The changing role of the GMCBMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d6363 (Published 14 October 2011) Cite this as: BMJ 2011;343:d6363
Helen Jaques speaks to Niall Dickson, chief executive of the General Medical Council, about the reforms under way at the council and the changing role of professional regulation
The General Medical Council describes its purpose as “to protect, promote, and maintain the health and safety of the public by ensuring proper standards in the practice of medicine.” Its main functions, as set out in the Medical Act 1983, are to keep a register of qualified doctors and erase from the register those whose fitness to practise isn’t up to scratch. However, the role of the organisation has shifted in the past 10 to 15 years to include promoting standards as well as maintaining them, in medical education and training and in professional conduct. The GMC’s chief executive, Niall Dickson, who joined the organisation in January 2010, now leads the organisation in carrying out these functions. Here he outlines how the GMC is changing and the challenges facing medical regulation in the United Kingdom.
Education and training
In 2010 the GMC took over the Postgraduate Medical Education and Training Board (PMETB) and with it the board’s responsibilities for assuring the quality of all levels of medical education and training in the UK. The GMC is now required to set standards in medical education and training—not only at undergraduate and postgraduate level but also in the continuing professional development of fully qualified doctors—and to ensure that the standards are met, via reports from medical schools, deaneries, and royal colleges. It is also required to carry out annual surveys of trainers and trainees and regular inspections.
“I think the merger with PMETB has had a profound impact on our work,” says Mr Dickson. “We’ve had a realisation check about the enormity of the responsibility that we now have. And I think it changes our relationship with the service quite profoundly, because one of our key responsibilities has to be protecting trainees from the pressures of service, and that’s not really been a role that the GMC traditionally has had.”
The effect that the pressures of service delivery could have on training is something that worries Mr Dickson greatly. “Trainees can’t be simply used to provide services and to fill gaps within the system,” he says. “Their education is really important. Otherwise we will pay a very heavy price further down the line if they’re not properly trained and supported.”
The European Working Time Directive, which limits trainees to 48 hours of working time a week, is one example where service pressures are already eroding time available for training, something the GMC is watching closely. Research published by the council this summer showed that the working time regulations have had a negative effect on training across Europe,1 and earlier research conducted by the council with UK deaneries found that some specialties—in particular surgery, obstetrics and gynaecology, emergency medicine, anaesthetics, and paediatrics—were struggling to balance training with the demands of delivering care to patients.2
The financial pressures that the NHS is currently facing, not least the “Nicholson challenge” to save £20bn by 2015, could also mean that service delivery trumps training, says Mr Dickson. “Certainly if you look back historically, when the health service is squeezed for money often people have traditionally gone for short term goals. Sometimes education and training have been affected by that,” he says.
Another factor that could result in training time being sacrificed at the altar of service delivery is the proposals outlined in the government white paper Liberating the NHS: Developing the Healthcare Workforce,3 says Mr Dickson. The white paper suggests that education should be delivered by local networks of employers, now rebranded as local education and training boards, and overseen by a new national body called Health Education England. “We have expressed some concern at the government’s initial proposals to create something that’s more employer led at local level,” he says. “I think, however, there was an acknowledgment of our concern about making sure that the educational role at local level was not somehow compromised by a quite understandable desire that employers need to be absolutely involved in this process as well.” One way of mitigating the risk of employers putting service delivery over education and training would be to introduce a local education champion, ideally someone in a deanery, he suggests.
Health Education England will hold the purse strings for training budgets and oversee national workforce issues. It’s also charged with setting the standards and assuring the quality outcomes of education and training, rather similar, it seems, to the role of the GMC. “I very much hope we won’t step on each other’s toes,” says Mr Dickson. “I very much hope Health Education England will use our standards in their commissioning process. So I think [the two organisations] can be complementary.” Health Education England’s role will be largely in commissioning education across different professions and seeing that standards are maintained throughout that commissioning process, he says. “But we have a separate set of responsibilities around the standards in medical education in particular and seeing that those are actually applied in practice on the ground.”
Niall Dickson on . . . continuing professional development
“I think it’s fair to say that traditionally the GMC has not been very active in the area of CPD, and I think revalidation will make us more interested in this area. It will be a requirement under revalidation as part of strengthened appraisal that doctors provide evidence that they are up to date, and part of that is engaging in CPD.
“Our new draft guidance makes it clear that we will not prescribe how each and every doctor should be doing this. We do not want to encourage a tick box approach or a GMC inspired point system. I think it’s about setting high level principles about what we expect doctors to do, and then how they actually do that in practice will be something they will discuss with their own organisation and through the appraisal process. And providing the principles are met we’ll be happy.”
Read more on the GMC’s new draft guidance on CPD at http://careers.bmj.com/careers/advice/view-article.html?id=20004802
One of the GMC’s big projects over the past 15 years has been revalidation, the five yearly process by which licensed doctors are required to demonstrate to the regulator that they are up to date and fit to practise.
