GMC’s supposedly independent training review included secret meetings with politicians

I read Mr Dean's recent article regarding the GMC and the Shape of Training review with admiration [1] and respect for the sheer determination and doggedness that he has shown whilst exposing how 'independent' these types of independent reviews are into our medical training. Here is a junior doctor that clearly cares enough about his training to not only investigate, but take to task (and then win) the regulatory body we all are beholden too - the GMC. Furthermore he did this in an entirely reasonable and appropriate manner. At the same time, he was also effectively taking on the 'medical establishment' and many other interested parties (which includes politicians). He did this independently without the support or backing of a committee or any other infrastructure - all the time putting his 'neck on the line'. This is highly commendable, but also shows courage and bravery. This is exactly the sort of person I want to represent me as a junior doctor. Someone that is happy to stand up and be counted and actually engage with other junior doctors and therefore represent their opinions. He does not have to 'tow the party line' or tame his thoughts and concerns ('we can't say that' approach as that is not in accordance with what X or Y college says) according to what organisation he may represent.

Therefore, on reading the response to this by Dr Rosemary Hollick, on behalf of the RCPE Trainees & Members’ Committee, I was disappointed to read that in the opinion of that particular committee, Mr Dean had 'under represented' the concerns of trainees! By virtue of the fact Mr Dean had set on this course in the first place, the high level of his own concern is evident for all to see. He is clearly deeply concerned with the Shape of Training 'plan' and I am sure that is echoed amongst most UK trainees. In fact, I wonder how many trainees would align their sense of huge concern more closely with Mr Dean, rather than the joint statement produced by the various trainee committees Dr Hollick references whose stated aim is to represent their trainees.

With this in mind I think it is only appropriate for Dr Hollick to read her own words stating that, "it is essential that trainees have a voice in the future shape of their training" - this is true, but this should apply to ALL trainees and not just those voices within particular committees.

I am therefore like many trainees in the UK and would only wish to congratulate Mr Dean and thank him for his efforts rather than criticise him.

Dr Philip J Smith

[1] Dean BJF (2015) GMC’s supposedly independent training review included secret meetings with politicians BMJ;350:h2400

Benjamin Dean is to be congratulated on an extra-ordinarily thorough and doggedly researched piece (The GMC’s training review lacked transpracency; BMJ 2015; 350:h2400). Through FoI requests he has been able to establish the true degree of independence and transparency of the GMC’s Greenaway report. This in itself should send shock waves through the medical establishment. That it hasn’t may attest to the nature of the relationship between the GMC, Department of Health, medical education quangos and other organisations. Some critically important questions arise that are pertinent to the GMC’s role as our regulator, as they may exemplify a maladaptive pattern of behaviour that is now deeply institutionally ingrained.

The Greenaway report is not the only document where the words independent and transparent might be used with some caution. The GMC Report on deaths of doctors whilst under investigation published in December 2014 was in fact an internal review (Horsfall S. Doctors who commit suicide while under GMC fitness to practise investigation: Internal Review General Medical Council December 2014). Though commissioned by it, the GMC has also said that the report was ‘independent’.

By a similar token, the GMC press released a study on fairness under investigation under the headline on 13th March 2015: “New research finds that GMC decisions are fair to doctors under investigation” (http://www.gmc-uk.org/news/26346.asp). The research was billed as ‘independent’ yet was once again commissioned and paid for by the GMC; how a review commissioned and paid for by the GMC can be independent is not clear. Not only that, the report only looked at how GMC processes were followed and interviewed no doctors nor sought the views of those under investigation (the subject of the headline). So the researchers sought the views of GMC FTP staff and found that the processes were ‘fair’. The result is therefore perhaps not surprising. But how can the report, having not considered the views of doctors, be construed as concluding, as the headline suggests, that GMC decisions are fair to doctors?

Another example of what might be termed ‘spin’ was the GMC Press Release headline (25th February 2015) “A major consultation by the General Medical Council (GMC) has found strong support for proposals to deal with the small number of doctors who put patients at significant risk or cause them harm” http://www.gmc-uk.org/news/26294.asp. The press release doesn’t mention that serious concerns were raised about the process of the consultation by several including a distinguished psychologist (http://www.bmj.com/content/349/bmj.g5744/rr/771934) nor that these concerns have never been acknowledged nor addressed by the GMC. For one thing, the consultation required doctors to identify themselves; hardly likely to encourage critical responses from a profession already suspicious of their regulator. Accordingly, approximately 1 per thousand registered medical practitioners responded to the consultation. This response rate surely raises a question in itself for it surely represents the failure of an organisation to connect with its registrants. Has the GMC considered if the consultation is in fact valid? The BMA’s response to the GMC was largely negative in respect of most questions posed, so how the GMC can claim ‘strong support’ is still a mystery. At the very least the headline reflects a lack of critical balance.

The duty of honesty and candour requires doctors to tell the whole truth and not leave out important salient facts-in short, not to mislead. In its dealings with the press and public, one would expect the regulator to hold itself to its own guidance-or even, arguably, to a stricter standard of conduct. The GMC has produced several documents on candour, openness and honesty. In Section 72 of Good Medical Practice (2013) contained within the section “Act with honesty and integrity”, guidance states: You must make sure that any evidence you give or documents you write or sign are not false or misleading: (a). You must take reasonable steps to check the information. (b). You must not deliberately leave out relevant information.

