Deprofessionalising doctors?

The independence of the British medical profession is under unprecedented attack

A patient seeing a doctor professionally in the United Kingdom has expectations of professional conduct that far exceed what is expected of citizens generally or employees of most institutions. This sense of professionalism is important to patients as it motivates doctors. The underpinnings of that professionalism, established over 150 years, have in the last 150 days all been questioned.

The medical profession in the United Kingdom first emerged through the medical royal colleges in 1505. The 1858 Medical Act united the medical profession and, almost 150 years ago, created the General Medical Council—a structure through which the profession could develop an ethical code,1 systematise education, and punish erring members. The council derives its authority from parliament; its membership includes 25% of lay members, soon to increase to 40%; it elects its own president; and it has been a model for other professions, such as the General Teaching Council.

Postgraduate education developed later, and the profession entered into a partnership with the State to regulate it. The Joint Committee on Postgraduate Training for General Practice (JCPTGP) and the Specialist Training Authority (STA) between them control postgraduate training for doctors. Both bodies have medical majorities, strong royal college influence, and elected medical chairmen.

The government is now proposing radical changes to these arrangements which carry with them the threat of deprofessionalising doctors. 2 3 Three changes have been proposed simultaneously.

Firstly, the NHS Reform and Health Professions Bill 2001 proposes a new (overarching) council with a lay majority and a lay chairman with power to direct the GMC and the other nine regulatory bodies for the other health professions. Section 24c refers to changes of “any of their functions”; there is ambiguity about ethical functions. Section 25 both creates a new duty of the GMC “to co-operate” with the new council and also states that it “must comply.”

Secondly, in its response to the Kennedy inquiry4 the government referred to the GMC reporting to parliament “through” the new council,5 thus relegating it to virtual subcommittee status.

Thirdly, in its consultation document Postgraduate Medical Education and Training: the Medical Education Standards Board (MESB)6 the Department of Health proposes fusing the Joint Committee on Postgraduate Training for General Practice and the Specialist Training Authority and creating a new board to take over their functions. In effect this proposes a state takeover of postgraduate medical education and training. “The Royal Colleges and Faculties will need to satisfy the Board … and meet standards set by the Board[my italics].” An appointed lay majority and a lay chairman are envisaged in the consultation document, with no guaranteed places for the colleges. Accountability to ministers is proposed.

Together these changes would transform medicine from an independent to a controlled profession. All organisations need to change with the times, and the idea of fostering communication between regulators is logical. However, a reasoned case against some proposals in the NHS Reform Bill is needed. It has been important for the profession to respond to these proposals, and the medical institutions—the Academy of Medical Royal Colleges,7 the BMA, the Joint Consultants Committee, and the Council of Heads of Medical Schools—have united to mount a response.

The debate on the second reading of the NHS Reform Bill on 31 January8 revealed concern among Liberal Democrat, Conservative, crossbench, and Labour peers. Alarm outside the professions has therefore emerged. As few as 10 lay people, unelected, perhaps without experience of any health profession, perhaps without ever having served on a conduct committee, and with no constituency to which to report, seem inappropriate to decide the rules for nine different health professions. Discussions involving the select committee on delegated powers and regulatory reform have helped. The government is now accepting this committee's proposal that before any direction to a dissenting regulatory authority can be issued approval must be obtained by an affirmative vote of agreement in both houses of parliament.9 The irksome words “must co-operate” and “must comply,” which threatened professional independence, are thus diverted to parliament, which is sovereign in Britain's democracy and whose directions the GMC is happy to follow.

The profession's policy has been to emphasise the importance of the relationship with parliament. Finessing that word “through” needed confirmation of a continuing direct link with parliament, and a recent letter from the secretary of state for health to the Academy of Medical Royal Colleges has helpfully confirmed that the direct link between parliament and the GMC will continue. Ideally, the president of the GMC would present the annual report in public, before a committee of both houses of parliament. There are precedents for this: since 1919 there has been an ecclesiastical committee, with equal membership from both houses. We would like parliamentarians to explore the possibility of setting up such a joint committee to improve accountability for the GMC and the health regulators. The media would ensure true, open accountability.

The third issue, the Medical Education Standards Board, is outstanding as the consultation period has only just closed. Here, the Academy of Medical Royal Colleges has suggested four tests by which government intent can be judged are: accountability to parliament; a 60:40 medical majority; strong academy/college/faculty representation at all levels together, with members chosen by the professional bodies themselves; and an elected medical chairman.10

The independence of the medical profession in the United Kingdom is under unprecedented attack through these government proposals. The profession's response is designed to preserve for patients a profession that is able to give independent advice. It is encouraging that we have gained some concessions, but more are needed, such as a joint committee and amendment of key words in the bill. The price of freedom is still eternal vigilance.11