One of the key benefits of revalidation, says Mr Dickson, is that the yearly appraisal process inherent in the system will identify and support struggling doctors earlier, before things get to the point where they might need to be referred to a fitness to practise panel. “Secondly, and equally importantly, I hope that it will encourage and support self reflection and reflection within teams, on ‘how well are we doing,’ ‘what are the data around our practice,’ and so on,” he adds. Another benefit is that revalidation will essentially force employers to introduce formal clinical governance and appraisal systems.
“Over the past 10 years, although clinical governance has become embedded in the health service, it has not become embedded in a uniform way; the quality of clinical governance varies between institutions,” he says. “One of the things I hope revalidation will do—and I think there’s some evidence that it’s already doing—is act as a catalyst to encourage organisations to put in place proper clinical governance. And proper clinical governance means that the doctors within that institution are able to access supporting information, they are able to reflect on what other colleagues and what their patients think about their practice, they have access to data about their own performance, they’re able to reflect on that performance, and so forth.”
There are concerns that compiling this supporting information—evidence that doctors are required to provide to prove they’re staying up to date—could be unduly onerous for doctors. The first round of revalidation pilots found that doctors undergoing the yearly strengthened appraisal that underlies revalidation were spending an additional 4-10 hours collating information and preparing for their appraisal, and 61% agreed that they had to put too much time into the process.4 “I think inevitably there will be people in the profession who think this is an extra burden; I’ve got an awful lot on at the moment, why am I having to do this extra thing?” says Mr Dickson. “I hope that the value of it will be seen over time, and it will only be seen over time if doctors themselves and the organisations in which they work embrace this in a positive way. Appraisal is something that is now pretty common in medicine, and we’re attempting to strengthen it but not to make it overly burdensome, and I think getting that balance is absolutely right.”
Some fears have been raised in the past as to how doctors who don’t work in standard NHS structures, such as locums and doctors in private practice, will be able to take part in revalidation. However, these issues are not “insuperable,” says Mr Dickson, and pilots are under way to investigate how to make sure that groups of doctors who are hard to reach have everything they need to conduct revalidation.5 “For some of these groups of doctors the challenge is greater, but actually the prize is probably greater as well,” he adds. “We need to have a system that’s flexible enough so that all doctors can do this regardless of where and how they practise. So we will have that in place.” Every doctor, irrespective of how they practise, should be able to find a responsible officer, he says. Locum agencies, for example, will become designated organisations with a responsible officer, as will private practice groups such as the Independent Doctors Federation. “So I think there are ways round some of these more exotic—if I could use that word—sort of careers,” he says. “We just have to make sure in a commonsense way we have systems that support them and enable them to demonstrate that they are competent and fit to practise.”
Originally pencilled in for 2010, the roll out of revalidation has now been pushed back to the end of 2012, after the health secretary, Andrew Lansley, said that the GMC needed more time “to develop a clearer understanding of the costs, benefits, and practicalities of implementation.”6 Nevertheless, Mr Dickson is confident that the system will be ready to go in 2012, although it won’t be a “big bang” introduction.
“We’re still heading towards what we hope will be the beginning of the roll out, which is late 2012, towards the end of next year. That is subject to the secretary of state in the UK government switching on the legislation, and we are confident that we will have in place within the GMC the necessary administrative arrangements to enable that to happen,” he says. “But we recognise that there’s still some way to go in that, and even by late 2012 I don’t think we’re expecting perfection throughout the whole system.”
Niall Dickson on . . . responsible officers for revalidation
“I certainly would not want one responsible officer sitting in the National Commissioning Board who’s responsible for all general practitioners. That would be utterly ludicrous, and I don’t think for a minute that [the government] will suggest that. Nevertheless, if they sit within the ambit of the board but are down at regional level and then are overseeing a process below that, fine.
“For us it’s important that the responsible officer is not at too low a level within the organisation, as it were, so that they are not compromised in terms of the responsibilities that they have. But they also need, of course, to understand the systems that they’re overseeing, so they can’t be so remote as not to understand what it is that they’re responsible for. We’re still waiting for proposals, and the areas that we’ve been concerned about are, first of all, primary care, and, secondly, doctors in training. The deans at the moment are the figures who are responsible officers for trainees. We want whoever replaces the deans—and it may be deans in another form or with a different name—to have that responsibility, that very important responsibility, for trainees.”
Read more about the role of responsible officers at http://careers.bmj.com/careers/advice/view-article.html?id=20002862.
Fitness to practise
Perhaps the GMC’s highest profile role, and also the role possibly of most relevance to the careers of practising doctors, is its regulation of doctors’ fitness to practise. The organisation can step in and put limits on doctors’ practice, or even strike them off the medical register, if they fall short of its high standards on clinical competence, ethics, and professionalism. Last year the GMC received 7153 complaints about fitness to practise, 63% of which were from members of the public.7 Only 3540 complaints, around half, were investigated by the regulator, with the remainder thrown out, raising the concern that many of the issues that get through to the organisation are irrelevant, trivial, or potentially vexatious.
