In future, the GMC will handle fitness to practise complaints in a much more streamlined way, says Dr Gerard Panting of the Medical Protection Society
Later this year, the GMC will introduce new fitness to practise procedures. Together with the introduction of revalidation, this will mark the most radical reform of the Council since it was established by the Medical Act of 1858 to provide a register of properly qualified doctors that would give some degree of protection from unqualified ‘quacks’.
Today, the GMC has four main functions:
- Keeping an up-to-date register of qualified doctors
- Fostering good medical practice
- Promoting higher standards of medical education
- Dealing firmly and fairly with doctors whose fitness to practise is in doubt.
Inevitably, the most high profile of these is its disciplinary function.
The current system
Under the current system complaints received by the GMC are investigated under its fitness to practise procedures in one of three categories – conduct, performance or health. These are long-winded and cumbersome and once an investigation has been allotted to a particular track, it can be extremely difficult to change to another.
In all three procedures, when the GMC receives a complaint, it is first assessed by a caseworker. After comments have been received from the doctor concerned, all the information is passed on to a screener who must assess whether aspects of the doctor’s conduct, performance or health warrant further investigation and/or action.
Under the conduct procedures, cases progressing beyond the screener are considered by the Preliminary Proceedings Committee, which meets in private and must decide if the matter should be put forward for a public hearing before the Professional Conduct Committee. Doctors found guilty of serious professional misconduct may be admonished, have conditions placed upon their registration or have their names suspended or erased from the Medical Register.
The performance procedures exist to identify doctors whose performance is seriously deficient. The assessment takes place in two stages. The first concentrates on the doctor’s working environment, the assessor looking at notes, talking to colleagues, and observing the doctor in practice. The second uses knowledge tests and observation in mock consultations and clinical situations at an independent assessment centre.
The assessor’s report goes back to the GMC case coordinator. If serious deficiencies have been identified, a statement of requirements is drafted. Doctors who fail to agree with those requirements or who fail to remedy them appear before the Committee on Professional Performance, which is empowered ultimately to suspend a doctor’s name from the Medical Register indefinitely.
The health procedures involve medical examination and an invitation to comply with appropriate medical supervision. In more serious cases, or those where the doctor fails to comply with the recommendations, there is a hearing before the Health Committee which may impose conditions on a doctor’s registration or suspend registration for up to one year.
The need to change
The GMC is struggling with an immense workload. Figures released in May 2003 1 show that in 2002, 5539 complaints were concluded against doctors, a 4% increase on the previous year. That year, the GMC struck off or banned more doctors from practising and placed more under supervision or restricted them from practising than in any previous year.
As in previous years, the vast majority of complaints against doctors were dismissed because there was a lack of evidence or the complaint did not fall under the GMC’s remit. According to the GMC, up to 25% of complaints received did not even identify the doctor about whom the complaint was being made. 1
The Professional Conduct Committee heard a total of 238 cases in 2002. 1 In 72 cases, the doctor’s name was either erased or suspended from the Medical Register, and 62 doctors were reprimanded or had conditions placed upon their registration.
More Health Committee investigations were carried out in 2002, with a total of 152 cases compared with 136 in 2001. 1 Many of these doctors (as is usually the case) had problems with alcohol, drugs or both.
In addition to its unwieldy nature and the excessive time taken to investigate complaints, there is concern that the current procedure does not allow inappropriate conduct short of serious professional misconduct to result in sanctions by the GMC.
The new system
These concerns will be addressed in a radical revision of the fitness to practise procedures. From 2004, these will fall into two parts: the investigation phase and the adjudication phase.
At the end of the investigation phase, doctors whose conduct is found to be inappropriate on the basis of a civil burden of proof (the balance of probabilities) may be given a warning.
At the end of the adjudication phase, the current distinction between performance, conduct and health will be largely replaced by a single question: whether there are aspects of the doctor’s conduct, performance or health that warrant interference with the doctor’s registration. The sanctions of erasure, suspension, conditions and admonition (reprimand) will stay the same.
This latest raft of changes comes hot on the heels of action taken in the wake of Harold Shipman’s conviction. In that case, there was concern that even after Shipman’s conviction for murder, the GMC had no immediate means of removing his name from the register or suspending his name from the register pending formal inquiry. It therefore established an Interim Orders Committee empowered to suspend a doctor’s registration for up to 18 months pending the final outcome of a fitness to practise committee.
To deal with the delays, the GMC has also introduced more fitness to practise panels manned by lay people and doctors who are appointed by the GMC but are not themselves GMC members.
Other healthcare regulators
It has been a bone of contention between the professions for some time that the GMC procedures appear to be more protective of doctors than, for example, the Nursing and Midwifery Council procedures appear to be of nurses. This is an issue that was picked up in the Bristol Inquiry report (recommendation 104):2
‘In the exercise of their disciplinary function the professional regulatory bodies must adopt a more flexible approach towards what constitutes misconduct. They must deal with cases, as far as possible, at a local level and must have available a range of actions which both serve the interests of the public and the needs of the professional.’
The report also advocated (recommendation 39) the establishment of a council for the regulation of healthcare professionals (also mooted in the NHS Plan). The idea was to form an over-arching body to:
‘… ensure that there is an integrated and coordinated approach to setting standards, monitoring performance and inspection and validation. Issues of overlap and gaps between the various bodies must be addressed and resolved.’
The Council for the Regulation of Healthcare Professionals (CRHP) was established under the NHS Reform and Healthcare Professions Act 2002. Its Council is made up of nine team members from the professions – one from each regulatory body – and ten representing public interest, so the majority are lay representatives.
The CRHP is totally independent of Government and reports direct to Parliament. Its job is to oversee and coordinate the work of regulators and/or healthcare professions. It is currently consulting with stakeholder groups on exactly how it should carry out its functions.
The functions set out in statute are:
- Promoting the interests of the public and patients in the field of the regulation of health professionals
- Promoting best practice in professionally led regulation
- Reporting annually to Parliament on its work with discretion to report on the performance of individual regulatory bodies and to compare their performance of similar functions
- Promoting cooperation and consistency across the regulation of all the healthcare professions in the interests of patients
- Developing principles of good regulation
- Advising ministers across the UK of professional regulation issues in healthcare.
The CRHP may also refer a regulator’s final decision on a fitness to practise case to the High Court or its equivalent throughout the UK for the protection of the public. As a last resort, it can also order a regulator to change its rules for the protection of the public. However, this would require the permission of both Houses of Parliament.
- GMC Fitness to Practise Council papers, May 2003.
- The Bristol Royal Infirmary Inquiry. Learning from Bristol: the report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984-1995. Command Paper: CM5207. July 2001.