Wendy Savage MBBCh(Cantab) FRCOG MSc (Public Health) Hon DSc
Member of the General Medical Council
October 2006
Proposals to strengthen the system to assure and improve the performance of doctors and to protect the safety of patients.
Response to Dame Janet Smith’s criticisms in her enquiry report into the murderous Dr Harold Shipman
CMO’s proposals:
44 recommendations grouped under headings:
- Effective and fair fitness to practise procedures
- Assure and improve the quality of practise
- Address the need for better information for public bodies and employers
- Structure and governance of GMC
Tenor of document seems at odds with the work Liam Donaldson has done before
The background information in the documents is useful but the recommendations do not all seem to follow logically. Dame Janet Smith seems out of step with most commentators who consider Harold Shipman to be an extraordinary anomalous doctor. As the CMO has quoted the Osbornes ‘HS would have passed any appraisal of fitness to practise with flying colours ‘ BMJ 2005 330:546. Donaldson has concentrated on getting away from ‘shame and blame’ and understanding the importance of systems failures, understanding why things went wrong and rehabilitation.
3 other enquiries:
Clifford Ayling GP 1970-1980s Poor handling of complaints and inefficient communication between organisations
Richard Neale O&G consultant 1985 NHS management gave reference. GMC President made erroneous decision when he returned from Canada then GMC lost file as did police until 1994
Kerr and Haslam Psychiatrists.1970-80s Complaints not believed – whistleblower treated badly
The other examples given of shocking cases are old but the basic problems was not so much with the GMC in the sexual abuse cases but with local systems of management of complaints and reluctance of boards to take the patients’ complaints seriously combined with a culture in which the consultants was unchallenged. Times have changed and I do not think that this would happen today. In Ayling’s case his partners accepted his denials (as in a similar case, Green, a GP in the Midlands) where other agencies such as police and social services failed to consult each other. Again I think the public awareness of sexual abuse is much higher and GPs are much more accountable today than in the 1970s and 80s. In the GMC the President no longer screens all complaints as was done in 1985 and the system is much more clear-cut with case-examiners medical and lay looking at each case which does not go forward after caseworkers have weeded out cases according to strict criteria. Again in the Neale case the role of NHS management who gave him a reference which enabled him to get locum jobs was nothing to do with the GMC.
GMC Functions at present:
Education-oversees undergraduate education-visits medical schools. 1993 Tomorrow’s doctors changed curriculum-for better
Registration 170,000 on register weekly updates and queries run into thousands
Standards and Ethics 1995 Duties of a doctor. Good Medical practice Welcomed by all
Fitness to practise Investigation and Adjudication separated 2004 new system
Although those members of the general public who understand that the GMC is the regulatory body for the medical profession and do not confuse this with the BMA (which is done by even highly educated people) tend to think of the fitness to practise aspects and do not know about the other roles of the organisation.
CMO’s proposals:
Education to PMETB Why? No evidence
GMC to do investigation new quango to do adjudication? Why not the other way round? GMC maintains register so should be body to strike off. Two thirds of complaints not GMC material so should be dealt with by ?HCC
GMC affiliates in every ‘Trust’ – why?
Civil standard of proof to replace criminal?
British doctors are respected throughout the world and there is no evidence to suggest that the GMC’s supervision of medical schools which are inspected every 5 years is unsatisfactory. As far as the proposals to leave investigation with the GMC and have a new body to adjudicate is concerned this seems to me to be the wrong way round. The proportion of complaints to the GMC which are not serious enough to go forward to a case examiner is two-thirds. In my view it would be better for some other body such as the Health Care Commission to be the portal for complaints about doctors (and other staff) and for them to investigate and refer serious cases to the GMC. The GMC associates are already trained and operate without reference to GMC Council members who already act like a Board although they are also on specific committees to deal with the various functions. The newly organised GMC has only been fully operational since November 2004 after major re-organisation in 2003 and should be given a chance to bed down. The idea of having a GMC trained affiliate in each Trust seems unnecessarily onerous and bureaucratic and expensive. Although about 1 in 200 NHS doctors is referred to the NCAS each year this is because Trusts have been required to consult with the NCAS before suspending doctors. In 85% of cases alternatives to suspension are found (which raises questions about the threshold for suspension and the culture of management) and only 10% go through a full assessment ie 1 in 2000 doctors. If appraisal is done properly these problems would be picked up earlier and this system is still in its infancy.
I do not think that an expensively trained doctor working in what is virtually an NHS monopoly should be struck off without clear proof that he is not fit to remain on the register. The arguments for the civil standard are not well made.
Conclusion:
The proposals are heavy handed, unnecessary in view of the changes that have taken place in the last decade such as
- Audit
- Appraisal
- ‘Clinical governance’
- Proposed system of revalidation
They may destroy professionalism will be expensive, time consuming and may fail.
The vast majority of doctors are conscientious, keep up to date and are more trusted than politicians . As Baroness Onora O’Neill said in her Reith lectures, and also quoted by Donaldson, ‘The efforts to prevent the abuse of trust are gigantic, relentless and expensive, and their results are always less than perfect. It is worth reading these lectures published as ‘A Question of Trust’ by Cambridge University Press as her analysis of the situation is excellent. Revalidation would have started in April last year and it was always seen as an evolving mechanism but owing to Dame Janet’s criticisms this idea has been put on hold. I reject the airline pilot analogy-doctors are not only self motivated to keep up to date they work in teams and their work is informally scrutinised by many people. We do not need to construct a whole new system to detect poor practice. If appraisal and NHS management did their job, patients would be protected. One could see that the NHSE’s response to the Shipman report was to deflect criticism away from the failings of the NHS on to the GMC – which arguably was not within Dame Janet’s terms of reference!