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The Chief Medical Officer, Sir Liam Donaldson, has recently published his recommendations1 on how the government should respond to the serious criticisms of medical regulation and the General Medical Council made by Dame Janet Smith in her final report of the Shipman Inquiry.2 In a thoughtful and well-written report, he places the regulation of doctors within the wider set of systems for improving and quality assuring modern practice. Doctoring is at the heart of the healthcare system. Sir Liam's focus throughout is, therefore, on how to make sure that in future everyone in the UK who needs a doctor gets a good doctor.3 It means that patients should feel they can trust any doctor without even having to think about it,2 and that doctors themselves would entrust members of their family to any colleague without a moment's hesitation.
So how could this be achieved? The foundation is to be an agreed definition of what a good doctor is and clear, practical standards of professional practice for achieving that. These standards would be thoroughly embedded into medical registration and licensure, certification for specialist and general practice, medical education and doctors' contracts of employment. Thus, a common standard of entry to the profession would be assured through a new, standardized national examination for all doctors (irrespective of their place of primary qualification) applying for registration with the GMC for the first time. For established doctors continuing competence to practise will be assured through revalidation embracing relicensure and recertification. The management of concerns about a doctor's practice would be made fairer and more effective by placing greater emphasis on:
At all stages implementation should be systematic, using robust, evidence-based methods of clinical governance, assessment and appraisal, and with full public participation. Inevitably, in the consultation that now follows, there are important matters needing further clarification and discussion. I offer five here.
The first is about the definition of a good doctor and the standards of professional practice that should underpin it. Sir Liam makes the point that there is no universally agreed definition of a good doctor. However, there is abundant evidence that the public do know what they want—essentially doctors who are technically competent, are capable of forming and maintaining good relationships with patients and colleagues, and are honest.4 That is why there is strong public (and international) support for the GMC's Good Medical Practice.5,6 This, together with the versions adapted by the Royal Colleges for each specialty and general practice, contains everything patients think is necessary to ensure patient-centred care. It embodies the essence of doctors' professionalism.7 It is some doctors who dispute the advice mainly to try and water it down. So the issue is really about getting greater buy-in from all doctors, whilst at the same time working with the Royal Colleges and medical educators on the generic and specialty-specific criteria and thresholds needed to make Good Medical Practice fully operational.
The responsibility for standards must surely rest with the GMC because it keeps the register, gives the licences to practice, and holds the specialist and general practice registers which indicate to the public who has been certificated and, in future, revalidated. A licensing body is nothing if it is not the ultimate setter and guardian of the standards—that is its foremost function.8 Of course, the council has to work with others to get the best result. To this end the GMC Standards Committee has the infrastructure, the know-how, experience and track record of doing this well. The plain fact is that the public will hold the GMC accountable anyway, whatever the government or anybody else says. Public confusion and irritation are likely outcomes if that accountability is obscured through a diffusion of responsibility.
Sir Liam's proposals for revalidation are excellent. They reflect the foundation principles and attributes set out in the original GMC consultation document in 2000,9 but they also take us forward to new ground. The Royal Colleges and specialist societies are to take lead responsibility for delivering the key recertification element of revalidation for their members. Here is a real opportunity for each of them to press ahead, encouraged by the kind of inspirational example of leadership given by the American physician Dr Troy Brennan.10 Sir Liam has clearly been influenced by the regulatory philosophy and methods used in other high tech industries such as civil aviation where regular, thorough assessment is combined with strong professional development and a supportive working environment to ensure safety through both competence and high morale. At first sight the numbers in medicine are daunting—177 000 doctors compared with 17 000 airline pilots. But they should become eminently manageable if one breaks the profession down into its individual specialty constituents. For instance, there are only 350 cardiac surgeons. With their national performance data set already established they are almost there. In general practice, the largest single branch with about 42 000 doctors in the UK, the numbers present a more formidable challenge.
The GMC, in its most recent proposals for revalidation, has favoured a light touch, risk-based approach in which the practice of some doctors would be looked at more thoroughly than others.11 Sir Liam questions the appropriateness of this for doctors, pointing out that there is no easy way of defining all high-risk groups in medicine. ‘The bottom line,’ he reasons, ‘is that lighter-touch regulation would mean that some ongoing risks to patients would have to be tolerated by society’. The strategy is not compatible with the concept of a guarantee to the public of a good doctor for all. It is therefore essential that the risk-based concept be clearly explained to the public during the consultation using numbers that quantify and illustrate the risk in very straightforward terms. The government will need to demonstrate that it has the public's fully informed consent if it decides to support this line. It is patients, not doctors, who may be killed or injured by poor doctoring.
Doctors are understandably anxious about the proposal to adopt the civil rather than the criminal standard of proof in fitness to practise cases. They may be helped by further explanation from the GMC or legal authorities. The civil standard was used in the past in health and performance cases. But a key point, not generally appreciated, is that the most contentious decisions are often around panel judgements involved in determining impaired fitness to practise and any actions to be taken on registration. Standard of proof is not central to these determinations. Doctors, and the public, are more likely to have confidence in future when the basis for these decisions is clearly related to the professional standards, and the reasoning behind them in individual cases is made absolutely plain and transparent.
The proposal to consolidate responsibility for medical education on the Postgraduate Medical Education and Training Board (PMETB) will be contentious because the undergraduate curriculum is a GMC success story and the PMETB is too new to have a track record on which to predict its future performance. There are clear advantages to be gained by bringing the two strands of education together. There is the added value of making the continuum of education a reality. Even more important is the concentration of educational and assessment expertise now badly needed if Britain is to stay at the leading edge in medical education. Then there is the complex set of issues around the hidden curriculum.12 This refers to the attitudes of medical teachers and the culture of the institutions to which they belong: all of which can have a huge influence on the kind of doctors the system produces. For all these reasons, medical education has got to be tied closely to the profession's standards. Logic would suggest incorporation in the GMC. But the requirement for a new order of specialization may be better achieved through the formation of a completely new body designed specifically to meet tomorrow's educational challenge. The arguments are finely balanced. More discussion is needed.
Finally, what of the GMC itself? Sir Liam, like Dame Janet, wants the council to concentrate on doing a smaller number of things well, for its medical members to be appointed in future and for the council to act like a board of directors. I agree. The key function of a modern professional regulator is to set the standards required for practice and, through its control of the registers, to be assiduous in making sure that all who hold registration with it abide by those standards. It needs to lead a team of partners, not try to do it all itself.
The council can only do this successfully if it has members who believe passionately in the mission and who are, if they are doctors, all known and respected by other doctors as role models of the good doctoring they wish to promulgate. The role model principle should apply, incidentally, to all doctors who work for the GMC for they are in a way its ambassadors to the profession and the public. All council members, lay as well as medical, need to be tall poppies in the field capable of giving strong leadership, not least because they will have a profound impact on the organizational culture on which the success of the GMC in future will ultimately depend. Selection by an open process is more likely to achieve this result than elections which have hitherto placed undue emphasis on representation. Professionally-led regulation should therefore be strengthened.
The recent criticisms of the current GMC will make it virtually impossible for it to make the cultural transformation needed with confidence and conviction, even if it wanted to. So a line needs to be drawn. The current council needs to be disbanded and its successor re-formed with members, medical and lay, who can give it a convincing fresh start. Introducing robust accountability to Parliament should help the process of change by adding the discipline inherent in the external scrutiny of performance.
The combined effect of Sir Liam's measures could be quite profound. They should help to strengthen professionalism in medical practice, be strongly reassuring to the public and patients, and appeal to the huge majority of conscientious doctors who take pride in the good name of their profession.