2006)
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Letter to the editor
- Walton of Detchant (27 July 2006)
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Rolling over
- Michael Schachter (29 July 2006)
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Chief Medical Officer’s Proposals on Reforms of GMC
- K C Mohanty (12 September 2006)
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Professor Sir Graeme Catto, President of the General Medical Council General Medical Council, NW1 3JN, submitted by Jo Wren, Media Relations Manager
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The report from the Chief Medical Officer for England has implications for all UK doctors and needs to be considered very carefully. Its aim is a system of medical regulation that puts patient safety first through the early detection, and where possible, remediation, of poor performance. If the report contributes to that aim, and commands public and professional support, it should be welcomed by everyone involved in healthcare. The Merrison report was the collective effort of Sir William Merrison and the other 14 members of his Committee of Inquiry, who took both oral and written evidence. A different process has been followed in this case. The Government, sensibly, has therefore decided on a period of consultation during which the recommendations can be properly debated, tested and costed. We have already said that we believe that the recommendations to divorce oversight of medical education from the other regulatory functions of standards, registration and fitness to practise are not in patients' best interests. We will now be consulting widely with our partners before we submit our considered response. It may be another 30 years before there is another opportunity such as this. We must seize it so that that future generations of patients can say that we did not fail them. Competing interests: President of the GMC |
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Brian D Keighley, General Practitioner Balfron, Stirlingshire, G63 0TS
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Editor, Professor Pringle’s editorial (22 July) reinforces the GMC's corporate view that its prime function is, and always will be, the protection of the public by promoting the highest standard of medical care in the UK, something that is best delivered in partnership with others. A recent tracking survey demonstrating the support of 75% of the public for the GMC as the medical regulator is testament to that. Pringle welcomes the bipartite approach to revalidation, especially that element applying to career-grade doctors. This, however, is to adopt only one view of the intention of revalidation, to be as near an absolute guarantee of competence as can be devised. The alternative view is that such a process would be better managed in an incremental fashion with the first step to define the meaning of registration or the holding of a licence with the guarantee of competence developing as a by-product. No matter which system prevails – 50% of all doctors will remain below average. Interestingly, however, he describes the 2003 proposals for revalidation as being entirely those of the GMC, perhaps forgetting Sir Liam Donaldson’s own letter to Dame Janet Smith of 10 November 2004 (1) which led her to believe that they were in the joint ownership of the GMC and the Department of Health. Pringle fails to track Sir Liam’s shift of opinion. Pringle rightly challenges Donaldson’s lack of cogent reasoning to move the overview of undergraduate medical education to a PMETB often perceived as struggling to deliver its existing core responsibility and points to the contentious issue of the standard of proof within fitness to practise cases. The GMC will use this report as a catalyst to produce a better future despite Professor Pringle’s premature belief that it would be a political disaster for the medical profession to reject Donaldson’s proposals. He appears, however, to forget that the views of one, senior doctor are merely the basis for a four month period of consultation that will involve the public as much, if not more, than the Government and the medical profession. To say the direction is set is perhaps a perilous conclusion one week into that four months. Sincerely Brian D Keighley (1) Smith J. The Shpman Inquiry: fifth report;safeguarding patients: lessons from the past - proposals for the future. Page 1082. Chairman: Dame Janet Smith. Cmnd 6394. the Stationery Office, London, 2004 Competing interests: Elected Medical Member of GMC for Scotland. involved in various revalidation working groups, GMC, GPC and RCGP |
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Adam J Pringle, General Medical Practitioner Lawley Medical Practice TF4 2LL
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"The intellectual case for two levels of revalidation is compelling" as Mike Pringle states, may well be true. However, as Sir Liam states clearly in his report "There is little disagreement with the assertion that in 2006 every patient is entitled to a good doctor. Yet, there is no universally agreed and widely understood definition of what a good doctor is. Nor are there standards in order to operationalise such a definition and allow it to be measured in a valid and reliable way" An intellectual case alone, in the absence of any tried, tested and validated tools that actually measure the quality of medical practice, is not sufficient to make anything more than an expensive disaster. The rest of us stopped believing that just because we wanted something to happen we could make it happen in early childhood. If 1% of us are removed in error