Annual accountability hearings: responses and further issues - Health Committee Contents



APPENDIX 4: GENERAL MEDICAL COUNCIL'S RESPONSE

Introduction

We welcome the Health Select Committee's report on the GMC, which will help us drive forward our already ambitious reform agenda.

We are committed to meeting the challenge set by the Committee to provide leadership to the profession, particularly in relation to the standards of performance and conduct we expect of doctors, so that patients across the UK get the highest quality care.

This document sets out our response to each of the Committee's recommendations. We will continue to keep the Committee informed of our progress throughout the year and we look forward to exploring these issues further at our next annual accountability hearing.

1.  Although, therefore, the Committee recognises that the GMC achieves a high level of operational competence, it remains concerned that the leadership function of the GMC within the medical profession, and within the wider health community, remains underdeveloped particularly in the areas of fitness to practise, revalidation, education and training and voluntary erasure. We hope that the GMC will embrace more ambitious objectives for professional leadership, some of which are described in this report. (Paragraph 4)

We are pleased that the Committee has recognised the GMC's high level of operational competence, and accept that there is no room for complacency. We remain determined to deliver ever more efficient and effective protection for patients.

We have outlined, in the course of our responses to the specific points raised by the Committee, the ways in which we will work to address the challenge of showing leadership as a regulator working alongside the medical profession and wider health community.

Revalidation of doctors

2.  The work undertaken by the Society of Cardiothoracic Surgery of Great Britain and Ireland in setting standards for that part of the medical profession is commendable. Its transparency will be welcomed by patients and should be a template (where clinically relevant) for further refinement of the revalidation process. (Paragraph 11)

3.  The GMC clearly has a considerable amount of work to undertake between now and the implementation of revalidation in 2012. Although we agree that all disciplines will not have developed their standards to an advanced level by that date, the GMC needs to accelerate its work with the medical royal colleges to further refine the standards for revalidation in specialist areas and to ensure that the process is meaningful to clinicians and transparent to the public. (Paragraph 12)

Revalidation remains the GMC's number one priority. We are determined and on track to introduce a system by late 2012 (subject to the Secretary of State's approval). Over time, revalidation will provide increased assurance that licensed doctors are up to date with and practising to the appropriate professional standards.

There are a number of key areas of work underway with our partners in the Health Departments, the Royal Colleges, Employers and others across England, Scotland, Wales and Northern Ireland, to ensure that local systems of clinical governance are in place and fit to support revalidation. These are led by the four health departments with support from the GMC.

At the same time, we have a major programme of work underway to ensure our own systems and processes are ready to support implementation.

We acknowledge there is still work to be done, to ensure doctors understand the implications of revalidation for their practice, including in specialist areas. We are committed to doing this, both in the lead up to implementation and beyond.

The Academy of Medical Royal Colleges is co-ordinating the development of supporting information guidance from each of the medical royal colleges and faculties for GPs and specialist doctors. Doctors are being advised that participation in national audits will be expected where these are relevant to the specialty or subspecialty in which they practice.

The Society of Cardiothoracic Surgery of Great Britain and Ireland (SCTS) has done commendable work in setting standards and they are more advanced in this regard compared to other specialities. This reflects two main factors. First, the enthusiasm of that specialty and the very hard work its leaders have done over a considerable number of years. Secondly, it is less difficult to measure outcomes for cardiothoracic surgery than in many other areas, for example general practice and psychogeriatrics.

We are working with the SCTS to explore lessons that can be learnt from their experience and we will continue to work closely with our partners in order to ensure that over time the information all doctors bring into their appraisals becomes more outcome based.

4.  As the GMC states, some doctors may decide to retire rather than undergo the process of revalidation; of those who pursue revalidation, some may require retraining and some may fail to meet the required standards. The GMC needs to ensure that it monitors the number of doctors who retire, leave the profession, have conditions placed on their practice or fail revalidation. It must develop and share this evidence with employers to ensure that future workforce planning includes the developing outcome of the revalidation process. (Paragraph 14)

We recognise that we will need to monitor the number of doctors who retire, leave the profession, have conditions placed on their practice or are referred to our fitness to practise procedures. We are currently developing our internal systems, processes and supporting technology. These monitoring requirements will be considered in all of that work.

The outcomes of all revalidation decisions will be shared with the relevant employers so that they can make the appropriate workforce planning and development arrangements.

Revalidation provides the formal context in which local systems of clinical governance must now be established. One of the benefits of this process is that as a result of yearly appraisals of their doctors, employers will have a more regular and informed understanding of their workforce planning and development needs without necessarily having to wait on a revalidation decision in consultation with the GMC every five years.

