Death knell of self-regulation?

Last month’s historic declaration by doctors that they had lost faith in their own self-regulatory system was a symbolic moment for the profession.

The vote by the British Medical Association, backing a motion of no confidence in the General Medical Council, gives the Government an opportunity to end self-regulation.

But even without such a move the policing and monitoring of doctors has begun a complete transformation.

The Department of Health has backed a new system of independent assessment of doctors in its consultation paper, Supporting Doctors Protecting Patients. This builds on the internal monitoring of performance introduced by hospitals under the process of clinical governance, introduced in April 1999.

An annual appraisal system, called for by the Ritchie Report into the malpractice by surgeon Rodney Ledward, has started appearing at some hospitals. And the GMC has recommended a five-yearly revalidation process, compulsory for all doctors. The GMC may be under fire, but this proposal has the support of the DoH.


Change overdue


In view of recent appalling scandals, which have included the serial killing by Harold Shipman as well as gross incompetence in the Rodney Ledward and Bristol hospital cases, change is clearly overdue.

The Chief Medical Officer Liam Donaldson stated bluntly in his letter introducing the Supporting Doctors consultation paper, “The present arrangements in the NHS for dealing with poor performance are highly unsatisfactory.”

But the dreadful publicity and the deep unhappiness within the profession raises another potential headache for personnel managers in the health service. Might the recruits dry up?

“I spoke to some trainee doctors the other day, and they are now saying, ‘With all this flak why did I choose to come into this profession?’,” said John Adsett, national secretary of the Association of Health Service Human Resource Managers.

There is a precedent. Social workers received similar bad publicity over child abuse cases in the late 1980s and early 1990s. Although recruits held up for a while, they have plummeted in recent years. The problem could become especially acute for medicine, as the advent of the 48-hour week for junior doctors within seven years will increase the demand.


Status


At the moment the Government can attract a good calibre of applicant to the profession despite long hours and low pay in training because of the status and reward at the end of it. If this status is perceived to be damaged, recruiters will have serious problems.

Adsett reported, however, that the problem is largely around the negative publicity, not the tighter policing. Although the new measures appear to be more draconian, in reality they are more proportional to the problem.

The complaint about the existing system is that it is either too weak or too strong, producing either inaction or the heavy intervention of lawyers in a drawn-out process. The long delays while on suspension were a key factor behind the BMA’s vote.

If an allegation is serious enough to warrant dismissal then it has to be reviewed by an external panel, which must be chaired by counsel. Both sides have the right to legal representation. “It is a case of three barristers sat in a huddle,” said Adsett.

The AHHRM supports the proposal for an independent review set out in Supporting Doctors, Protecting Patients, which sets out a clear, four-stage process.

Karen Bell, president of the NHS personnel managers group the AHHRM, agreed that the negative image is the challenge, not the new measures.

“A member of the public reading the press at the moment would be worried. They would have the impression that there are all these poorly performing doctors, but in fact most do a good job.

“We had Shipman and Bristol and there were a number of indicators that probably should have prompted us to look to see why that was happening. We are now looking at these indicators with the Commission for Health Improvement, and also through clinical governance, at health authority level and in primary healthcare.”


Revalidation


And she backed the idea for compulsory revalidation every five years. “We have been doing this with nurses for a long time and they find it very valuable. It enables them to say to their employer that continuous professional development is essential. They need support in this process, and we owe it to patients.

“If I thought it was draconian I would not support it,” Bell added. “If you get a failing professional you use the disciplinary procedure, but only as a last resort. It will be the same for doctors. This is supportive and developmental – it is not about sacking people.”

Clinical governance, introduced by the Government in April 1999, is not an appraisal of individuals but it enables early detection of performance problems. It requires NHS trust boards to monitor clinical performance on a regular basis and compare it with national standards.

Poor practice quickly becomes apparent and would almost certainly have picked up the problems with the gynaecologist Ledward, who carried out poor surgery, and in the Bristol hospitals, where there was a high rate of infant mortality.

“If you take Bristol you would know that in comparison to national norms the clinical performance was poor,” said Bell.

Clinical governance has brought in a key role for personnel professionals, who ensure that any training needs uncovered by the process are followed through.


Appraisals


Some trusts have gone further and brought in annual appraisals. Adsett, who is head of personnel at Basildon and Thurrock General Hospital, has just obtained the go-ahead for such a scheme. He involved consultants in designing the arrangements to help ensure their acceptance.

“We had an away-day afternoon,” Adsett said. “Any consultant could come along, and we came up with a consensus from those who were there.”

The role of HR, said Adsett, is to make sure internal procedures take place. “It is important that HR makes sure that appraisals are happening and are running fairly, and to make sure that if any follow-up action is indicated that it is taken.”

All public sector professions are now scrutinised to a high degree. Those with responsibility for health and well-being of citizens can expect nothing less.

But there is a huge challenge for personnel professionals and other managers to ensure that this necessary process is supportive, or else understaffed hospitals – causing more death and misery than isolated scandals – will be the result.

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