Harold Shipman's murderous trail has forever altered the relationship between doctors and patients in this country. A cunning and determined psychopath outwitted his patients, professional colleagues, and the police, and evaded the attention of the General Medical Council (GMC). He succeeded because his crimes were monstrous and incomprehensible to his peers and even to the necessarily jaundiced eye of the police.
Harold Shipman would, of course, have passed any appraisal of fitness to practise with flying colours. Many of his patients, despite all evidence to the contrary, remained desperately loyal to “Dr Fred,” believing that he was the best doctor in the area. His bedside manner was exemplary and the quality of his clinical notes of a high standard. The only straw in the wind that could have been taken more seriously was his previous brush with the GMC for misuse of opiates. The GMC's inability to continue to monitor the situation has resulted in a number of recommendations in Dame Janet Smith's Shipman inquiry report, Safeguarding Patients: Lessons from the Past—Proposals for the Future, namely better monitoring of prescribing, tighter controls on controlled drugs, and revising the rules on certification of death (www.the-shipman-inquiry.org.uk/fifthreport). All these place sensible checks in the system, which will pick up an abnormal pattern earlier.
The public, quite rightly, wish to know that there is an effective system of regulation to protect them from murderous or incompetent doctors. The question for society is what combination of carrot and stick will generate well trained, sensible, and effective physicians, aware of their limitations, able to engage in constructive self criticism and yet able to instil confidence in their patients.
By nature of their calling, most doctors are intelligent, self motivated, and altruistic. Any system of revalidation should positively motivate doctors to perform even better, while identifying individuals with difficulties. Monitoring is more likely to be effective when remedial measures are largely educational and supportive. Unfortunately, supportive measures inevitably attract the charge of protectionism, while the big stick of the GMC, wielded frequently as Dame Janet recommends, would engender fear, paralysis, disillusion, and even suicide among doctors who may not be at fault, and may be lost to the workforce as a result of their experience.
A huge amount of effort has already gone into modernising self regulation: this country is already further advanced than any of our European counterparts. The National Clinical Assessment Authority (NCAA), after a prolonged gestation, is managing to identify problem doctors early, institute remedial training, and return most of them to useful clinical activity quickly while weeding out those requiring further attention from the GMC. This is done in the absence of a blame culture, which permits openness and honesty. It allows fellow professionals to express their concerns in the knowledge that their colleagues' practice will be looked at objectively as a whole rather than focusing on one serious error, which any practising clinician will recognise at some stage in his or her own career. The NCAA is by far the best route to the identification and rehabilitation of underperforming doctors and should be strengthened.
The big stick of the GMC, wielded frequently as Dame Janet recommends, would engender fear, paralysis, disillusion, and even suicide among doctors
When patients, colleagues, employers, or the NCAA identify clear suspicions of serious professional misconduct it is important to launch a swift, decisive, and transparent investigation. This should deal promptly with malicious or spurious complaints, yet fully investigate more dangerous situations. Dame Janet correctly points out that the GMC cannot act as both prosecutor and judge. However, the royal colleges, with their vast experience of the standards expected from a member of their specialty, could be used in a similar way to the Crown Prosecution Service, to decide whether there was a case to answer, applying the equivalent of the “Bolam test” (by which a doctor is judged not negligent if a responsible body of medical opinion says his or her practice was acceptable at the time) to recommend trial by the GMC if there was sufficient evidence of serious professional misconduct. Dame Janet recommends agreeing standards, criteria, and thresholds for serious professional misconduct. This would be a mistake, as criteria change rapidly in a world of advancing technology and shifting morality. The evolutionary common law system of this country is well suited to allowing a respected body of professional men and women, in partnership with lay assessors, decide, using current accepted standards of practice, whether there is a prima facie case to answer. Their decision should be open to public scrutiny. Only if the assessors decide there is a case to answer should the doctor's details be made public.
When the evidence indicates a doctor should appear before a conduct panel, a college assessor could present the case for the “prosecution.” The doctor would be represented by his or her defence organisation, and a panel of medically qualified and lay judges would be provided by the GMC. The standard of evidence should remain “beyond all reasonable doubt” where erasure from the register is at stake. The profession has nothing to fear either from the medical judges being appointed, rather than elected, or from lay judges.
Revalidation by summative annual appraisal, with its sometimes mind-numbing tick box approach, is rightly perceived by Dame Janet to be ineffective in identifying underperforming doctors. Surely as a profession we can do better. There have already been difficulties in identifying and training adequate numbers of general practice appraisers and the time lost from clinical practice in implementing a universal scheme is significant. High quality educational events, creating challenging clinical scenarios, objectively assessed could provide the answer. These could be used in a similar fashion to a pilot undergoing routine simulator training. At the end of the experience, doctors should feel stretched and stimulated to fill gaps in their knowledge. Those few not reaching the grade would be able to receive further educational support or limit their practice appropriately. Completing practical, measurable assessments in this way would be more acceptable to the general public than an appraisal in private by another doctor.
Former BMJ editor Richard Smith is correct in his analysis that a minimalist approach to the conundrum of revalidation and regulation will not succeed (BMJ 2005;330: 1-215626781). However, an imposed solution that fails to capture the imagination and aspirations of the profession will leave both doctors and patients the poorer. This is a time for creativity and positive thinking to enable us to find a solution to restore the faith of the British public in their doctors and that of the British medical profession in their leaders.