The GMC, racism, and complaints against doctorsBMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7042.1314 (Published 25 May 1996) Cite this as: BMJ 1996;312:1314
Inadequate data collection and obscure decision making processes make extent of bias hard to judge
The General Medical Council (GMC) is facing up to its critics. Responsible for overseeing the self regulation of the medical profession in Britain, and criticised in the past for its lack of public accountability,1 the GMC has opened its doors to independent scrutiny. Last year it invited two independent reviews, one by the Audit Commission of its processes for determining doctors' fitness to practise, the other by the Policy Studies Institute to look into suggestions of racial bias in its handling of complaints against doctors.2 The institute's report is published this week.3 Although its authors found no evidence of overt racial discrimination, they conclude that deficiencies in the GMC's data recording and decision making processes make it impossible to tell to what extent racial bias exists. What began as an investigation into one aspect of the GMC's activities has ended up as a serious indictment of its entire process.
The report includes statistical analysis of all complaints against doctors dealt with by the GMC between September 1993 and August 1994, about 1000 doctors in total. Of these, 50 were eventually found guilty of serious professional misconduct and 23 were struck off the medical register. Serious professional misconduct is the only judgment for which a doctor can be struck off in Britain. It is defined solely in terms of case law, and many members of the public believe that the threshold for making a judgment of serious professional misconduct is far too high.1
The GMC considers complaints in three stages, and the researchers found that the proportion of doctors who qualified overseas and those with ethnic minority names increased at each stage. Preliminary screening is done by one of three medical screeners, who are members of the council. Those complaints (about 15%) considered to warrant further inquiry—based on there being, in the opinion of the medical screener, a possibility of serious professional misconduct—are passed to the preliminary proceedings committee. This committee sits in private and can decide to take no action, issue a letter of warning to the doctor concerned, or refer the case to the professional conduct committee. Doctors who qualified overseas accounted for 29% of all complaints received by the GMC in the year under study, similar to the proportion of doctors in Britain who qualified overseas (about 25%). But overseas qualified doctors accounted for 50% of cases considered by the preliminary proceedings committee, and 58% of those referred to the professional conduct committee.
Of those who reached the professional conduct committee, a higher proportion of British and Irish graduates were eventually struck off (48% compared to 31% of overseas graduates). Despite the small numbers (12 and 11 doctors respectively) this suggests that complaints against doctors who qualified in Britain or Ireland have to reach a higher threshold of seriousness of misconduct or weight of evidence before they will be referred to the professional conduct committee.
These differences have not, however, allowed the researchers to declare racial bias. To do this they would have needed clear criteria against which to judge the validity of the GMC's decisions in each case at each stage. The problem is that no such criteria exist. In their absence, it remains possible that the more frequent referral of overseas qualified doctors was justified because the complaints about them were more serious or better supported by evidence.
When asked to define serious professional misconduct, the GMC turns to the words of Lord Justice Scrutton in 1930: it is “no more than serious misconduct judged according to the rules, written or unwritten, governing the profession.”3 The report concludes that these rules remain obscure, and as long as that is the case the GMC's proceedings can never be entirely open. This obscurity is especially evident in the screening stage. The two subsequent stages take place in committee and are therefore less vulnerable to subjective interpretation. In contrast, the three screeners currently act in isolation, with limited written guidance in the form of an internal GMC training note describing some behaviours that are considered not to constitute serious professional misconduct.
The GMC has welcomed the report's findings and is already acting on its recommendations. It is examining ways of improving its mechanisms for collecting, recording, and using data and is developing a programe for training staff in crosscultural awareness. It also plans to commission a prospective study to try to explain the rising proportion of overseas qualified doctors within the complaints procedure. A major challenge remains: how to balance the need for more accountability and visible uniformity in decision making with the need to leave room for interpretation and unforeseen circumstance.
The GMC is right to resist imposing a rigid, all embracing definition of serious professional misconduct: this could never be flexible enough to cope with all eventualities. An alternative approach might be the one developed by the GMC for assessing seriously deficient professional performance.4 This would still be based in case law, allowing interpretation within the light of current circumstances, but it would provide clearer articulation of the types of cases to be considered.
The GMC should be praised for proving its commitment to openness, both in commissioning and publishing this report. But it cannot afford to sit on its laurels. The report does not find it guilty of racial bias, but neither does it find it not guilty—it cannot because of the parlous state of the organisation's records. Public bodies have a clear responsibility to maintain records that will allow their processes to be independently monitored. Otherwise how can an organisation be held accountable to its members or to the public? As the authors of the report make clear, inadequate records and obscure decision making processes will leave the GMC open to accusations of bias until such accusations can be positively disproved.