Outside of revalidation, as further evidence of our commitment to develop and share information which may support future workforce planning, we have recently published a report, The State of Medical Education and Practice. This report uses the wide range of information held by the GMC from across our Education, Registration and Fitness to Practice functions to provide a picture of today's medical profession and some of the key challenges it faces. In publishing this report, we hope to initiate an important debate with employers, educators, the profession and other regulators on what action is required to respond to these challenges for the doctors of today and tomorrow including in workforce planning.

5.  Of the Officers who will have to make recommendations about revalidating doctors, only a minority feel that the process will help with the early identification of doctors with performance issues. Early identification of problem doctors is a core task of the professional regulatory system, and the GMC needs to ensure that its systems of appraisal and revalidation achieve this task. (Paragraph 15)

We believe in a four layer model of regulation

Personal regulation. The individual practitioner's values, supported by their professional ethos, should be what most effectively ensures good care for every person that they care for.

Team regulation. Peers and colleagues should provide assurance, with everyone working together to ensure that each other's care is safe, effective and respectful.

Workplace regulation. The culture of care in the team should in turn be embedded and sustained by effective leadership, management and clinical governance in the organisation that provides, or arranges the provision of, care.

National regulation. Professional regulatory bodies and the bodies that regulate the providers of health and social care services provide a national framework of assurance.

We believe that each of these four layers of regulation will be strengthened and formalised by the implementation and roll out of revalidation:

Encouragingly, the independent report on the Revalidation Pathfinder Pilots, published in June found that 70% of the responding Responsible Officers expect the full roll-out of revalidation to lead to improved patient safety, improved quality of care and improvements in patient experience. In addition, of those Responsible Officers who participated in the most recent pilots, 53% expected the full roll out of revalidation to result in a reduction in the amount of time it takes to "identify and rectify poor practice".

While there is still work to do to refine and improve the systems of local clinical governance on which recommendations for revalidation rely, these findings suggest good progress is being made in this important area.

To support the early identification of problem doctors we are taking steps that will create better links between the GMC and employers for identifying, investigating and managing concerns. This year we are introducing a network of dedicated Employer Liaison Advisers. Their role will include developing good links with Responsible Officers across the UK to support an earlier two-way exchange of information and advice on poorly performing doctors or those about whom the employer has potential concerns.

We will continue to work with employers and Responsible Officers to support them in making sure there are robust local systems of clinical governance and appraisal in place within their organisations which support doctors with their appraisal and revalidation.

6.  The Committee notes the negative media reports about the time taken to undertake revalidation and hopes that the GMC will ensure that lessons are learned from the revalidation pilots, particularly in how it can support locum doctors. It also needs to ensure that the underlying processes that doctors are expected to undertake are not unwieldy and overly time-consuming, and that they are an effective means of gathering the required evidence. (Paragraph 18)

The Responsible Officer Regulations, together with revalidation, establish the principle that gathering and reflecting on information about their practice will become a part of every doctor's professional life.

However, we understand doctors' concerns that introducing revalidation should not unduly add administrative requirements over and above that necessary for good medical practice.

We remain committed to ensuring that our proposals for revalidation are robust but proportionate and flexible for all practising doctors. Following our consultation last year, we streamlined and simplified the supporting information required for appraisal so that all doctors regardless of their practice will collect a common set of core information.

We have also learnt from the pilot findings. Specifically, the IT system developed by the NHS Revalidation Support Team was intended to support appraisal (as distinct from revalidation) and was only designed for the pilot. The NHS Revalidation Support Team has now started a second year of piloting, as part of which they will be testing the process with locum doctors.

We want better safer care for patients; to achieve that we must give doctors the space to reflect on their practice, to gather information about their performance and to benchmark their results, however we understand that doctors need to find the process both rewarding and effective.

The next year of preparation will help to ensure the system works well for all doctors, wherever and however they practise.

