Reports > The Fifth Report > CHAPTER FIFTEEN - The General Medical Council >
Criticism of the General Medical Council and the Movement for Reform
External Criticism
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15.44 |
In his book, ‘The Doctors’ Tale‘, Sir Donald Irvine (a member of the GMC from 1979 and its President from 1995 until 2002) described how the GMC came under increasing criticism from many quarters from the 1980s onwards. In his Reith Lectures of 1980, entitled ‘Unmasking Medicine’, Professor (now Sir) Ian Kennedy, currently Chairman of the Commission for Healthcare Audit and Inspection (now known as the Healthcare Commission), was deeply critical of the GMC. He doubted that medical self-regulation would be adequate by the end of the twentieth century. He observed that, although the GMC had a duty to protect the public interest, it had no method of consulting with the public. He alleged that it dismissed far too many complaints about doctors without adequate investigation or public scrutiny. He considered that the GMC was not properly held to account by the Privy Council. He was concerned that the GMC’s approach to its disciplinary procedures was governed by the amount of money it was prepared to spend on them. He suggested regular re-registration in place of the presumption that a doctor, once qualified, remained fit to practise unless and until it had been proved, on receipt of specific complaint, that s/he was unfit. He also suggested that there should be an inspectorate that would be able to look into all aspects of a doctor’s professional practice. He observed that specific guidelines would be needed as to what constituted good practice. |
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Another voice of criticism was that of Mrs Jean Robinson, one-time Chairman of the Patients Association and a lay member of the GMC. In 1988, she published a monograph in which she was deeply critical of the opacity of the GMC procedures and of their failure to do anything to protect patients from the poor clinical performance of incompetent doctors. Professor Rudolf Klein, of the University of Bath, criticised the GMC’s reactive approach to complaints of misconduct and its complete failure to tackle the problems of poor performance. |
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In 1989, the British Medical Journal published a series of articles by Mr Richard Smith, then an editorial assistant. These were severely critical of the GMC. It was said that the GMC was too large and its membership too old and too conservative. It was too interested in internal issues and was not sufficiently concerned about issues of medical education and clinical incompetence. Also, it should have been (but was not) seen to be serving the public interest; instead, it complained when criticised in the media. |
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One might summarise those criticisms by saying that the GMC was ‘doctor-centred’. It appeared to assume that all doctors were good, competent and conscientious until proved otherwise. It would deal with the profession’s ‘bad apples’ for the sake of the profession. It would do so in its own way and did not welcome scrutiny. Its procedures were designed to be fair to doctors and to ensure that no doctor would lose his/her right to practise without very good cause. It did not focus on the reasonable expectations of the public and it did not see itself as having a duty to ensure that all members of the medical profession were willing and able to provide a proper professional service. |
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Since the time when this criticism was at its height, the GMC has made considerable efforts to change. The development of the performance procedures in the early 1990s, and the improvements in the health procedures, which I shall describe later, are examples of this. In ‘The Doctors’ Tale’, Sir Donald Irvine described his election to the Presidency on a ‘reforming ticket’. He won the election but explained that the road to reform was not always easy. To some extent, events were to push the GMC forward. The tragedies of the Shipman case, the events surrounding the failure of paediatric heart surgery at Bristol Royal Infirmary and the case of Rodney Ledward (a consultant gynaecologist, whose lack of skill had caused injury to many of his patients over a period of 15 years or so) were important agents of change in the late 1990s. However, even before then, an expression of concern about the possibility of racial bias within the GMC had led to a wide-ranging examination of the GMC’s internal procedures and to many important procedural changes. |
The Work of the Policy Studies Institute
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In 1994, an analysis of the nature and outcome of cases considered by the PCC over a ten-year period was brought to the attention of the GMC. This analysis appeared to suggest that doctors from the ethnic minorities were more likely to be brought before the PCC than were white doctors. To its great credit, the GMC decided that these concerns must be fully investigated. The GMC instructed the Policy Studies Institute (PSI) to do the work and gave the PSI team full access to all the relevant material that was available. |
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Allegations of racial bias are completely outside the Inquiry’s remit. However, allegations that the GMC is biased towards doctors are not. The Inquiry is aware that there is a public perception that the GMC often favours the doctor as opposed to the complainant in its decision-making processes. This is an allegation of bias in another form. The work of the PSI team was to shed a great deal of light upon the procedures of the GMC. Those procedures are of interest to the Inquiry. Only if the GMC’s procedures were thorough, fair and transparent would it be possible to say whether there was bias against complainants and whether patients were being properly protected from the actions of doctors reported to the GMC for alleged misconduct or incompetence. |
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The purpose of the PSI study was, first, to look for evidence of racial bias in the existing GMC procedures and processes and, second, to consider whether any changes should be made to minimise the risk of racial bias in the future. The study was confined to the GMC’s conduct procedures. The study team was led by Professor Isobel Allen, Emeritus Professor of Health and Social Policy, University of Westminster PSI. Initially, Professor Allen and her colleagues analysed complaints made to the GMC against doctors in the 12 month period to August 1994. A Report (the 1996 PSI Report), setting out their findings and recommendations for change, was presented to the Racial Equality Group of the GMC in November 1995 and published in 1996. |
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The PSI team had considerable difficulty in carrying out its work. It found that the GMC data was largely recorded by hand. There was no reliable log or database of past complaints. The way in which complaints were classified made it difficult to analyse their seriousness. Papers relating to past complaints were stored in the same files as enquiries, general correspondence and press cuttings. Papers relating to an individual doctor were not necessarily filed together. An analysis carried out by the PSI team cast doubt upon the accuracy of statistics previously produced by the GMC. As a consequence of these difficulties, the 1996 PSI Report made detailed recommendations about steps which should be taken to establish a reliable and accurate database of complaints. The Report also made many observations and recommendations about the GMC’s procedures for handling complaints. I shall refer to some of these in the Chapters that follow. |
