APPENDIX 4: GENERAL MEDICAL COUNCIL'S RESPONSE
We welcome the Health Select Committee's report on
the GMC, which will help us drive forward our already ambitious
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
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
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.
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
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.
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
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
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.
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
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
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
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
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
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
We will use the findings of this research to ensure
our systems and processes are adequate for meeting future public
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
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.
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
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
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
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
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
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
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.
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
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)
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
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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