The medical profession in the United Kingdom was shaken by the discovery that Harold Shipman murdered around 250 of his patients when working as a junior hospital doctor and general practitioner between 1971 and 1998.1 A public inquiry recommended fundamental changes to the accountability of doctors. Issues addressed by the inquiry include death certification, monitoring of prescribing, complaints systems, disciplinary procedures, and regulation. Medical regulation in the UK shares many features with other countries, so that although this case is unique to the UK, the implications are of international importance. The case and subsequent inquiry have revealed the weaknesses of current systems of medical regulation and shown that radical reform is necessary.

This article discusses how detailed the standards to judge a doctor's fitness to practise should be, and the way in which explicit standards can be developed. The recently published fifth report of the Shipman Inquiry highlights the lack of explicit standards, a shortfall that makes it unclear when questions should be raised about a doctor's fitness to practise and may lead to inconsistent decisions.2 The development of detailed standards would be a major step in improving regulation, as would defining the relationship between doctors and patients.3 It could be argued that specifying standards of fitness to practise would reduce the complex art of clinical practice to a naive checklist. However, patients expect the profession's regulatory body (the General Medical Council (GMC) in the UK) to define minimum standards for doctors. If the regulators are not clear about what is unacceptable, how can patients decide …