each year - a small error rate in such an ill-defined system, then 40% of doctors will suffer incorrectly at the hands of this system in our working lives. These eminent doctors are suggesting we reform our system of validation, and set it against a set of national standards that have yet to be written, aiming to measure something which cannot be measured. In a world where NICE cannot reach the same answers as the BHS, this can only be a recipe for disaster. Anybody pretending to intellectual validity and scientific rigour would test and validate their tools first, and design their system later. The evidence that the fashionable assessment tools of the day (360 degree feedback, and appraisal) are useful in identifying failing doctors is sorely lacking - indeed we have been clearly told that appraisal is not for that purpose, but is a formative process for personal development. Professor Pringle believes that all General Practitioners should be Memebers of the Royal College of General Practitioners - and intends to use these reforms to force this upon us. Yet there is no evidence that GPs who are not College members are bad GPs, so why should they be forced to do this - we do not yet live in a totalitarian state. I accept that he has declared his conflict of interest. (I am a member, so have no conflict to declare here). The plan proposed is for a single doctor in each area to be the GMCs local affiliate - which given the suicide rate amongst doctors is a level of power akin to life or death, and is the ideal post for the next aspiring Dr Shipman. Who would dare report their suspicions of someone who can despatch them to the gulag? We are to replace the GMC fitness to practice panels (a mix of doctors, lawyers, and lay members) with independent panels with an identical composition - do the Professors really have so little faith in the probity of their colleagues that they see membership of the GMC as a conflict of interest? I agree that the changes in appraisal are negative, and that the Postgraduate Medical Education and Training Board should not have more responsibility - it is at present failing to deliver its current responsibilities effectively, with qualified GPs waiting months for the certificates that allow them to work independently. He fails to recognise the consequences of a shift from 'beyond reasonable doubt' to 'balance of probabilities' - a shift that places careers in jeopardy, and lives at risk. This is unreasonable, given that we also face Criminal, Civil and Coroner's courts, together with Local, PCT, GMC and CHRE complaints hearings. It may be a political disaster to reject these reforms without proposing a better alternative - but it would be a greater disaster to burden us with this untried bureaucratic monolith. If I declare that of the first 1,788 doctors to read my criticisms of the CMOs report on doctors.net, 789 agreed strongly, and the rest, bar one, didn't comment, will Professors Pringle and Donaldson accept that it has been rejected by the profession, beyond reasonable doubt? Or, failing that, at least on the balance of probabilities? Competing interests: None declared |
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Adrian K Midgley, GP Exeter EX1 2QS
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Mike Pringle's opening could lead one to think that there has been a loss of confidence in doctors, if it is not carefully parsed or read with knowledge of the situation. Not so. He points out that GP membership of th RCGP is around half of the craft, some having felt obliged to pay for an exam but not wished to continue as members, some never having needed or perhaps wished to join. He neglects to draw the conclusion there, that as well as an increased willingness to disclose a lack of trust in the GMC - since its membership was diluted with quangoists lacking medical degrees, the RCGP as a body and its current heads also enjoy less conifdence of the GPs they would now like to regulate than they might hope. This looks more like a power grab than anything carrying professional respect and agreement. Meanwhile, the public continue to trust the doctors they have experience of considerably more than the bodies that wish to regulate them, and in the case of those political ones wishing to control the whole affair, with good instinct. Competing interests: None declared |
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ben dean, sho oxford
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Like many initiatives launched with apparently good intentions by politicians and their kind, the CMO's report flatters to deceive in the eyes of many. There are many ways to criticise the report, despite its concise length of 200 pages plus. Dr Adam Pringle (1) has already critiqued the report very eloquently on doctors.net and seems to have a large amount of support from those in the profession. I would like to pose some questions to those who think the report is a good and practical base from which to work. The chain of events that has led to this overhaul of the medical profession seems to have been a certain Dr Shipman. A cynic would argue that the CMO's report does nothing to make a second Shipman less likely and instead uses the smokescreen of Shipman to drive through a series of politically motivated hammer blows to the dying freedom and independence of the medical profession. A cynic would also argue that the system was in place to detect a Shipman, it was only gross incompetence of a few individuals that let the system down. One has to accept that no system is perfect and certain individuals will always make costly mistakes, no matter how the system is changed. I feel by trying