Reports > The Fifth Report > CHAPTER FIFTEEN - The General Medical Council >
The 'Old' Fitness to Practise Procedures in Outline
|
15.33 |
The ‘old’ FTP procedures were governed by a range of statutory and internal, non-statutory provisions. The primary legislation was contained in Part V of the 1983 Act. However, each set of procedures had its own set of statutory Rules. In the past, the GMC had difficulty in obtaining amendments to the Rules or securing the passage of new secondary legislation. However, the provisions of section 60 of the Health Act 1999 enabled the GMC to secure much more speedy amendment of the Medical Act and the introduction of secondary legislation. Section 60 enabled the Department of Health to make certain amendments to primary legislation, including the 1983 Act, by Order in Council. Such an Order is subject to affirmative resolution in both Houses of Parliament. The making of regulations and rules under the 1983 Act in relation to FTP procedures and revalidation is a matter for the GMC itself, but they have to be approved by Order of the Privy Council. The GMC also has a set of internal Standing Orders, comprising procedures that have been approved by the full Council. Some of these dealt with aspects of the FTP procedures. In addition, there are internal processes and guidance governing the way in which the GMC handles individual cases. It is not clear to me to what extent these internal processes and guidance have been expressly approved by the full Council. They may be approved by the Fitness to Practise Committee or may possibly be made under powers delegated to the Chief Executive. |
|
15.34 |
As I have already explained, the three separate FTP procedures were introduced at different times and to fulfil different perceived needs. Some form of disciplinary procedure to deal with misconduct has existed for as long as the GMC itself, although many changes have been made over the years. For many years, the conduct procedures dealt with doctors who had been convicted of criminal offences and with those who were alleged to be guilty of serious professional misconduct (SPM). The health procedures came into effect in 1980 to meet the need to protect the public against doctors who were unfit to practise on account of ill health, while at the same time treating such doctors in a non-punitive and supportive way so as to help them to recover and to be rehabilitated into full practice. The performance procedures were introduced in 1997 and were intended to give the GMC the power to deal with doctors whose standard of professional performance was seriously deficient but whose poor performance could not be categorised as SPM. |
|
15.35 |
The concept of SPM has given rise to considerable difficulty in interpretation. In Chapter 17, I shall discuss the meaning of SPM and the various attempts that were made over the years to define it. For the moment, suffice it to say that a wide variety of different forms of misbehaviour might amount to SPM. Often, these related to the doctor’s dealings with his/her patients (for example, sexual misconduct), but behaviour which brought the medical profession into disrepute or which undermined public confidence might also amount to SPM even though it did not directly involve patients. For example, dishonesty in research might amount to SPM. In connection with clinical treatment, it had long been recognised that the wilful neglect of clinical responsibilities, such as a refusal to provide treatment when necessary, might amount to SPM. But negligent, as opposed to wilful, failures in connection with clinical treatment might also amount to SPM provided that the failure in question was sufficiently serious. It seemed to be assumed that members of the GMC would recognise a case of SPM when they came across it although, in fact, the evidence suggests that the issue of whether conduct amounted to SPM gave rise to frequent differences of opinion. |
|
15.36 |
Similarly, there was no accepted definition of what was meant by seriously deficient performance (SDP). As with SPM, it seemed to be assumed that members would recognise it when they came across it. As with SPM, the lack of any authoritative definition gave rise to difficulties and differences of opinion. I shall discuss the meaning of SDP in Chapter 17. |
|
15.37 |
All complaints, allegations and expressions of concern reaching the GMC were considered first by a case manager. He or she would follow detailed instructions when considering whether the matter should be closed at that initial stage or whether it should advance into the FTP procedures. If s/he decided that the case was to proceed, s/he would send it either to a medical screener or, if it was clear that the case involved issues of ill health, directly to a health screener. The medical screener would consider whether the case raised any FTP issue, be it SPM, SDP or serious impairment of fitness to practise by reason of ill health. If s/he thought that it did, the case would be transferred to the appropriate Section. If s/he thought that no such issues were raised and that the case should be closed, a lay screener would examine the papers. If the lay screener agreed that the case should be closed, it would be. From that stage onwards, the procedures differed. |
The Conduct Procedures
|
|
15.38 |
If either the medical or lay screener decided that a question of SPM had arisen, the case was handled in the Conduct Section and went to the PPC, which decided whether the case should proceed to a hearing before a panel of the PCC. Hearings before the PCC took place in public. If the PCC panel found the doctor guilty of SPM, it had the power to administer a reprimand, to impose conditions on the doctor’s registration (such as practising under supervision or undertaking further training), to suspend the doctor from practice for up to a year or to erase his/her name from the medical register. |
The Health Procedures
|
|
15.39 |
