Health CommitteeWritten evidence from The Royal College of Radiologists (GMC 06)

Summary

This evidence raises two issues as regards the functions of the General Medical Council, as follows:

Shortcomings in the arrangements regarding the introduction of the system of revalidation of doctors in the UK; and

The regulation of teleradiology.

Revalidation

1. We are pleased to see that a system of revalidation of doctors is to be introduced by the GMC and that the arrangements appear to be proportionate and achievable. We are also pleased to be playing our part in that, as regards providing specialty specific support, guidance, information and tools for those who practise clinical radiology and clinical oncology.

2. It is of concern, however, that the system of revalidation is being introduced without there being in place systems for dealing with the remediation or retraining of doctors who will need such support. It seems likely that the numbers of doctors falling into these categories will increase, particularly in the early months following the introduction of revalidation. To our knowledge, there have so far been two working parties looking into the question of remediation: one was led by the Academy of Medical Royal Colleges and the other by the Department of Health. The publication of the latter was heavily delayed. A third working party also led by the Academy of Medical Royal Colleges is now in train and we are contributing to its work.

3. The outcomes from the remediation reports to date have been inconclusive; they appear to identify the problems and issues but have not come up with any clear solutions. We feel that this is a major omission and to the detriment not only of the doctors involved in the revalidation process, but also to patients and the public and the overall effective functioning of the system of revalidation. Whilst it might not be the case that remediation arrangements should fall wholly within the remit of the regulator, it seems surprising that the GMC has not been more actively involved in addressing the issues.

4. The other aspect of the system of revalidation that is also lacking is arrangements for quality assuring the processes. To our knowledge, the issue was raised many months if not years ago, but little action appears to have been taken. It is only now that we are seeing work undertaken to define what quality assurance is needed, how it might be introduced and who should be responsible for it. We would have thought that this should be a clear responsibility resting with the regulator. We would hope that the position is rapidly addressed to give confidence to the arrangements for revalidation. Doctors, patients and the public will want to know that these new systems are being reviewed for their effectiveness and quality with the prospect therefore of them being improved if needed.

Teleradiology

5. The Royal College of Radiologists has been concerned for a few years that there is a gap to the detriment of patients and the public in regard to the regulation of teleradiology. Teleradiology is the remote reporting of imaging investigations used to diagnose patients. Increasingly, teleradiologists based outside the UK are being engaged to report the images of UK patients.

6. This has created a two tier system of regulation. Unlike doctors practising in the UK, doctors based outside the UK are not required to be on the specialist register of the General Medical Council (GMC) or to have a licence to practise, even though they are practising on patients based in the UK. The GMC can only regulate doctors whom it registers and only those practising in the UK are required to have a licence to practise. Whilst some overseas-based radiologists delivering teleradiology services may voluntarily choose to register with the GMC (or maybe required to do so by their employer), it is not a statutory requirement. Therefore they will not be required to revalidate as they do not have a licence to practise in the UK.

7. For example, a teleradiology company reporting images of UK patients may use GMC-licensed UK-based radiologists some of the time, and offshore non-GMC licensed radiologists at other times. Thus, should a fitness to practise question arise in the care given to a UK-based patient, the means to resolve that will depend on whether the radiologist concerned has a licence to practise with the GMC. Hence the protection for patients in terms of holding the doctor to account for their fitness to practise, may depend on which day of the week or time of day their images were reported.

8. UK patients have the right to expect that all doctors involved in their care will be regulated to the same standard, and that in the case of substandard care, patients will have the right of redress. This would involve action either in the UK legal system, or referral to the doctor’s regulator, so that their fitness to practise may be assessed. If the doctor is not regulated by the GMC, such regulatory referral would have to be made to the doctor’s regulatory body in another country, with standards which may differ from those of the GMC, and where complaints systems may be completely different, and in a different language. This is neither practical nor reasonable.