to improve a reasonable system, the CMO is likely to create an expensive shambolic bureaucratic nightmare. Doctors already face numerous tests of their fitness to practice on a daily basis with every patient they see, is revalidation going to improve patient care or make it worse? Who pays for the revalidation and what happens to the GMC subscription that doctors currently pay? What happens when a doctor fails revalidation, who finds out, can they continue to practice, who retrains them, who pays for the retraining and how are they re-assessed? (You see how this shambolic nightmare starts to appear) What happens as regards revalidation for doctors doing research, for doctors in politics (Sir Liam for example) and doctors in other areas of work? Why are no other professions required to undergo revalidation? Why are some professions such as politicians allowed large amounts of responsibility, with no education in their area of decision making, and minimal accountability for their decisions? (An example of this accountability is Patricia Hewitt's delegation of dealing with public petitions, as regards her decisions to cut services, to PCTs) Why reduce the burden of proof to a balance of probabilities? A doctor’s career will depend on this. There are so many other ways doctors can be held accountable: Criminal, Civil and Coroner's courts, together with Local, PCT, GMC and CHRE complaints hearings. Given Sir Liam's many references to the airline industry (2) and comparisons between this industry and our own- why can one industry be highlighted in such a biased fashion? Why not compare doctors to politicians, and then by the same faultless logic one could conclude that doctors require no formal training, no prior knowledge of medicine, minimal accountability and certainly no revalidation. One could also conclude that there would be no need for fitness to practice hearings at all, doctors could just ignore examples of their own negligence while lying through their teeth and ignoring the tricky questions. I digress, but seriously I feel encouraging an open and honest culture from above is the best way of dealing with errors, this seems to be a long way from the totalitarian centrally controlled system ruled by fear of present. Why not deal with this culture of intimidation and fear? The CMO's report, if allowed to come into effect, will be the death of a self-regulating medical profession putting yet more power in the hands of those currently in control. Like so much recent legislation such as the Criminal Justice Bill, recent Anti-Terrorism Bills, and the pending Legislative and Regulatory Reform Bill (3) - it is merely another measure that increases the power of an increasingly authoritarian regime. I hope the medical profession unites against it. Yours, Dr B Dean 1. http://bmj.bmjjournals.com/cgi/eletters/333/7560/161 2. http://news.bbc.co.uk/1/hi/health/5201684.stm 3. http://www.timesonline.co.uk/article/0,,1072-2049791,00.html Competing interests: a dislike of politicians |
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David M Lewis, General Practitioner Watford, UK WD24 7PH
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Dear Madam Prof Pringle implores us not to protest at the CMOs proposals. However, I submit that the point of consultation is not to simply agree with the author of the report but to protest when inequity is self- evident. Dr A Pringle's summary of concerns are well made, as are Dr Dean's points. Doctors.net forum is buzzing with indignation at many of the proposals, if not all of them. It would be wrong to dismiss these out of hand. There are several points that make me pause and consider the motives and soundness of the proposals. 1. The use of anecdotal evidence to infer that appraisal of GPs is
not fit for purpose.
There is a sense of intellectual poverty if GPs and their appraisal system can be attacked without better evidence than 'anecdotal reports'. It is very dangerous to assume that the United Kingdom must dilute self-regulation of doctors because many coutries elsewhere are doing so. Doctors are a power to be reckoned with, and this issue in particular would, at a stroke, immasculate us. Nevermind the assurances that whistle blowers will be protected by employment legislation; we all know that this is not the case in practice. Things could get so much worse if Sir Liam Donaldson gets his way here. The GMC was set up in 1848 because of cronyism. Thomas Wakely, the founder of 'The Lancet' spent a lot of time fighting the (non-elected) medical establishment and the GMC grew out of this fight - elected members of the profession overseeing safe medical practice. The lessons of history have not been learned - unelected people overseeing the profession will not have the trust of the doctors they oversee, and the public will not be protected because politics will very definitely get in the way of sound, evidence-based healthcare. In fact, this is at the heart of the problem as Thomas Wakely knew 160 years ago. Indeed, I would like to know the evidence that patient safety is any worse than it was more than 100 years ago. I respectfully suggest that our citizens have never had such highly trained doctors looking after them; a situation that I see being destroyed by the proposals before us. The Medical Royal Colleges are standard setters, but they have never been designed as 'policeman'. The nurturing role they currently have could be sacrificed on the alter of assessments and monitoring. It seems they are being bribed to take on this role (for the reasons Prof Pringle suggests) but I believe it is a poisoned chalice. Getting it wrong will give the politicians ammunition to curtail teh independence of the Colleges in the same way the GMC is being hounded now. The PMETB cannot manage its current activities; I dread to think how it will handle the expanded role outlined for it by the CMO. Junior doctors have been well served by independent scrutiny of hospital posts until old system was replaced by PMETB. I see no evidence that the working life of junior doctors has been improved by the changes, in fact I am aware that working conditions are worse than they have ever been for the hospital doctors in training. In short, the proposals are bad for doctors and bad for patients. The CMOs proposals are, in my opinion, a sop to the politicians and do not do Sir Liam Donaldson any credit at all. David Lewis FRCSEd, MRCGP
