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The General Medical Council (GMC) has been submitted to a highly detailed forensic examination and found severely wanting. It has broken its contract with the public—to protect patients in exchange for the privilege of self regulation—and if it wants to survive it must now launch into a further round of reforms, even while those of the last few years are still being implemented.
The forensic examination has been conducted by Dame Janet Smith as part of her inquiry into the issues arising from the case of Harold Shipman, a general practitioner who murdered over 200 of his patients. Her fifth and final report, which is over 1000 pages long and makes 109 recommendations, examines the performance of bodies responsible for monitoring primary care and makes recommendations on how better to protect patients in the future.1 I want to concentrate here on what Dame Janet said about the GMC.
Dame Janet's examination of the GMC has been complicated by her prey being on the move. But if the leaders of the council ever hoped that they could reassure her that she need not worry because reforms were under way they must have been seriously disappointed. She finds deficiencies not only in the “old” fitness to practise procedures but also in those introduced at the beginning of November 2004 and in the revalidation procedures to be introduced next April.
The GMC accepted when giving evidence to the inquiry that its “old” procedures “failed... to meet the reasonable expectations of patients and the public.”1 Nobody, I suggest, could dispute her analysis of the many defects of the “old” procedures. It might be argued that Dame Janet wasted her time and the public's money in the critique, but it was well worth doing not only for scholarly and legal completeness but also because many of the defects live on in the new procedures.
One fundamental problem is that whenever there is a trade off to be made between protecting the public and being fair to doctors the council has taken the side of doctors. “And thank goodness” will be the reaction of many BMJ readers, but if it is to command public and parliamentary confidence then the council must put patients and the public first. Another persistent problem is that the council has never agreed “standards, criteria, and thresholds” for serious professional misconduct. The result has been inconsistency in decision making. With the new procedures no standard is set for a finding of “impairment of fitness to practise.”
Another problem has been that the GMC has been both prosecutor and judge, which conflicts with the Human Rights Act 1998. The GMC hopes to get round this problem by ensuring that the adjudication of fitness to practise will be made by people who are not members of the GMC. These people are, however, selected, trained, appraised, and if necessary fired by the council. This, argues Dame Janet, is insufficient separation of investigation and adjudication.
Dame Janet then turned her attention to revalidation and again found serious deficiencies. The law defines revalidation as “an evaluation of a medical practitioner's fitness to practise,” but Dame Janet concludes that the arrangements that will begin next April will do no such thing. In order to be revalidated doctors will have to have been appraised and will need a “clinical governance certificate.” But appraisal is a purely formative process that will not provide an evaluation of fitness to practise, and the certificate will simply state that nothing adverse is known. “A doctor will fail to be revalidated only if his or her performance is `remarkably' poor,” concludes Dame Janet.
Guaranteeing a doctor's fitness to practise is no simple business, and the original discussions around revalidation recognised the need for multiple methods of assessment. These, however, would be expensive, time consuming, and probably lead to many doctors failing to be revalidated—destroying professional lives, reducing the workforce, and creating a big need for retraining. Intense battles thus began, and the GMC retreated—to the point where revalidation will not do its job. Expediency, says Dame Janet, replaced principle.
Dame Janet reaches the same diagnosis on the GMC as its latest president, Sir Donald Irvine: the culture is wrong. It is reactive rather than proactive, prefers that doctors should be trusted rather than held accountable, places consensus before leadership, is driven by expediency and compromise, and in the last analysis will put fairness to doctors ahead of patient protection. Sir Donald, who was effectively forced out by the old guard, aspired to a culture “enthused with a spirit of openness, driven by the conviction that one's decisions must be routinely open to inspection and evaluation, like the openness that pervades science and scholarship.”2 Instead, he saw the GMC dominated by “minimalists who still hankered after the old style of medicine... to do the least possible consistent with good appearances.”3
The root of the reactionary culture, concludes Dame Janet, is the fact that elected members (all doctors) control the council. They see it as their job to represent doctors rather than regulate them. Dame Janet wants more medical members appointed rather than elected, something that is unlikely to please rank and file doctors who have rebelled in the past over “taxation without representation.”
The old guard or minimalists are not entirely philosophically bankrupt. They can gain some comfort from another woman with an incisive mind, Onora O'Neill. In her Reith lectures she argued that attempts to replace trust with accountability may have gone too far: “The efforts to prevent the abuse of trust are gigantic, relentless, and expensive; their results are always less than perfect.”4 There can never be so much transparency that trust is no longer necessary, and the challenge is to arrive at the correct balance of trust, transparency, and accountability.
The government will respond to Dame Janet's report early this year, but if the GMC wants to improve its performance—and survive—it will need to accept many of Dame Janet's proposals. This will mean overhauling fitness to practise procedures that have only just started, strengthening revalidation processes, and yet again changing its constitution. Does it have enough stomach for the battles ahead or will expediency again prevail? I doubt its ability to reform, but I'll be happy to be wrong.
This article was posted on bmj.com on 13 December 2004
Competing interest: RS wrote a series of articles in the BMJ highly critical of the GMC in the late 1980s.