Proposed changes to the GMC should ensure an ongoing revalidation and appraisal system for all doctors in practice, says Dr Gerard Panting
The long awaited review from the Chief Medical Officer, Sir Liam Donaldson, of the General Medical Council's (GMC) Good doctors, safer patients was published on 14 July,1 along with a parallel review of all the non-medical healthcare regulators.2
The role of the GMC
Running to 218 pages and culminating in 44 recommendations, the review is more radical than many had anticipated. It suggests that the GMC should be stripped of its roles in overseeing undergraduate medical education and adjudicating 'fitness to practise' complaints. These are to be decided on the balance of probabilities in future, not beyond reasonable doubt, and by a new, and as yet unnamed, body.3
The GMC would remain responsible for investigating and prosecuting the more serious cases, but would delegate much of the less serious 'fitness to practise' work to locally based GMC affiliates. Sir Liam also recommends toughening up the revalidation proposals.
As a result, the GMC itself becomes responsible for corporate governance of the organization and should be restructured to become a leaner, fitter board.
All these ideas are now the subject of a consultation exercise, due to close in November 2006, which means the GMC must endure still more time in limbo before its fate is known.
The GMC has undergone massive changes over the past decade; but in the Shipman Inquiry,4 Dame Janet Smith, DBE, was highly critical of it and particularly scathing about the plans for revalidation.1
In his evidence to the Inquiry, GMC president, Sir Graeme Catto, famously described revalidation as 'an MoT test for doctors'. Dame Janet said there was no such thing; there was no test, and the public should not be misled into thinking that there was.
Her proposal was to move from a formative to a summative appraisal process, with reference to available data, recorded complaints and formal testing.4
When responding to the Shipman Inquiry report, the government commissioned Sir Liam Donaldson to undertake his review, and so it is not surprising that many of Dame Janet's views are reflected in these recommendations. 1
Revalidation and appraisal
So what will all this mean in practice, if it is finally implemented?
Revalidation will affect everyone who wishes to retain a licence to practise. The idea here is that revalidation should have two components:
- first, for all doctors, the renewal of a doctor's licence to practise and, therefore, their right to remain on the Medical Register (re-licensure)
- second, for those doctors on the specialist or GP registers,'re-certification' and the right to remain on these registers.
The emphasis in both elements is a positive affirmation of the doctor's entitlement to practise, not simply an apparent absence of concerns.1
The aspiration is that this will enable the GMC to guarantee the ongoing fitness to practise and competence of all doctors in active practice. It is ambitious, and some may say unattainable, and if introduced will be heavily reliant upon data analysis.
The review also states: 'A clear, unambiguous set of standards should be created for generic medical practice, set jointly by the General Medical Council and the (Postgraduate) Medical Education and Training Board, in partnership with patient representatives and the public. These standards should…incorporate the concept of professionalism and should be placed in the contracts of all doctors.'
It continues '… a set of standards should be set for each area of specialist medical practice. This work should be undertaken by the medical Royal Colleges and specialist associations, with the input of patient representatives, led by the Academy of Medical Royal Colleges.'1
NHS appraisal should then be standardized and audited. The appraiser should make judgments against these generic standards to provide a more rigorous and objective process, and make use of all available data. As methodologies and the quality of data improve, much more information should be used in the appraisal process.1
The parallel review on non-medical regulations suggests that all healthcare professionals, not just doctors, should undergo similar periodic revalidation.2
The review suggests that doctors approaching retirement age should be invited to a review with their GMC affiliate to decide whether a further 5-year period of re-licensure is 'desirable and appropriate'.1 As many doctors may wish to continue in part-time practice after retiring from the NHS, or at least keep their options open, these interviews may prove less fruitful that anticipated.
But who will these GMC affiliates be, and what else will they do? They will be medically qualified individuals, licensed by the GMC, established within each organization that provides healthcare.
Each affiliate will be paired with a lay person, and together they will work with complaints and administration staff, thereby forming a wider team. This team will identify, and bring to the affiliates' attention, complaints raising concerns about a specific doctor's performance or conduct.
Affiliates will be authorized to deal with fitness to practise issues. They will have the power to 'agree' a 'recorded concern' with the practitioner, but not to impose sanctions on registration. They will also inform employers or contracting organizations, and the GMC, which will collate all concerns centrally.
Recorded concerns will be reviewed by a national committee, which may discuss individual cases with the affiliate who recorded them, and could refer the case on to the GMC for further assessment or investigation.
Should the doctor refuse to accept a recorded concern, the complaint would automatically be referred to the GMC. The Council will be responsible for rigorous training, accreditation and audit of affiliates, and for providing comprehensive support.
Where appropriate, affiliates, together with the complaints staff, will be expected to offer to meet complainants to address their concerns about specific doctors.
This will be their chance to explain any actions taken, or the reasons for apparent inaction.The doctor who is the subject of the complaint may be required to attend these meetings at the affiliate's discretion.
Judging fitness to practise
Fitness to practise procedures could also change fundamentally.
The GMC would no longer be responsible for prosecuting and deciding fitness to practise cases; instead a new adjudication body would be established, with the GMC acting as complainant. Separating out these functions has been a discussion point for some time; first because of the Human Rights Act and the right to a fair trial, and second because of perceived inconsistency between regulators.
But this change would require primary legislation, and with pressure on parliamentary time, bringing the proposal into effect may take some time.
In any event, the Council for Healthcare Regulatory Excellence exists primarily to provide consistency and to appeal against unduly lenient decisions by regulators.
It is more likely that, in the short term, there will be a move towards deciding cases on the civil standard of proof (the balance of probabilities, rather than the criminal standard) beyond reasonable doubt.
This was recommended in the Shipman Report, where Dame Janet Smith argued that in protective jurisdictions, the civil standard is the appropriate one to adopt. Doctors are less likely to agree.
As James Johnson, Chairman of the BMA, said: 'Patient safety is paramount and no one wants to put people at risk by bad practice. But it seems wrong to be able to take away a doctor's livelihood because of something found on a balance of probability rather than proving something beyond reasonable doubt.
It opens the door to miscarriages of justice, which will devastate the lives of doctors and their families.'5
One other issue that will have to be addressed is who will pay for all this? With so much change on the horizon, many doctors will want to know why they have to pay a retention fee. Reviews of this sort have to come with a regulatory impact assessment, which includes an estimate of the cost. In this case it comes to around £150 million per year.1
- Department of Health. Good doctors, safer patients: Proposals to strengthen the system to assure and improve the performance of doctors and to protect the safety of patients. A report by the Chief Medical Officer. London: DH, 2006.
- Department of Health. The regulation of the non-medical healthcare professions. A review by the Department of Health. London: DH, 2006.
- Department of Health. Healthcare Professional Regulation: public consultation on proposals for change: Good doctors, safer patients and the regulation of the non-medical healthcare professions. London: DH, 2006.