Competing interests: None declared |
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Martin Toal, Pharmaceutical Physician Bagshot, Surrey GU19 5PJ
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I must take issue with Mike Pringle's assertion that to reject the Donaldson report would be a political disaster for the medical profession. Rather, I would suggest that to accept a politically motivated report which will fail to achieve almost any of its expressed aims, yet will add to the burden of time, money and stress expended by doctors on its processes, and possibly thereby reduce patient safety, would be the greater disaster. A lay reader of the Donaldson report and Pringle's rather uncritically supportive editorial would imagine that patient safety can only be assured by external bodies, not by doctors themselves. This is a nasty and unwarranted slur on the profession, who rightly enjoy a high and robust reputation among the public. This reputation has been earned through hard work and dedication to patient safety and care. Clearly one of the main drivers for the Donaldson report has been Shipman. Sadly, the unpalatable truth is that no relicensing or revalidation procedure will prevent another Shipman, or indeed an angel of death, the latter being numerically more common if perhaps individually on average less prolific. Fortunately such cases are very rare. Donaldson has also missed at least one genuine opportunity to improve standards. Study leave provision is under ever greater financial pressure, to the point now where many doctors find it very difficult to get approval for funding to attend even one conference a year. I am aware of trusts where doctors are encouraged to accept funding from the pharmaceutical industry, in which I work, to attend meetings and conferences. Given the universal acceptance of the importance of life-long education and training, taken along with the relentless pace of medical innovation and knowledge, it is self evident that this situation is unacceptable and potentially harmful to patient safety. Donaldson could have made robust recommendations to secure adequate and appropriate study leave which would ensure that doctors are able to attend a minimum level of pre-defined training and educational, perhaps to include one national conference in the relevant specialty. Pringle makes no mention of education save to relish the expanded role for the Royal Colleges in the proposed new mechanisms, and the consequent need for all doctors to have some affiliation, no doubt accompanied by the appropriate fees. This enthusiasm may be misplaced, and the Royal Colleges have yet to prove their ability to manage such a system. In particular, Pringle's own college, the Royal College of General Practitioners has recently shown that its thinking on standard setting for public consumption is grossly out of touch with the views of many others in the profession, including many of its own constituents (1). (1) BMJ 2006;332:1410 (17 June) Competing interests: Pharmaceutical Physician: married to a NHS Consultant |
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Peter Gooderham, Tutor Cardiff Law School, CF10 3XJ
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As a retired GP and academic lawyer, I shall confine myself to two observations. 1) I was taught, and still believe, that self-regulation is a hallmark of any profession. Professionals are best placed to decide if a member of the profession is fit to practise, not fit to practise, or if limits should be placed upon his or her practice. There is a compelling argument for legal input and lay input into the disciplinary process. However, a doctor accused of making an error in, say, dealing with a life- threatening emergency at 3 a.m., should primarily be judged by doctors with experience of managing the same sort of presentation in similar circumstances. I do not believe that public confidence in the disciplinary process will be enhanced if the decision is primarily made by those without key professional experience. I would welcome comments from other professionals on this principle. I would not be competent to judge an engineer on bridge design, for example, and I doubt if engineers or the public would be confident in my standing for so doing. 2) The civil standard of proof is a major threat to the medical profession. That applies notwithstanding the necessary adjustment in sanctions which certainly should apply if this is brought about. A finding against a professional person at a regulatory body is a major blight on his or her scope to practise. So also, to a lesser extent, is the very fact of a case being brought. This proposal is a recipe for a larger number of "disciplinary cripples" within the profession, which is itself unlikely to improve professional or public confidence. That is not to say that those falling below the standards of their profession should not be disciplined, but loss of livelihood and reputation should depend upon findings being beyond reasonable doubt. Having practised medicine for 15 years, I left practice in 2003, without regret, and appreciative of the experience I gained, especially the lessons learned about life, and the ability to help people with significant problems. My overwhelming response to the current proposals is that I would not advise an intelligent teenager to pursue a medical career unless their livelihood did not depend on continuing it for a working lifetime. That is a cause of concern and regret. Competing interests: PG has worked with two authors on this page whose work has already been posted. |