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On the issue of racial bias, Professor Allen and her colleagues reported that they found ‘no evidence of any overt racial discrimination or bias in either the procedures or the processes relating to conduct’. Nor did they find evidence of any form of overt racial discrimination or bias in any interview or informal encounter with GMC staff or members or in any written comment found on the GMC files. Nevertheless, the statistical analysis carried out by the PSI team clearly showed that doctors who had qualified overseas or who had a name which suggested that they belonged to an ethnic minority were more likely than those who had qualified in the UK or Ireland or who had an English or European name to be referred on through the FTP procedures, as opposed to having their case closed at an early stage. The major difference between the groups was found in the proportion of each group referred by the PPC for a hearing before the PCC. These differences could not be satisfactorily explained because of the opacity of the GMC processes. |
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The 1996 PSI Report made clear that the fact that there were differences in outcome between the two groups did not of itself mean that there was racial bias within the GMC. It might just have been that the complaints against overseas qualifiers and those from non-English/European countries were more serious than those against members of the other groups. However, the possibility of bias could not be ruled out. The main conclusion of the Report was that, unless all the GMC procedures for handling complaints against doctors were transparent and open, it would not be possible to demonstrate that there had been no bias. The Report recommended a number of steps that the GMC should take in order to make its procedures more open, transparent and consistent. I shall discuss those recommendations later in this Report. |
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In 1998, the GMC commissioned a follow-up study from the PSI, which resulted in a further Report. The aim of this follow-up study was to identify any factors which might explain differences in the representation of overseas qualified doctors at the various stages of the GMC conduct procedures. Before beginning its follow-up study, the PSI team recommended some immediate changes to the GMC procedures. These were designed to streamline the screening process and to improve the transparency and consistency of decision-making. I shall describe these changes in Chapter 19. The PSI team carried out a quantitative analysis of complaints received by the GMC in the calendar years 1997, 1998 and 1999, and examined the results for evidence of racial bias. In addition, the study examined the screening process, including the effects of the changes to the process which had been introduced by the GMC on the advice of the PSI team. The study also examined the decision-making processes of the PPC. |
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By the time the follow-up study began, the GMC had made considerable progress in implementing the recommendations contained in the 1996 PSI Report. In particular, its data collection system had been computerised and the process of tracking complaints had been made much easier. However, the number of complaints received by the GMC annually had increased markedly and considerable delays were occurring in the processing of complaints. At this time, the GMC had a relatively small staff, many of whom had been employed for a long time. Skills had been passed on by personal contact and mentoring and the GMC had not at that stage developed systems which would enable it to enlarge its staff and train new personnel to deal with this increased workload. |
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The analysis performed by the PSI team showed that, in all three years studied, there was an unexplained discrepancy between the number of UK qualified doctors referred to the PCC by the PPC and the number of overseas qualified doctors so referred. For example, in 1999, of the cases referred to the PPC, the proportion of UK qualifiers sent by the PPC for hearing at the PCC was 33%, whereas the proportion of overseas qualifiers sent was 54%. Professor Allen and her colleagues could not account for that difference. They noted that, since the PPC did not keep a contemporaneous record of its deliberations and gave no reasons for its decisions, no firm conclusions could be reached. There were also significant, unexplained differences between UK and overseas qualifiers in the outcomes of cases heard by the PCC. |
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The 2000 PSI Report made a number of recommendations, which I shall discuss in later Chapters. For the moment, it suffices to say that the general thrust was that, in order to provide consistency and transparency in GMC decisions, there was an urgent need for the development of standards and criteria. In particular, there was a need for a clear definition and an agreed interpretation of SPM. |
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In 2002, Professor Allen and her colleagues were commissioned to carry out further work for the GMC. They conducted a preliminary analysis of the data relating to complaints received by the GMC in 1999, 2000 and 2001. Their findings were set out in a Paper. The analysis showed marked differences between the relative proportions of UK and overseas qualified doctors referred to the PPC by individual medical screeners. Some screeners referred equal proportions of UK qualifiers and overseas qualifiers, whereas other screeners referred three times as many overseas qualifiers as UK qualifiers. As the distribution of cases to the screeners was said to be random, it appeared that the screeners must be applying different standards. Again, the proportion of overseas qualifiers referred by the PPC to the PCC was higher than that of the UK qualifiers. There were also continuing differences between UK qualifiers and overseas qualifiers in the outcomes of cases heard by the PCC. Once again, Professor Allen and her colleagues observed that it was possible that the complaints received about overseas qualifiers had been more serious than those about their UK counterparts. That would explain the disproportionate referral rates and the differences in outcomes. But, in the absence of objective criteria against which decisions could be measured, it was still impossible to demonstrate this. |
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Thus, in three studies, conducted over a period of nine years, the PSI found unexplained differences in the treatment by the GMC of overseas qualifiers as compared with UK qualifiers; the overseas qualifiers were more severely dealt with. This may or may not indicate that there is racial bias within the GMC. The importance of these findings, from the Inquiry’s point of view, is that the procedures are lacking in transparency. It ought to be possible to refute a suggestion of bias if it can be demonstrated that decisions are taken according to objective criteria and by the consistent application of established standards. Professor Allen has repeatedly advised the GMC that it will be unable to refute the allegations of racial bias unless and until it develops objective standards and criteria. It seems to me to follow that, without such standards and criteria, the GMC will be unable to satisfy the public that it is complying with its duty to protect patients. |
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The 'Old' Fitness to Practise Procedures in Outline