When a case was referred to the Health Section (by either a caseworker or a screener), it would be considered by a health screener. In the past, two medical members of the GMC acted as health screeners. From March 2004, two medically qualified case examiners were appointed to act as health screeners in place of the GMC members who had previously fulfilled this function. A very large proportion of all cases dealt with in the health procedures involved psychiatric problems of one sort or another. The health screener would write to the doctor inviting him/her to be examined by at least two medical examiners, usually psychiatrists. On receipt of the examination reports, the health screener would decide whether the doctor’s fitness to practise appeared to be seriously impaired and, if so, s/he would devise a list of conditions (based on the recommendations contained in the examination reports) to which the doctor would be invited to agree. These might include restrictions on the circumstances of practice (such as not practising single-handed) and would always include a requirement that the doctor submit to medical supervision. If the doctor was continuing to practise, there would be a requirement that a professional supervisor should be appointed. |
|
15.40 |
If the doctor agreed to the proposed conditions, the doctor was said to enter the ‘voluntary’ health procedures. He or she accepted the conditions and the health screener oversaw their operation, seeking periodic reports from the medical supervisor. If and when satisfied that it was appropriate to do so, the health screener might vary the conditions or terminate them, leaving the doctor free to practise. If the doctor did not accept the conditions thought appropriate by the health screener, or if the doctor refused to be examined at all, or was unfit to agree to conditions, the health screener might decide to refer the case to the HC, which had the power to impose conditions upon the doctor’s registration (in effect, the same kind of conditions as the health screener would have suggested) or to suspend him/her from practice for up to a year. The HC sat in private. It did not have the power to erase a doctor from the medical register although it could renew and extend either conditions or suspension. In certain circumstances, it could make a direction that a doctor’s registration should be suspended indefinitely. |
The Performance Procedures
|
|
15.41 |
The performance procedures were similar in operation to the health procedures in that they might be entered voluntarily or might operate by compulsion. When it appeared to a medical screener that a doctor’s professional performance might have been seriously deficient and that it was appropriate to take action, s/he might invite the doctor to agree to an assessment of his/her performance by an Assessment Panel. If the doctor agreed, the case would be passed to the Performance Section, where arrangements for the assessment would be put in motion. A case co-ordinator would be appointed. In the past, two medically qualified members of the GMC acted as case co-ordinators. From March 2004, two medically qualified case examiners were appointed to act as case co-ordinators in place of the GMC members who had previously fulfilled this function. |
|
15.42 |
The Assessment Panel would comprise one lay and two medically qualified assessors, one of whom practised in the same (or a similar) specialty as the doctor under scrutiny. One medical assessor would be appointed as the lead assessor. An assessment might take some months to arrange and complete. When the assessors had submitted their report, the case co-ordinator would decide whether the doctor’s performance appeared to be seriously deficient. If so, s/he might devise a statement of requirements to which the doctor was invited to agree. The statement might require the doctor to undertake training in some aspects of his/her practice and might specify limitations (e.g. a requirement to practise under supervision) on his/her practice. If the doctor accepted the statement of requirements, s/he would enter the ‘voluntary’ performance procedures. The case co-ordinator would require periodic progress reports and, in due course, would arrange for a reassessment to be carried out. If all was satisfactory, the case co-ordinator might decide that the doctor should be free to practise without restriction. If the doctor failed to agree to or comply with the statement of requirements, or refused to co-operate in some other way, or if the case co-ordinator did not think that voluntary procedures were suitable, the case was referred to a panel of the CPP. The panel usually sat in private. If the panel decided that the doctor’s performance had been seriously deficient, it might impose conditions on the doctor’s registration or suspend the doctor from practice for up to a year. It had no power to erase a doctor’s name from the medical register. Both conditions and suspension could be renewed and extended. In certain circumstances, a CPP panel could make a direction for indefinite suspension of a doctor’s registration. |
The ‘Silo Effect’
|
|
15.43 |
Because the three different FTP procedures came into existence at different times, they operated separately and independently of each other. Although, in some limited circumstances, it was possible for a doctor to be transferred from one set of procedures to another, a case could not be handled within more than one set of procedures at any one time. Thus, if a doctor presented with problems that included conduct, performance and health issues, a decision had to be taken as to where they were to be handled. The GMC referred to this as the ‘silo effect’. The new FTP procedures have been designed to overcome this fundamental difficulty. It is intended that all cases will be investigated using flexible powers to obtain evidence of various kinds, including expert opinion about clinical practice, medical or psychiatric reports on the doctor’s health, and performance assessment reports. If conduct issues arise, they will usually be determined by a FTP panel but the panel will also be able to consider any issues of performance or health which remain in dispute or which require the imposition of conditions or other sanction. |
|
Present Structure
