Introduction

Several high profile cases of poor medical practice in the United Kingdom have brought self regulation into question. Pressure for change is great, but experience from other Western countries suggests that abandoning the existing systems is not the best way forward. The United States and Canada both have well established systems of self regulation that are being gradually adapted to include a requirement for regular recertification. Although the healthcare environment in the UK is somewhat different, North America presents important lessons on how to ensure doctors are competent.

Should we abandon self regulation?

Stacey, the distinguished British sociologist, has written extensively about self regulation over the past two decades. In 1997, she concluded that given the alternatives, it is, on balance, the best option.1 The prominent American sociologist Friedson has come to similar conclusions, after having a different view several years previously.2 He argues that ideological attacks on professionalism have distracted us from the fact that we are profoundly dependent on organised bodies of specialised knowledge and technique. This assault has created a sense of distrust that further weakens the credibility of professional institutions' ability to offer an independent and moral viewpoint. Friedson suggests that the monopoly of expert authorities cannot be avoided as it is essential for nurturing specialised knowledge.

The political philosopher Onora O'Neill also raised the importance of trust in the BBC Reith lecture in 2002.3 She pointed out that it cannot be legislated or managed by numbers alone:

Intelligent accountability, I suspect, requires more attention to good governance and fewer fantasies about total control. Good governance is possible only if institutions are allowed some margin for self-governance of a …