Self regulation must be made to work
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7504.1385 (Published 09 June 2005) Cite this as: BMJ 2005;330:1385
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The 1983 Medical Act came about because rank-and-file doctors insisted on participating in the regulation of their profession. The 1995 and 2002 Acts by contrast are attempts by an elite group to impose its will on the profession. To achieve this, they distort public opinion and forge alliances which exclude ordinary doctors.
Doctors are the envy of other professions. In poll after poll, the public say that they trust and are more satisfied with doctors, ahead of clergymen, judges, professors and the police. Even after the Bristol and Shipman stories broke, they still say doctors are doing an excellent job(1). The public have confidence in doctors but not in NHS institutions or those who manage them. How is it then that the medical profession is in the dock? The answer lies in the loss of self-confidence by the profession’s elites.
Doctors’ leaders have become incapacitated by their desire to atone for Bristol and Shipman. These scandals happened on their watch. To this end, they are prepared to sacrifice anything and everything. The president of the GMC says he does not believe in self-regulation. The Chief Medical Officer wants doctors, who repair damaged human bodies, to emulate airline pilots, who chauffeur. The president of the Royal College of Surgeons is content for nurses to play surgeons. The BMA agree contracts which turn NHS consultants into assembly line workers and trainees into shift fodders.
What to regulate? There is no necessity for the regulator to have a judicial function. Tort law and legislation are more than adequate. The courts are unlikely to be clogged up by the relatively few cases that would transfer from the GMC were its judicial functions to be abolished. When one pays for a service, one expects a certain standard of work. The legal positions of supplier and consumer are enshrined in the Supply of Goods and Services Act 1982 which also covers consultation with professionals. The Act offers better consumer protection than the NHS or GMC can muster. The law states that the supplier must provide service with reasonable care and skill. ‘Reasonable’ refers to work carried out to the standard of the average tradesman. It is similar to the Bolam test(2).
The public require assistance only in identifying the tradesman, the one qualified to do the job. The public need to know who has the right to provide medical services and who has the right to use professional titles indicating expertise. This is the primary reason for having a regulator – to provide a register of those with the knowledge and skills which go with the title of doctor or specialist. The regulator as registrar should set standards. This the GMC currently does for undergraduate medical education but not for specialists. It should now do so explicitly. The Royal Colleges should be contracted by the NHS to carry out the training. The new PMETB which merely perpetuates the old discredited system should be disbanded. Postgraduate medical education and training in the UK is a shambolic mess. The top priority for the regulator should be to sort this out.
Dame Janet(3) recommends a database of doctors with warts and all. The notion that this would be of value to patients is purely a romantic one. There is no concrete evidence to support it. Ex-president Clinton presumably had such information yet chose to have his operation at a unit which was not at the top of the league. There would be no smokers if information or pariah status was the key. The regulator is too remote from the shop floor to police it. Diagnosing, prescribing and operating rights have been extended to professionals whose education and training in the science and art of medicine are well below that of doctors. If they are fit to practice medicine, then by definition their standard is the minimum that is required for the job. Since a doctor is never likely to fall below this standard, revalidation for doctors makes no sense.
How to regulate? The public favour self-regulation. They expect doctors, being the ones with the professional expertise, not laymen to regulate doctors. Instinctively they know that self-regulation protects patients from political manipulation. There is no better illustration than what happened in Nazi Germany. The public are currently not offered what they want. The regulator is elitist and Dame Janet’s recommendation perpetuates this elitism. For political correctness, the regulator currently keeps at arms length the doctors that it is supposed to be regulating. There also is the plethora of regulators which has created confusion and disillusionment.
The medical profession is a broad church with varying practices. The law recognises this in the Bolam test. Medical practice is dynamic and continuously changing. Hence, the law scrupulously avoids elevating one shade of medical opinion over another(4). The ideal regulator is constituted in such a manner as to reflect this diversity. The Royal Dutch Medical Association (KNMG) is an example of such a regulator. Through the KNMG, education, accreditation and registration are organised and performed entirely by the profession itself.
