“Shipman and Beyond: the Future Regulation of Healthcare Professionals”

On 14^th July 2006 the UK’s Chief Medical Officer, Professor Sir Liam Donaldson, published his long-awaited review into the quality assurance and safety of medical practice in the UK, including the system for medical regulation.

“Good Doctors, Safer Patients” (“the Donaldson Report”) was primarily the response to the recommendations made by the Fifth Shipman Inquiry Report (2004), which examined the role of the General Medical Council, and the wider arrangements for medical regulation.

The Shipman Inquiry had concluded that existing NHS procedures for detecting and dealing with poor clinical performance were inadequate, allowing such practice to extend over many years without appropriate action being taken.

In particular, the lack of coordination between professional, educational and regulatory bodies and NHS employers, meant that concerns about problem doctors were seldom shared at an early stage.

The Shipman Inquiry was also critical of the GMC, concluding that the culture, membership, working practices and governance structures were more likely to support the interests of doctors than protect patients. The GMC’s then proposals for “revalidation” (re-licensing) of all doctors’ fitness to practise received particular criticism.

Good Doctors, Safer Patients is a long report spanning over 200 pages, and making 44 key recommendations. It needs to be read with the linked report “The Regulation of the Non-medical Healthcare Professions”, chaired by Andrew Foster (“the Foster Review”).

The proposals have received qualified support from patients’ groups, a lukewarm response from the GMC, and a hostile reaction from many healthcare professionals. 

Action Against Medical Accidents (“AvMA”) welcomed the proposal to move from the criminal standard of proof to the civil standard in fitness to practise cases, on the basis that a doctor who is “probably” a danger to the public should not be allowed to practise. It also supports the proposal to strip the GMC of its adjudication role, which would be dealt with by a new independent tribunal. However, it is concerned that the proposals for revalidation are vague, and that the requirement for complainants to receive appropriate and independent advice and support receives scant attention.

The GMC supports the proposal for an enhanced “two tier” registration database, with greater public and employer access to a doctor’s registration status, the proposal that the GMC should be accountable to Parliament, and that revalidation should build on local appraisal systems. However, it maintains that following recent changes to its constitution and fitness to practise procedures, the case for further change has not been made out, and will be unnecessarily disruptive. Further, it strongly objects to the loss of its role in supervising medical education.

Perhaps not surprisingly some of the most scathing comments have come from within the healthcare professions. “Hospital Doctor” condemned the proposals as unfair: “…How will an independent tribunal - set up to be more patient-oriented - perceive the grey areas of medicine, when they’re also adjudicating with a lowered burden of proof? It has the potential to destroy the lives of many decent doctors…”. It also suggested that the proposal for delegated “GMC Affiliates” to assist with the investigation and resolution of complaints in each NHS Trust, and to forward more serious cases to the GMC centrally, will be unworkable, as no one will want such a part-time job.

Some experts are calling for more radical surgery on the GMC than even Donaldson proposed. Former GMC President Sir Donald Irvine says that it should be completely disbanded, and reformed with new medical and lay members: “…The recent criticisms of the current GMC will make it virtually impossible for it to make the cultural transformation needed to achieve this with confidence and conviction, even if it wanted to…”.

Whilst both reports are welcome, change is unlikely to be swift. The reports are subject to consultation until November 2006, and draft legislation is unlikely to appear until late 2007.