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Shahid. S Baig, Principal Sceintist, Health research EUROPEAN COMMISSION
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Dear colleagues, I would like to make some observations concerning the employment of doctors, particularly from mainland Europe. From my own experience, the process of seeking employment by young doctors, and having the right credentials in very lengthy and complicated within mainland Europe ( even between France and Belgium!). The accreditation of qualifications and recognition of all elements of training by the Medical Association and the equivalent of our GMC requires time and more often results in examinations. Your point of medical standards and the cultural difference ( language) are very valid from a UK point of view, and MUST be addressed. As, we will see an OPEN market approach to the provision of health care in the UK. Translated, this would mean the US model of cheap clinics run by the commercial sector. This is based on the current thinking of the government. Not all Member States(MS) have numerous clauses within their medical training programmes, as a rule those who can afford to pay for the education/training have the advantages. Some MS already have seen the emergence of cheap private dental clinics. . The only way the quality of medicine in the UK can be maintained is by demanding evidence of assessed results of the rotation programme in their training, as well as using an existing standard, such as passing part 1 (A&B) of the relevant Royal College from non UK qualified doctors . This would ensure an even playing field, which would ensure the care and the safety of the patient. This would at least give a uniform approach to the clinical competence as well as the required cultural sensitivity. I am certain that the current despondency both within the profession but more so in the public would benefit from a debate on the issue of clinical competency. S.S.Baig B-1049, Brussels- Belgium Competing interests: None declared |
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Michael G Peckitt, University Tutor University of Hull, c/o Philosophy Dept, Hull, East Yorkshire, HU6 7RX
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Dear Editor, I am an academic, and in academia we have had 'Mentoring schemes', where an elder, often more experienced Faculty Member would evaluate one's performance in the Lecture Hall and suggest improvements. Granted a bad 'report' would not result in my being sacked, but either way, were one the academic equivalent of Dr.Shipman nor would it stop me harming the students - something which I assure I do not do. If someone is really determined to pass or get around a revalidation test, they will. This net will simply not catch most of the desired suspects. Competing interests: Articles published may go towards RAE |
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Walton of Detchant, na House of Lords
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Dear Editor I am sad to learn that my friend Liam Donaldson, in his report ‘Good doctors, safer patients’ has been much influenced by those siren voices within government and without, who seem determined to emasculate the General Medical Council and to destroy the long-hallowed principle of professional self-regulation. I well recall when, in a notable lecture entitles ‘How to Ruin the Professions’, the late Lord Hailsham said that professional self-regulation is one of the glories of a civilised society, and that the alternative of regulation by the State is too fearful to contemplate. That view was warmly echoed by Professor (now Lord) Dahrendorf in his Jeffcock Lecture to the Royal Society of Medicine; he spoke with authority, having been a German citizen who had witnessed at first hand the malevolent effects of State regulation of medicine and of other professions in that country. Of course, I recognise that a number of notable cases in the last few years have dented public confidence in the GMC and its procedures. Nevertheless, in the 1980s, when I chaired sessions of the Council’s Professional Conduct Committee, almost invariably, when the issue arose as to what action to take against an erring doctor, the professional (ie medical) members of the panel were more severe in their conclusions than the excellent lay members, themselves distinguished in many diverse fields, who sat in pairs on the panels set up to hear cases, and generally took a more compassionate and lenient line before final decisions were reached. The massive reorganisation of the Council imposed by government a few years ago has not, in my somewhat distant view, improved its procedures greatly. Knee-jerk reactions by government have not helped - in establishing, for example, a Council for the Regulation of Healthcare Excellence, this creating an unnecessary additional tier of decision- making. When it is now suggested that the standard of proof in cases to be heard before the proposed new tribunals is to be reduced from that appropriate for the criminal court to the standard of ‘on the balance of probabilities’ which operates in the Civil Courts, I cannot but be alarmed. Indeed, I am tempted to quote John McEnroe by saying “You cannot be serious!”