Conclusion? Dame Janet and other self-appointed people’s champions are united in their disdain for ordinary doctors and in their deference to the elites of medicine. Consequently, they recommend that doctors be shackled with rules and regulations and also be under the thumbs of professors, knights and lords. The Bristol and Shipman enquiries which should have been about the shortcomings of individuals have been used to indict a whole profession unlike that which followed the miscarriage of justice scandals. Representatives of other professions, pursuing their own agenda, now seek to dictate the internal affairs of the medical profession. The time has come for us to defend our profession. We own the profession, not they.
References 1. www.mori.com/polls/2001/bma2001.shtml 2. Bolam v Friern Hospital Management Committee (1957) 2 All ELR 118 3. www.the-shipman-inquiry.org.uk/fifthreport.asp 4. Bolitho v. City & Hackney Health Authority [1997] 4 All ER 771
Competing interests: None declared
Competing interests: No competing interests
Time for a radical rethink
The need to persist with pursuing the goal of self regulation is well made. Parallels drawn with other countries and lessons we may learn is also opportune. If we fail to convince the politicians that we are capable of self regulation it can only be our fault. Why should we fail when others have succeeded. We were given the opportunity but through our indecision and by chopping and changing our plans we have not instilled confidence in any one, neither the public nor the politicians. The profession was totally unimpressed.
If however we are to be successful then we have to set about it the right way even if it means a radical rethink . A fresh start with an enlightened approach to revalidation based on the ‘purpose of revalidation’ as proposed by Sir Liam Donaldson is the answer. Having encouraged us to follow this sensible route it would be a pity for Sir Liam to set aside the conclusions.
I have in the past made proposals based on this approach in previous rapid responses and in a letter to the editor, in press, in the BMJ. The expectation of the public is the provision of safe and effective healthcare. Revalidation should therefore be based on this. Clinical governance approach which seemed to be the route initially favoured by the NHS before it was abandoned by the GMC in favour of Fitness to Practice (FTP) should be resurrected. I have also proposed the use of the expertise of the Advisory Committee on Clinical Excellence Awards and perhaps in the case of hospital consultants to incorporate revalidation into the discretionary points (DP) and the Clinical excellence Awards (CEA) scheme. Recipients of DP or CEA would be unlikely to be found wanting for revalidation and this may be taken into account. Involvement of the ACCEA does not detract from self regulation.
May I conclude my proposals with what might be considered outrageous in some quarters. Revalidation as it is proposed is unlikely to evoke any great enthusiasm in the majority of doctors. The statutory definition of revalidation as an ‘evaluation of a medical practitioner’s fitness to practise should be discarded. Revalidation should be designed to be a proud achievement. The term revalidation should be replaced with one denoting performance and achievement - a catch phrase to inspire. Can someone think of one please. It is even worth pausing to question the use of the term appraisal. Should not the terminology reflect the purpose of appraisal, namely to reflect on past performance to identify the successes and build on them, to note where improvements could be made and above all to set targets for the future. The title should reflect the concept of personal development and advancement. Appraise is to estimate or asses the value or quality of according to the Oxford dictionary. Is this anywhere near what an appraisal should be about? What’s in a name you may ask, but most of us can do with a few props.
As recognised by Dame Janet Smith it would require a very low performance level not to be revalidated. If it is to encourage doctors to aim for higher levels of achievement and to win the confidence of the public, it is perhaps worth recognising performance grades. There are bound to be those who will fail and a group that will achieve revalidation effortlessly. There will however be a group that would be borderline. It is important that these doctors are encouraged to perform better. It may well be that they come up for review sooner. Much more could be achieved through this approach. Should the revalidation certificates with the revalidation grades be in the public domain or be accessible to patients?
I hope the review team will come up with a scheme that will inspire doctors, win the confidence of the public and dare I say delight the politicians. We want a scheme that we can proclaim from the roof tops, not imposed on but embraced by the profession. Sir Liam the ball is in your court.
Competing interests: passionate interest in the subject!
Competing interests: No competing interests