So let us suppose for one moment that the boot were on the other foot; the GMC were investigating an important report written by doctors who had colluded with, let us, say, the Pharma industry (who in turn had a vested interest in the findings of the report) and had failed to declare this fact. This would be viewed as scandalous and the authors would very likely be held to be in breach of their professional responsibility. Maybe the GMC sees itself immune from its own guidance in respect of the concepts of candour and openness. But if it doesn’t demonstrably set an example, how can it expect its registrants to take its guidance seriously?

This response was edited by Sharon Davies and reposted on 23 June 2015

So the “independent” Shape of Training report[1] is tainted by political shenanigans, unreported meetings with interested parties and unsuccessful resort to the lawyers[2], about which the Chief Executive and Registrar’s explanations seem quite unpersuasive[3]. It is also characterised by deliberately altered evidence and illogical interpretation of unpublished research to support one of its major theses.

A far-reaching recommendation of the report is that medical students should be fully registered at the time of qualification (p32). Towards this theme, evidence is adduced from site visits made by the Shape of Training team and from ‘research’ on possible differences between graduates of the various medical schools.

In its original evidence document on the site visits (published in July 2013 and reported in Pulse[4], but now taken down from its website), the Shape of Training team reported: “We heard from almost all employers that they were concerned that many doctors when leaving medical school are not fit to take up their foundation programme posts. They suggested medical graduates often lack professionalism and do not have essential skills necessary for their job. Many employers suggested they had to teach graduates basic skills as part of their postgraduate training.”

Not a ringing endorsement of current UK graduates being safe to practise as they leave medical school, such that one could bring forward full registration by a year, one might think. But no matter, as by the time the evidence was re-presented in an annex to the final report, "We heard from almost all employers ..." had been altered to: "We heard from some employers …” which has altogether different and far less concerning implications.

Moreover, that there are substantial and statistically highly significant differences between medical schools in terms of the subsequent examination performance of their graduates is extremely well known: largely concordant data have long emerged from the assessments of the Royal College of General Practitioners[5], the Membership of the Royal Colleges of Physicians (UK)[6] and the Royal College of Anaesthetists[7].

Yet the Shape of Training report ignores all this published research, simply quoting unpublished ‘correspondence from the Medical Schools Council’ to the effect that: "…. the results of the Situational Judgement Test show that 88% of those who took the assessment across all UK schools achieved between 35.0 and 45.0 points (scale 0-50). Results from the 2013 Prescribing Safety Assessment pilot, which was taken by students at 29 UK medical schools show that 98% of students passed." It then concludes, extraordinarily, that "This suggests that the level of attainment of students across UK medical schools is broadly similar."

Neither of these statements suggest any such thing, of course—though the second one does suggest that the standard of the PSA test was set at an extremely low level. But as stated, they are used by the report in support of the reasonableness of the ‘earlier registration’ theme. They perhaps also demonstrate the inappropriateness of seeking dispassionate comments about possible differences in their graduates' performance from the medical schools' lobbying body, the Medical Schools Council.

Two small pieces of negative evidence, perhaps. But, taken together with Mr Dean’s research into the lack of transparency, the shocking secrecy and the spendthrift use of doctors’ registration fees on lawyers in an attempt to frustrate his enquiries, they impugn the credibility of this report.

1. Greenaway D. Shape of Training: securing the future of excellent medical care. General Medical Council, 2013. http://www.shapeoftraining.co.uk/static/documents/content/Shape_of_train...
2. Dean BJF. GMC’s supposedly independent training review included secret meetings with politicians. BMJ 2015;350:h2400
3. Dickson N. Re: GMC’s supposedly independent training review included secret meetings with politicians. http://www.bmj.com/content/350/bmj.h2400/rr-0
4. Mooney H. Medical graduates 'not fit to take up foundation programme posts', say employers. Pulse Today 11th July 2013. http://www.pulsetoday.co.uk/your-practice/practice-topics/education/medi...
5. Wakeford R. MRCGP Statistics 2012-2013. http://www.rcgp.org.uk/training-exams/mrcgp-exams-overview/mrcgp-annual-...
6. McManus IC, et al. "Graduates of different UK medical schools show substantial differences in performance on MRCP (UK) Part 1, Part 2 and PACES examinations." BMC medicine 6.1 (2008): 5.
7. Bowhay AR, Watmough SD. "An evaluation of the performance in the UK Royal College of Anaesthetists primary examination by UK medical school and gender." BMC medical education 9.1 (2009): 38.

I would like to congratulate Mr Dean for the tenacity, bravery and strength of conviction he has shown in bringing this remarkable set of occurrences to light. He has done postgraduate medical trainees in the UK a great service.

I could not agree more with his conclusion that any report on the future of a large group of public sector workers should be transparent (not least one which claims to be independent), or in other words, honest about the motives for making its recommendations.

I find it particularly hard to believe, as the GMC respondent claims, that describing the meetings between Greenaway and various politicians as 'secret' is inaccurate, chiefly (and ironically) because the GMC appears to have worked so hard to conceal their existence.

If there truly was nothing to hide, as should have been the case, then the publication of such minutes should have been a five-minute job resulting in no publicity adverse or otherwise. The reverse being true strongly suggests otherwise.

Moreover, defending the lack of minute taking in such meetings as 'common practice' only serves to highlight the chronically over-generous concessions being made to politicians in the shaping of our public services, often in exchange for nothing more than short shrift come budget day and a privatisation agenda that we have never endorsed. Our pandering has done us no favours.

Perhaps it would serve the GMC, and indeed every medical organisation, to constantly bear in mind who they serve - primarily patients, and secondarily professionals. Keeping us all in dark, and then actively fighting against us being informed, helps no one.