. Erasure from the Medical Register is a decision which, at one fell swoop, removes a doctor’s livelihood, and with this revised standard of proof, I cannot but express concern that injustices will occur, however, expert and judicious the newly-established tribunals will prove to be. And why on earth is it proposed to remove responsibility for the oversight of basic medical education from the Council’s Education Committee, which has had a proud record of monitoring the performance of Britain’s medical schools, and the content and efficacy of their qualifying examinations? When I was Chairman of the Education Committee of the Council before becoming its President, I was proud of the 1980 Recommendations on Basic Medical Education which we produced and which were regarded internationally as being innovative and far-sighted. Years later, under the tutelage of Professor David Shaw, the revised recommendations, entitled ‘Tomorrow’s Doctors’, were equally well-received and have been generally accepted, with the relevant recommendations being implemented by the UK medical schools. Here again, I am tempted to say “if it ain’t broken, don’t fix it!”. I must also comment upon the report by Dame Janet Smith, which made many useful and thoughtful recommendations, not least in relation to death certification, the role of the Coroner, the regulations relating to the prescription of dangerous drugs and the provision of cremation certificates, but moved on to much more uncertain ground in recommending changes at the GMC, making some proposals which are in my view wholly impractical and could have done nothing to prevent the emergence of another Dr Shipman. Many of the recommendations now made by Sir Liam will require legislation, which I am confident that I and other doctors as well as lawyers will scrutinise carefully when it comes before Parliament. All of this is proposed at a time when the relentless torrent of government- promoted so-called NHS reforms is leaving the members of the medical profession bewitched and bewildered, involving requirements which often seriously erode time more properly devoted to patient care. It is remarkable that the standards of medical care in our communities and hospitals are as high as they generally continue to be in the face of all of these onslaughts. In the meantime perhaps I might ask, with tongue in cheek, whether the Government will now establish a major committee made up of doctors, distinguished laymen and a minority of lawyers, to examine in depth the regulation of the legal profession; if it does, even in my 84th year, I would be happy to serve. Yours Walton of Detchant
Competing interests: None declared |
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Michael Schachter, Senior lecturer in Clinical Pharmacology and Honorary Consultant physician St Mary's Hospital London W2 1NY
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The great majority of doctors favour revalidation in some form, although it remains to be seen whether the process will be more than bureaucratic box-ticking. It is the other aspects that doctors should react to, and not with the grovelling acquiescence favoured by Professor Pringle. Firstly, although the GMC has many faults and needs reform, the principle of professional self-regulation is surely worthwhile. Is anyone suggesting that lawyers should abandon theirs? In which context we should be grateful to the GMC for their "intransigent" response to the latest Shipman report. Secondly, we have the issue of reduced burden of evidence in disclipinary cases. This make it more than likely that people will be at least temporarily deprived of their livelihood on the basis of flimsy evidence poorly assessed. In effect individuals will get criminal penalties based on civil rules of evidence. What a step forward! Finally, we have Professor Pringle's particular favourites, the GMC affiliates. These will be familiar to all connoisseurs of the former Soviet Union, where every factory and appartment block had its Party commissars to check for incorrect thinking. Come to think of it,this would have been an ideal post for Dr Shipman, so highly respected as an appraiser of his colleagues. Competing interests: None declared |
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K C Mohanty, Member of the Employment Appeal Tribunal (High Court), London &Consultant Physician Scunthorpe General Hospital
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The article by Pringle M (BMJ 2006; 333: 161) did not go far enough to explain Chief Medical Officer’s reforms on GMC. Dame Janet Smith, Court of Appeal Judge was commissioned to look in to the case of Harold Shipman, a GP who murdered more than 200 patients. She said that the Shipman debacle along with other events in 1990’s such as retention of children’s organs at Alder Hay Hospital in Liverpool and poor quality of children’s heart surgery at Bristol had opened the eyes of the public, that things can go wrong even with the most trusted organisation like NHS.1 A recent MORI poll showed that the trust in doctors remained high but the trust in the profession was 150 year all time low.1 Referring to the trust in doctors Dame Janet said that the trust should not be blind, rather it should be based on confidence in doctors’ competence. In response to Dame Janet’s Report the Chief Medical Officer (CMO), Professor Sir Liam Donaldson produced his proposal on sweeping changes at the GMC which contains 44 recommendations under “Good Doctors and Safer Patients”.2 The CMO’s proposals are for consultation during November 2006. There are four main areas of CMO’s reform which will fundamentally