7.  Doctors from the European Economic Area and Switzerland seeking to practice in the UK cannot routinely be language and competence tested by the GMC. (Paragraph 21)

8.  The GMC along with the Government is working towards resolution of this with partner organisations across Europe. The Committee takes the view that current legal framework is at odds with good clinical practice, which is clearly unacceptable. The GMC has plans, within the boundaries of UK law and the EU Directive, to manage the constraints on language and competence testing by using the Responsible Officer role to establish that EEA (the EU plus several other European countries) doctors are fit to practise in the UK. The Committee accepts this way forward as a short term measure. (Paragraph 22)

9.  Although this short term measure is welcome, the Committee believes that public confidence in the medical profession requires the issue to be addressed authoritatively. It is clearly unsatisfactory that the competence to practise of health professionals should be assured by a work-around, and we look to the Government, GMC and the relevant European bodies to work as a matter of urgency to produce a long-term solution to this problem. (Paragraph 23)

On Tuesday 4 October, the Secretary of State for Health announced that the Government will introduce measures that will ensure all doctors who come from overseas to work in the UK must not only have the right qualifications, but also the language skills needed to practise medicine safely.

The changes have two main components. First, the Medical Act will be amended to give the GMC explicit new powers to take action where we identify concerns about the language skills of EEA trained doctors as part of the registration process, including in the small number of cases where we have a doubt about their language skills, if for example they use a translator or say that they cannot speak English. Secondly, Responsible Officers across England will have a mandatory duty at a local level to check the English language skills of all overseas doctors before they can be employed. Discussions are ongoing with the administrations in Scotland, Wales and Northern Ireland to see if the Responsible Officer scheme could also apply or whether there is a more appropriate local system.

These measures mark the culmination of many months of hard work to close this loophole in UK law, which has been causing so much concern to patients and their families. We will continue to work with the Department of Health to implement the changes as quickly as possible.

This proposed scheme, which is compliant with European law, will be a significant improvement on the current situation and will provide greater protection to UK patients.

We do not regard it as a short-term measure. We would however like to have even more power to assess the linguistic and clinical competence of doctors from the EEA in the same way that we can for doctors that qualified outside of Europe. We will therefore continue to engage, together with other UK and EU healthcare professional regulators, in the review of the recognition of professional qualifications Directive in the coming months.

Fitness to practise

10.  The Committee notes that there is an increase in referrals of doctors to the GMC, and of nurses to the NMC, as well as an increase in the number of general NHS complaints. The Committee welcomes the fact the GMC has commissioned research into this phenomenon in order to better understand what is driving this increase, and to ensure that their systems and processes are adequate for meeting the future needs of the public. We look forward to reviewing the preliminary findings of this with the GMC at our next accountability hearing. (Paragraph 27)

This trend in increasing referrals to the GMC is something that we are keen to understand in detail and we welcome the Committee's support for the work we have commissioned in this area.

We will use the findings of this research to ensure our systems and processes are adequate for meeting future public need.

11.  The Committee welcomes the ongoing good performance of the General Medical Council (GMC) in resolving 90% fitness to practise cases within fifteen months. However, we agree with the GMC that fifteen months is indeed too long to conclude such cases and we recommend that the Council for Healthcare Regulatory Excellence (CHRE) their regulatory body, should set the GMC a more demanding target for future years. (Paragraph 29)

We have launched a significant series of reforms to our fitness to practise procedures so that cases can be resolved more quickly and in a manner that is less stressful for all involved while ensuring the principle of patient protection is upheld at all times. We consulted widely on these reforms earlier this year and have now begun work to implement these changes. Some of them will require legislative change.

In the meantime, we are determined to continue meeting our target of resolving 90% of fitness to practise cases within 15 months.

12.  Some of the decisions made by fitness to practise panels of the GMC defy logic and go against the core task of the GMC in maintaining the confidence of its stakeholders. Furthermore, they put the public at risk of poor medical practice. (Paragraph 35)

13.  The GMC holds the dual but potentially conflicting roles of prosecutor and adjudicator in fitness to practise cases. The GMC proposes to establish an Independent Medical Practitioner Tribunal Service to create a greater separation between these functions, and the Committee supports this proposal. We also urge that performance management of fitness to practise panellists commence as soon as is practicable. (Paragraph 36)

14.  The GMC currently has no right of appeal over decisions made by independent fitness to practise panels. The Committee does not seek to undermine the existing power of appeal held by the Commission for Healthcare Regulatory Excellence, but agrees that the GMC needs also to have a right of appeal in cases where it thinks panellists have been too lenient. We urge the Government to move quickly to make the necessary legislative amendments. (Paragraph 40)

We welcome the Committee's support for our proposal to modernise the GMC's fitness to practise procedures, including the establishment of the independent Medical Practitioner Tribunal Service (MPTS).

We also welcome the Committee's recommendation to allow the GMC a right of appeal against independent panel decisions we feel do not adequately protect the public.

Both these measures were also supported by the majority of respondents to our public consultations earlier this year.