“I hope we have the right triage to stop [trivial or vexatious allegations reaching fitness to practise hearings],” says Mr Dickson. “I do recognise, however, that where allegations are a bit more serious and we do start to investigate them, that causes enormous anxiety for individual doctors. And it’s something obviously we have to do, and the fact is that we’re getting more of these and so there will be more examples of it.” He suggests that the GMC does everything possible to minimise the trauma and stress that a doctor can experience as a result of a fitness to practise complaint: “We try to investigate as quickly as we can so that if there is nothing to [the allegation], then they don’t have that cloud hanging over them. But we need to make sure that the way we communicate to doctors is clear and sympathetic,” he adds, “and that they understand the difficulty they will face as they go through this process and are clear that what we’re trying to do is not punish them but protect patients.”
One way the GMC is trying to speed up the process is by proposing that doctors can opt not to have a public hearing if they accept the allegations levelled against them and the sanctions that the regulator puts forward. “Going through a public hearing is traumatic for witnesses, and it’s certainly traumatic for the doctor and his or her family,” says Mr Dickson. “This new approach is predicated on a very clear principle, which is that the GMC is not here to punish doctors: if we can find a way in which we can reach agreement with the doctor about what action should be taken to protect the public, then why would we need to go and subject everybody involved to that public hearing?” This new approach will require a “culture change” within the GMC, he concedes. “It will also require a cultural change among medical defence organisations so that it’s a slightly less adversarial process and so that we’re trying to reach a common understanding about what is in the best interest of patients,” he adds.
There have been some concerns that this new approach might mean some doctors accepting sanctions that they might not necessarily agree with to avoid the trauma of a public hearing, something that Mr Dickson accepts is possible. “We will hear at an earlier stage the doctor’s mitigation and the reason why this happened and so forth and see the extent to which the doctor is demonstrating insight into it and how we can take things forward from there,” he explains. “But then it will be up to the doctor to decide—and I’m sure some will say, ‘Well, I don’t want a hearing and, you know, I’m a bit reluctant to accept this, but I accept it and I’m willing to accept it because that seems a better option for me.’ But they would still absolutely have the right to go to a panel for it to be determined there if they wanted to.”
Niall Dickson on . . . reforming the fitness to practise process
“At present as an organisation we are, in effect, the policeman, the prosecutor, and the judge and jury. So what we’ve decided to do is create an organisation within the GMC family but where the autonomy of the fitness to practise panels is more visible than it is now. Under the new arrangements, we’re setting up a medical practitioner tribunal service, which will be an autonomous service within the GMC. This will create within the GMC a very clear ‘Chinese wall’ that does not allow our fitness to practise work on the prosecution and investigation sides to see into the panel side at all. It’s increasing the separation and thereby, I hope, reinforcing the fact that the decisions these panels make are their own. And we are also seeking the right to appeal, as the GMC, against those decisions where we think they’re too lenient. Obviously if they’re too harsh, the doctor themselves may decide to appeal.”
Hear more on the fitness to practise reforms at http://podcasts.bmj.com/bmj/2011/09/23/caring-for-the-carers/.
Niall Dickson on . . . regulating clinical commissioning
“I don’t think there are any new principles which need to be applied that haven’t already applied in our existing guidance. So what people are being required to do—GPs will be required to do—will I think raise conflicts of interest. And I think that the principles that we’ve set down should be the basic guidance which doctors have to apply. So those are, for example, that you have to recognise conflicts of interest, you have to be transparent about them, and you mustn’t let those conflicts of interest influence your decision. If necessary you must withdraw yourself from that position if you think it’s being affected.
“If it were found that doctors were making decisions about the way care was commissioned and harming the interests of patients in order to line their own pockets, then that I’m afraid is contrary to good medical practice. If they had a conflict of interest which they had failed to declare or make clear either to patients or in the decision making process, that is contrary to good medical practice. The guidance I think is fairly clear: if in doubt, declare it.”
Read more on the GMC’s role in regulating doctors’ conduct with respect to clinical commissioning at http://careers.bmj.com/careers/advice/view-article.html?id=20004744.
Future of healthcare regulation
The GMC has come a long way since it was founded as the General Council of Medical Education and Registration of the United Kingdom by the Medical Act 1858. Where does Mr Dickson see the organisation going in the future?
“I think that professional regulation is on a journey. I think that journey started probably in the mid-1990s when Good Medical Practice came out and the GMC started being interested in positively what doctors should do rather than simply being interested in setting out what they should not,” he says. What is being expected of the GMC is increasing, and the organisation is being required to become more proactive in ensuring standards among doctors. “Not intervening in doctors’ lives,” he says, “but making sure we’re closer to the healthcare system—and we have to be because of our educational responsibilities as well as our practice responsibilities—and that we’re interested in doctors throughout the whole of their career in a positive sense, not intermittently intervening when something goes wrong, because we want to support improvements in practice.”
BMJ Careers podcasts
Hear Niall Dickson speak on exams, continuing professional development, responsible officers, and the fitness to practise reforms in a BMJ Careers podcast at podcasts.bmj.com. You can hear him discuss fitness to practise issues in more detail at http://podcasts.bmj.com/bmj/2011/09/23/caring-for-the-carers/.
Competing interests: None declared.