affect all the doctors practising in UK. They are as follows;
Burden of Proof The doctors were simply lucky to have the application of a “Criminal Standard” to their civil wrong by the GMC, until this anomaly was found by Dame Janet Smith ( Court of Appeal Judge) in her Shipman Inquiry Report. The practical implication is that if a Criminal Standard is applied, less number of doctors will be found guilty and most will escape any punishment. One bright example is that OJ Simpson the famous American football player was tried for murder of his wife. As a criminal case the Court applied the Criminal Standard and he was found “Not Guilty” which was based on beyond reasonable doubt. He was also sued in the Civil Court for the same murder of his wife. The Court applied the Civil Standard and he was found “Guilty”. He did not go to the prison as he was found not guilty on criminal charges where the test was simply different. Therefore lowering the standard of proof ( from almost 100% to 51%) will result more doctors being found guilty and loosing their registration. Adjudication The Judiciary in 1960’s and 70’s depended on Police to prosecute alleged criminals. The process was not perfect and the CPS with proper lawyers was created as a result. Now CPS prosecutes all criminal cases. In 11th or 12th Century the defendants of alleged crime were prosecuted and judged by the same people, even after appropriate representations of the defendants. If this happened there was a great deal of bias and there was no justice for the defendants. Dame Janet Smith found exactly the same practice with the GMC today in the 21st Century. GMC being a regulatory body in its judicial functions, now investigates, prosecutes and gives judgement, like courts existed about 1000 years ago. Appointed members of the GMC Members of the Tribunal will be appointed through a Judicial process with very highly skilled and capable people through national advertisement. Since the Standard of Proof will be lowered, more doctors will be brought before the Tribunal necessitating an establishment of a permanent Tribunal. The members of the Tribunal will be given sufficient training and will be very experienced as they will serve until the age of 70 unlike GMC members for a fixed term. However the members of the GMC will be appointed by the Public Appointments Commission and it is envisaged that most members will be doctors. They will probably serve for a fixed term. The members of the GMC will be accountable to the Parliament and a committee of MPs will scrutinise their functions each year. Professionally led regulatory body The Chief Medical Officer said that the onus would be on doctors to prove their competence rather than the GMC to demonstrate incompetence. There will be two levels of revalidation i.e. relicensure and recertification.3 Relicensure will be implemented through 360 degrees appraisal with lay input. Recertification will be obtained through appropriate training of the doctors through their own Royal Colleges with approval of GMC. This is quite different from GMC’s original revalidation which was suspended by the CMO after Shipman Enquiry. Evidence from USA shows that recertificatiin improves the quality of care without a doubt4 . Other proposals GMC will also lose its educational role for the undergraduate studies. This will be transferred to the Postgraduate Medical Education and Training Board (PMETB). Professor Pringle, Professor of general Practice in his editorial article3 did not support this transfer as it was not well argued in the CMO’s proposal. There are opposition from other doctors5 and from GMC.6 GMC President, Sir Catto’s view to keep the control of undergraduate education with GMC may be preferred. All students will be registered with the GMC, according to the proposal Lack of other proposals in the CMO’s Report The most important aspect is medical negligence which is not addressed. At present this process bypasses the regulatory body fully. Usually MPU or the MPS get involved at an early stage and take over the case. Only in some cases where there is a criminal conviction following medical negligence, the GMC is notified. Secondly there is no funding available at present to train the doctors as study leave monies are scanty and at some Trusts it is not available. Funding The cost of reforms will be between £70m and £78m. More cases will go to Tribunal when Standard of Proof is lowered. On average if 50% cases are lost by the GMC bringing the cases to Tribunal then the cost will exceed £78m a year. Cases at the level of Tribunal are very complicated may cost £0.5m each and there should be provision for appeal from the Tribunal which even costs more. However doctors are expected to pay only £18m towards this total cost. BMA argues that why should the doctors pay when most of the reforms are designed towards the significant improvement of patient care? However the training and education and administration may cost £18m. K.C.Mohanty
Reference 1.Tessa Richards. Chairwoman of Shipman Inquiry protests at lack of action. BMJ 2006:332:1111 2.Andrew Cole. England to consider shake-up of medical regulation BMJ 2006;333:163 3.Pringle M. Regulation and revalidation of doctors BMJ 2006;333:161- 162 4.Does certification improve medical standards? BMJ 2006; 333:439. 5.Twisselmann B. Letter to Editor BMJ 2006.333:303 6.Catto G. Response from GMC. BMJ 2006:333: 303 Competing interests: None declared |
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