Now that these proposals have been approved by the GMC's Council we are now moving as quickly as possible to appoint the first chair of the MPTS and we will continue to work with the Department of Health (England) to make the necessary legislative changes.

15.  Doctors from Mid Staffordshire NHS Foundation Trust whose practice was in itself blameless but who failed to act and raise concerns about colleagues are now also under investigation by the GMC. A clear signal needs to be sent by the GMC to doctors that they are at as much risk of being investigated by their regulator for failing to report concerns about a fellow registrant as they are from poor practice on their own part. (Paragraph 43)

16.  The Committee recognises, however that doctors and other practitioners who have raised concerns by other staff have sometimes been subject to suspension, dismissal or other sanctions. The Committee therefore intends to examine this issue in more detail in due course. (Paragraph 44)

The Committee rightly challenges us to send a clear signal to doctors of the importance of speaking out if they are aware of poor patient care. We know there is more we can do in this area and we are committed to taking up this challenge. We also believe it is incumbent on healthcare employers to ensure that they create an open and transparent working culture in which all staff feel able to raise concerns, and indeed are encouraged to do so.

Later this year, we will be consulting on an updated version of our core guidance, Good Medical Practice, and producing new advice about raising concerns.

However, we recognise this is not just about releasing guidance - the important point is that we work to ensure doctors are aware of these issues and their obligations to act appropriately in every instance. We will be working with the wider profession including employers and other professional and system regulators to take this forward.

With specific regard to Mid Staffordshire, we are investigating a number of doctors who allegedly failed to take appropriate action despite being aware of the concerns surrounding the quality of care being provided. This includes two doctors in management positions at the Trust itself and one at the SHA. We are also investigating one further doctor who allegedly failed to implement an action plan to address concerns which had been identified and were known to the Trust's management.

17.  In contrast to the approach of the Nursing and Midwifery Council, the GMC has put its fitness to practise cases relating to Mid Staffordshire "on hold" until the inquiry has concluded. The Committee believes that this is neither fair to the public, or to the registrants under investigation. We urge the GMC to set out its rationale for this, publicly and clearly. (Paragraph 45)

Investigations into doctors working at Mid Staffordshire NHS Foundation Trust have been ongoing. In line with our usual practice, we had decided not to close any investigations while the Public Inquiry was still receiving evidence which might have changed our view of a case.

However, given that the Inquiry will not be receiving any more evidence and the length of time since these investigations were opened, we wrote to the Inquiry to ask if it had any further information which might be relevant to our investigations so that our decisions on individual cases can be fully informed.

They have advised that they do not have any further information which touches on any individual practitioner at the Trust, and that any relevant information that has already been provided to the Inquiry will have been referred to in oral evidence or exhibited to relevant statements and is therefore in the public domain.

As a result we are now deciding what action should be taken in regard to these cases and will be progressing them in line with our normal procedure.

18.  We suggest that the GMC further considers risk-based approaches to proactive regulation and how these could be developed with its employer liaison services. (Paragraph 49)

We are taking proactive steps that will create better links between the GMC and employers for identifying, investigating and managing concerns.

This year we are introducing a network of dedicated Employer Liaison Advisers. Their role will include developing good links with Responsible Officers across the UK to support an earlier two-way exchange of information and advice on poorly performing doctors or those about whom the employer has potential concerns.

As this service matures, the Employer Liaison Service should maximise the potential risk based regulatory benefits of revalidation, encouraging and supporting employers in earlier, meaningful interventions where concerns or risks about doctors are identified in the context of anticipated systems of local clinical governance.

19.  The Committee appreciates the seriousness with which the GMC has treated the suggestion that doctors from black and minority ethnic backgrounds are overrepresented in fitness to practise cases. The finding that this relates to overseas trained doctors and not ethnicity per se does not alter the fact that a problem exists. (Paragraph 53)

20.  The GMC needs, as matter of urgency, to do more to understand the risks associated with overseas-qualified doctors. It should offer timely induction and needs to assure itself that those doctors in peripatetic locum positions are adequately supervised and supported. If a doctor is not safe to practise in the UK then the GMC must ensure that they do not do so. (Paragraph 54)

We are committed to ensuring that our processes and procedures are fair for all doctors, including those from BME backgrounds and those who trained overseas.

We will continue towards gaining a better understanding of why some groups of doctors, in particular those who qualified outside the UK, are over represented both in the proportion of complaints we receive and in our fitness to practise procedures.

