The White Paper on medical regulation, entitled ‘Trust, Assurance and Safety’, was published last week as a response to the CMO of England Sir Liam Donaldson’s report, ‘Good Doctors, Safer Patients’, the Foster review of non-medical regulation and the government’s response to the recommendations of the fifth report of the Shipman Inquiry.
It heralds a major shake-up of medical regulation in the UK.
The GMC will see a radical overhaul of its structure and function.
In the future all council members will be independently appointed and lay members will make up at least 50 per cent ‘to dispel the perception that councils are overly sympathetic to the professionals they regulate’.
The Appointments Commission will appoint members on the basis of predetermined criteria and competencies on behalf of the DoH. The council’s membership will decrease to make it more ‘board-like’.
The GMC will become answerable to politicians, presenting annual reports to UK parliaments and will lose its adjudication role in fitness-to-practise cases.
To achieve this, the White Paper says: ‘The government will seek legislative agreement to establish an independent body to adjudicate on fitness to practise cases involving the medical profession.
‘Doctors and the GMC will have a right of appeal against the decision of the independent body to the High Court or the Court of Session.’
GPs will face revalidation every five years, which will consist of relicensing and recertification.
Work on this needs to be carried out, but some components are already emerging. A major part of recertification will be based on information that shows how clinically effective each doctor’s treatment of his or her patients has been in the past.
The White Paper does not specify how, but concedes that this will ‘not be straightforward’ because some doctors ‘often take patients with more serious illness or multiple illnesses’.
Another component will be ‘summative and formative assessment’ checks. Such checks for GPs will be devised by the RCGP and consist of three main parts: knowledge, communication and technical skills.
The process will take about a day of GP time and a large part of £35 million that the government will give to it will be used to fund time out of practice.
GP revealed an online multiple-choice knowledge test that RCGP Scotland has developed for registrars, which may be adapted as a tool for revalidation (GP, 9 December 2005).
GP also revealed performance tests being developed by the GMC, which Professor Jane Dacre, GMC adviser on competence testing, believes ‘have a definite future’ in revalidation (GP, 20 October 2006).
The objective-structured clinical examinations (OSCE) are ‘designed to be more appropriate to GP practice’ looking at ‘everyday procedures more than practical procedures’, according to Professor Dacre.
Fitness-to-practise hearings will be judged on a sliding scale of proof, as proposed by the CMO and backed by the GMC, where evidence required is determined according to the severity of the misdemeanour. It means that proof will drop from a criminal to a civil standard ‘on the balance of probabilities’.
At a local level, the government will pilot a series of ‘GMC affiliates’, who will provide ‘prompt, independent and local responses to patient concerns’ and offer regional alternatives to national fitness-to-practise procedures.
They will cover SHA areas in England but a number of pilots with different levels of engagement will have a national roll-out.
National changes will see the Council for Healthcare Regulatory Excellence (CHRE), receive enhanced powers to scrutinise the GMC’s handling of fitness-to-practise cases.
Information about GPs
‘No one believes that professional livelihoods should be threatened by malicious local gossip,’ says the White Paper. ‘Equally, everyone is concerned when it emerges that problems with a health professional were local common knowledge and no one took action.’
The DoH will draw up protocols for sharing ‘soft information’ and decide what should be shared regionally and nationally.
The medical register will be developed ‘to become the single authoritative source of information on doctors, including disciplinary action by employers and alert notices’. Access to it will be on a tiered basis depending on the status of who is asking.
The DoH also wants to define a common approach to ‘good character’. It will ask the CHRE to recommend a single standard definition of good character.
The government has opted for the GMC proposal of a three-board model covering undergraduate, postgraduate and continuing professional education.
The DoH will work with the GMC to set up an undergraduate board and a continuing professional development board.
The Postgraduate Medical Education and Training Board (PMETB) will continue as a separate entity, running the postgraduate board within this approach.
‘Many reforms set out in this White Paper will require primary legislation,’ it says. ‘Other measures need to be enabled by seeking parliamentary approval for secondary legislation.
‘The White Paper sets out the key principles for a lasting settlement for professional regulation, but putting those principles into practice will require the advice and participation of a wide range of stakeholders.’
While the White Paper marks the culmination of three enquiries, it is reasonable to expect that it is only the start of major changes in regulation.