9. The College considers that the same standards of care must apply to all UK patients, irrespective of where their radiologist is based. This is stated in the RCR’s publication: Standards and recommendations for the reporting and interpretation of imaging investigations by non-radiologist medically qualified practitioners and teleradiologists (1) (standards 9 and 10): https://www.rcr.ac.uk/docs/radiology/pdf/BFCR(11)2_reporting.pdf

10. The College has discussed this issue over years with the GMC and the Care Quality Commission (CQC). It has been brought to the attention of the Department of Health (DH). The RCR is pleased that both regulators have acknowledged the problem and have set out steps to address the position. However, that must be regarded as a stopgap solution. We have seen no enthusiasm or willingness on the part of either regulator to address the situation through a proper regulatory mechanism, neither have we seen clear evidence of the two regulators wanting to work together in this regard. Clearly, with the CQC only having a remit in England, it would also be necessary to involve the equivalent regulators in Wales, Scotland and Northern Ireland to ensure coverage throughout the UK.

11. The RCR is of the view that further steps are needed to protect patients and that action is needed because:

(a)further technological advances are almost certain to enable the further and rapid growth in teleradiology/telemedicine;

(b)the prospects for multiple supplier delivery of radiology services in England under the changes envisaged by the Health and Social Care Act could well see much greater use of teleradiology; and

(c)patient care and protection could be compromised.

12. The RCR issued a statement in May 2012:

http://www.rcr.ac.uk/docs/newsroom/pdf/Telerad_PS_May2012.pdf and has written to the chief executives of all trusts or equivalent bodies in the NHS throughout the UK and to the chairs of the emerging clinical commissioning groups in England drawing to their attention this issue and recommending how they can minimise the risks to their patients.

13. We recommend as follows:

Short term

GMC:

(1)the GMC should ensure that those doctors who it registers and who are actively involved in providing or commissioning teleradiology services are aware of their duties in regard to telemedicine. This is set out in paragraphs 54 and 55 of the core GMC document Good Medical Practice (2) as follows:

54 Delegation involves asking a colleague to provide treatment or care on your behalf. Although you will not be accountable for the decisions and actions of those to whom you delegate, you will still be responsible for the overall management of the patient, and accountable for your decision to delegate. When you delegate care or treatment you must be satisfied that the person to whom you delegate has the qualifications, experience, knowledge and skills to provide the care or treatment involved. You must always pass on enough information about the patient and the treatment they need.

55 Referral involves transferring some or all of the responsibility for the patient’s care, usually temporarily and for a particular purpose, such as additional investigation, care or treatment that is outside your competence. You must be satisfied that any healthcare professional to whom you refer a patient is accountable to a statutory regulatory body or employed within a managed environment. If they are not, the transfer of care will be regarded as delegation, not referral. This means you remain responsible for the overall management of the patient, and accountable for your decision to delegate.

[Please note that words which are particularly important in this context have been emboldened]

The GMC publication Leadership and management for all doctors (3) also has relevant guidance as set out in paragraph 82:

82. If you are responsible for managing resources, or commissioning or delivering health services, you should have detailed knowledge of how management processes work and how they affect the delivery of patient care.

(2)the next edition of Good Medical Practice (GMP) (2) and any related guidance issued by the GMC should state that patients who are being cared for in the UK should be able to rely on the same standards of and requirements for regulation by a doctor, irrespective of whether that doctor is located within or outside the UK. All doctors involved in the care of UK patients should also be subject to the same requirements for the regular review of their practice. We have made this point fully in our comments in response to the GMC’s consultation on GMP.

CQC—The CQC should require any doctor providing medical services to patients in England to hold a licence to practise with the GMC as a contractual condition. The appropriate regulatory bodies in the other three home countries should do likewise.

GMC and CQC should, as a matter of urgency, enter into a joint statement along similar lines to those the GMC has entered into with equivalent system regulators in other UK countries. The same approach to regulation should apply across the whole of the UK in the interests of patients.

Longer term

The Department of Health acting across the whole UK should enable the GMC to regulate all doctors who practise on UK patients through legislative change.

July 2012

Prepared 3rd December 2012