Related to this and as evidence of our recognition of the Committee's challenge for us to show leadership within the profession, we have published a report, The State of Medical Education and Practice, which uses the wide range of information held by the GMC from across our Education, Registration and Fitness to Practice functions, provides a unique picture of the make-up of today's medical profession including an assessment of the demographic trends which characterise and challenge the profession of today and tomorrow.

We agree that there should be more thorough induction processes for overseas medical graduates coming to work in the UK and that there is more work that the GMC can do in this area. For many newly-arrived doctors an adequate induction is often unavailable. As a result they are not always aware of the ethical and professional standards that they will be expected to meet, how the health service in the UK operates or how medical practice is managed and regulated. As a contribution to help support doctors who are new to UK practice, we intend to work with employers and professional organisations to develop a basic induction programme for all doctors new to the register. Ideally we believe that all doctors should have to complete the programme before they practise, whether they are trained in the UK, elsewhere in Europe or further afield as everyone who treats patients needs to be supported to do that safely.

As the Committee highlights, we are not currently permitted by law to test the skills or language competency of doctors entering the UK from the EEA. However, as stated above, the Secretary of State for Health has recently announced that the Government will introduce measures that will allow us to ensure that all doctors who come from overseas to work in the UK must not only have the right qualifications, but also the language skills needed to practise medicine safely.

Voluntary erasure

21.  Several cases have been brought to the attention of the Committee of doctors applying to remove themselves from the register during an ongoing investigation into their practice by the GMC (so called voluntary erasure). The Committee has no objection to the principle of voluntary erasure as it can be a useful tool to protect the public. However, in some cases, interested parties have been given little or no time to raise an objection to applications for voluntary erasure, and the GMC was not able to offer a clear explanation of this. (Paragraph 61)

22.  Applications for voluntary erasure must not be granted by the GMC unless interested parties have been given adequate notice of an application and have been offered an opportunity to voice an opinion on the matter. (Paragraph 62)

23.  The Committee fully supports the publication of the facts of any case of voluntary erasure where there is a fitness to practise allegation about the doctor concerned. The GMC needs to ensure that turning voluntary erasure into an admission of guilt does not have a perverse impact in reducing the numbers seeking it and therefore erode public protection. (Paragraph 64)

We welcome the Committee's support for our proposals outlined in our consultation paper published earlier this year to reform the GMC's fitness to practise procedures in a way that will provide quicker resolution and less stress and anxiety for all concerned while upholding our commitment to ensuring patient safety.

At present, under our current legislation, in cases where the doctor would be willing to accept our proposed sanction the majority still go to a public hearing. We believe that this is not always the most proportionate or effective way of protecting patients. The consultation paper (attached for reference)[21] proposed that where there is no significant dispute about the facts of a case, doctors should be able to accept sanctions, including suspension and erasure, without their cases going to a hearing. The proposals in the consultation paper received support from both medical professionals and the public.

The central change proposed in the consultation paper is to hold face-to-face meetings with doctors at the end of our investigation to encourage them to accept the sanction necessary to protect the public without the need for a public hearing. We envisage that doctors will be advised of our proposed sanction based on the available evidence and invited to provide any new information which may alter our view of the seriousness of the matter prior to the meeting.

Where the doctor accepts the sanction necessary to protect the public, we propose to publish the outcome on our website with sufficient information to enable the public to understand the appropriateness of the sanction. Our intention is to be able to extend this approach to the full range of sanctions (including suspension and erasure) however this will require amendments to the Medical Act 1983 before we are able to fully implement the programme. In the meantime we intend to pilot the new model in all cases other than suspension and erasure cases to test the new process.

We would like to clarify that, under these proposals, where erasure is accepted by the doctor, this would not be the same as voluntary erasure. Voluntary erasure allows a doctor to relinquish their registration and therefore no longer need to pay our registration fee. This is mostly used by doctors retiring, changing career, taking maternity leave or moving abroad. In exceptional circumstances voluntary erasure may be granted to doctors where there is a fitness to practise concern when the doctor is too sick to respond to our procedures or take part in a public hearing or is unlikely to return to medical practice and we are satisfied that it is in the public interest to remove them from the register. We are sorry if this has caused some confusion and we are currently considering whether we may need to use different terms to better distinguish between the two processes.

The Committee has raised concerns that in some cases we did not provide sufficient advance notice to the complainant about an application for voluntary erasure. We would like to assure the Committee that our policy is to inform complainants and offer them an opportunity to submit comments, regardless of whether voluntary erasure has been requested prior to or during a hearing. Clearly in the instance highlighted to the Committee, this did not happen and we are sorry that insufficient notice was given in this case. We will take steps to ensure that this does not happen in the future.



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