17 December 2004
The irony of Dame Janet Smith's fifth report from her long-running Harold Shipman inquiry, which last week recommended a comprehensive overhaul of the General Medical Council, is that it has little to do with the activities of the murderous doctor.
Smith's remit, a source of long-held private concerns at the GMC, has extended so widely that the report, Safeguarding patients: lessons from the past, proposals for the future, is less an analysis of the regulator's role in the Shipman case, more a critical study of the self-regulated doctors' profession.
But that should not detract from a report widely welcomed as an incisive contribution to the debate on the standards and regulation of medical professionals. Publicly, even the under-fire GMC describes the 1,300-page study as 'impressive and enormously helpful'.
In the New Labour era of patient empowerment and choice over health issues, it could prove to be a benchmark for reform.
Despite recommending around 50 changes to the way the GMC conducts its business, Smith finds the watchdog had not failed in its duty when dealing (or, more precisely, not dealing) with Shipman. How could the GMC have failed, she argues, when it had not been passed information that could have uncovered Shipman's activities?
What Smith did conclude is that the organisation, established in the Victorian 1850s, often acts as a sort of gentleman's club, and is more inclined to serve doctors' interests than those of the patients it is designed to represent.
Smith says: 'A significant change of culture is necessary& However, I do not feel confident that it will do so.'
Despite this, she stops short of recommending the abolition of the GMC. Instead, Smith proposes separating its investigative and judicial functions, with an independent body established to hear disciplinary cases.
To ensure even-handedness, she proposes significantly increasing the number of lay members on the Council, including a majority on the new disciplinary body, and making the GMC accountable to Parliament.
Significantly, Smith also recommends an independent review of the GMC's new 'fitness-to-practice' assessments for doctors within four years. One senior health expert this week told Public Finance that, with health ministers now peering over the watchdog's shoulder, that is possibly 'the last chance the GMC has of getting its house in order'.
The GMC is acutely aware of the need to show improvement. It issued a statement which said: 'We recognise that Dame Janet makes serious criticism of the way we operated our procedures in the past.
'We accepted at the outset of the inquiry that our past fitness- to-practice procedures were not adequate. New procedures were introduced in November, as part of the biggest reforms of medical regulation in 150 years.'
The GMC's health sector peers are conscious of the need for an outward-looking regulator, but are supportive. A recent report by the King's Fund think-tank warns that all 'doctors need to be more responsive to patient and public expectations and play a more active role in improving health services'.
But author Dr Rebecca Rosen told PF that, in the case of the GMC, a 'balance must be found' between ensuring the interests of patients are met and trusting doctors' expertise.
Niall Dickson, the King's Fund's chief executive, adds: 'We need to find monitoring systems for doctors that are rigorous and protect patients, but at the same time recognise that most doctors are doing a good job.'
And therein lies a problem. GMC sources claim doctors have 'very strong concerns' about passing increasing responsibility for complex decisions about their competencies to members of the public or other professionals.
The Department of Health is aware of these concerns and the need to balance the tradition of self-regulation with a more precise commitment to patient care. Health Secretary John Reid will 'consider in detail' Smith's recommendations before responding in 2005.
But Smith has already sounded a note of caution about the GMC's preferred remedies. She is concerned that the watchdog's planned five-year checks on doctors' performance the 'revalidation' programme due to come into force in April have been watered down by the profession so much that they will be ineffective.
As a commitment to the new patient-centred era, there is a feeling that the GMC could do worse than consult again before taking this first step on the road to improvement.