Analysis And Comment Professional regulation

Does certification improve medical standards?

BMJ 2006; 333 doi: (Published 24 August 2006) Cite this as: BMJ 2006;333:439
  1. Kim Sutherland (, senior research associate1,
  2. Sheila Leatherman, research professor2
  1. 1 Judge Business School, University of Cambridge, Cambridge CB2 1AG,
  2. 2 School of Public Health, University of North Carolina, Chapel Hill, 27599 NC, USA
  1. Correspondence to: K Sutherland
  • Accepted 2 August 2006

The English chief medical officer recently recommended certification of doctors to improve professional regulation. Could a system similar to that used in the United States, which is associated with better care, be the way forward?

Worldwide, the regulation of medical professionals is central to attempts at quality improvement in health care. The arguments for strengthening professional regulation come from evidence of systemic underperformance and isolated cases of egregious behaviour in individuals. We review data on the effect of certification in the United States on quality of care, and we consider the implications for the current debate on revalidation in the United Kingdom.

Problems in the UK

In the UK routine data continue to highlight uneven quality of care compared with other countries.13 Good doctors, safer patients lists recent cases of exceptionally poor clinical practice or criminal conduct: Harold Shipman, Clifford Ayling, Richard Neale, William Kerr, Michael Haslam, Rodney Ledward, and the department of paediatric cardiac surgery at the Bristol Royal Infirmary.4 Although rare, such cases still occur and point to failures in underlying systems for detecting and preventing unsatisfactory performance at an early stage.

Furthermore, over time the skills and knowledge of medical professionals can erode, with potentially serious consequences for quality of care. In a systematic review of the relation between experience and quality of care, over half of the studies (32 of 62; 52%) reported an association between decreasing performance and increasing years in practice for all outcomes assessed. These results suggest that older doctors and those who have been practising for many years have less factual knowledge, are less likely to adhere to appropriate standards of care, and may also have poorer patient outcomes.5

Role of professional regulation

Professional regulation has three main purposes. The first is to ensure that minimally acceptable standards of care are being provided. The second …

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