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Commentary

Volume 355, Number 9220 10 June 2000

		Doctors in the NHS: the restless many and the squabbling few

Rant and rancour are the prevailing sentiments that are scarring present discussion about the UK's National Health Service. The latest rash of national newspaper editorials makes it clear that, as far as professional self-regulation is concerned, "enough is enough".¹ Last week's Independent on Sunday concluded that, in the light of the report into Rodney Ledward's gross surgical incompetence (see p 2058 ), "The General Medical Council has been drinking in the 'last chance saloon' too long. Disband the GMC". The Sunday Times, in a broader attack on the NHS, argued that "The brutal truth now is that the NHS is failing . . . The GMC, with its 79 doctors and 25 lay people, failed long ago".² And on June 5, The Guardian launched its coverage of the government's health- service reforms with the headline, "Blair gets tough with doctors. 'Consultant is king' culture must end . . .".

This escalating confrontation is not only between politicians and the profession. Doctors are now vigorously attacking one another. At the British Medical Association's Annual Representative Meeting, to be held in London later this month, its agenda committee proposes "That the GMC: (i) neither protects patients nor supports doctors; (ii) has lost the confidence of the public and the profession; (iii) should be disbanded". Professional implosion is a pitiable sight. How did this appalling position come about and what is the way out?

The quality of medical care in the UK was catapulted into the public, and political, arena in 1998 with revelations about events in Bristol Royal Infirmary's paediatric cardiac surgical unit.³ The GMC's judgment--to strike off the medical register two out of three doctors brought before its professional conduct committee--was quickly followed by Ledward's assaults, Harold Shipman's murders, Alder Hey's hidden child organs, and a stream of reports describing various surgical and pathological blunders. The government launched separate investigations into each incident, but the Bristol inquiry is likely to be the most far-reaching in its conclusions. A preliminary report has already alluded to "an arrogance born of indifference" among doctors.⁴

Until Bristol, quality issues had not been high on the agenda for the UK Royal Colleges, the BMA, and even the GMC. Doctors' leaders preferred to focus the national health debate around NHS funding, a subject that always galvanised public support and diverted scrutiny from their own affairs. After Bristol, and with firm government commitments to higher funding for the health service, there was nowhere to hide from such uncomfortable truths. Yet anyone following the present crisis might imagine that the leaders of these bodies had spent the past 2 years fiddling furiously while their decadent empire was consumed by flames of public mistrust. Such a reading of events, although partly justified, ignores important efforts by a quiet minority to grasp reform while doctors still had the chance to do so. It is their work that is now being undermined by colleagues more concerned with their own self-interests than with regaining the confidence of patients.

In the GMC's judgment about Bristol, its conduct committee, chaired by Council president Donald Irvine, cited issues that went well beyond the case before them.³ They emphasised the importance of setting explicit standards of clinical care, assessing competence, measuring reliably a doctor's personal performance, opening up a closed medical culture to uncover areas of weakness, giving those wishing to raise concerns a safe forum in which to do so, and encouraging doctors to act early when a colleague's standard of work seemed to be in decline. It was the GMC--not politicians, not newspaper editors, not government inquiries, not Royal College presidents, and not BMA leaders--that set this agenda 2 years ago.

The GMC built on this late, but nevertheless good, start with its notion of revalidation: "that all registered doctors must be able to demonstrate regularly, through a link with continued registration, that they remain fit to practise in their chosen fields." Although revalidation has commanded support among ordinary medical practitioners, a vocal anti-revalidation group of current and ex-BMA leaders has done much to create confusion and give the appearance of professional resistance to proper public accountability and institutional change. For example, James Johnson, chairman of the BMA's joint consultants committee, has argued that the GMC's "changes are at best unachievable and at worst misguided".⁶ And Sandy Macara, a former BMA Council chairman, recently tried to suppress widespread consultation on the GMC's draft guidelines for revalidation.

Meanwhile, the Royal College of General Practitioners enthusiastically embraced the notion of revalidation. The college sent a draft consultation document concerning the meaning of good medical practice for general practitioners, together with clear definitions of terms such as "professional competence" and what makes a good general practitioner, to all its members in October, 1999. Contrast Johnson's wholly negative attitude with that of Mike Pringle, chairman of the College's council:⁷

"The introduction of revalidation will help restore the confidence and trust of the public and the government in professionally led regulation. The recent consultation proposals for revalidation for clinical general practice have been well received by the profession and have been overwhelmingly supported. We need to work towards a comprehensive system that promotes good care, detects problems early, and encourages all doctors to be keeping well above the minimum 'fitness to practise' level".

In less ringing, but still positive tones, George Alberti (president, Royal College of Physicians) agreed that "annual appraisal can work hugely to our benefit".⁸ Brian Jarman, a member of the Bristol inquiry team, has also praised the GMC's efforts to set explicit standards of good medical practice.⁹

The GMC is not without deficiencies. Its powers need to be strengthened by government to tighten control over who can be readmitted to the medical register after being struck off. Those who are familiar with its workings are fully aware of the tensions between its elected leaders, lay and medical, who want to see change implemented quickly, and its administrative staff, who are more cautious about stepping into unknown and politically vulnerable territory. The resources brought to bear on complaints procedures are insufficient to create a fast and effective system that can satisfy an anxious public. And few people remain comfortable with an organisation that acts as both investigator and adjudicator of complaints, especially when the majority sitting on professional-conduct committees remains medical.

These problems, together with the cascade of cases after Bristol, have helped to drive the government's alliterative strategy of partnership, performance, professional, patient-care, and prevention challenges, the national plan for which will be announced in July. Many doctors fear future political incursions into a previously apolitical professional space. The internecine strife among doctors, which has severely reduced the profession's influence over likely change, therefore represents a stunning failure of nerve and leadership at one of the most critical times in the profession's history. There is still a slim chance to recover this desperate situation. But if doctors are to help lead a professional renewal, as they surely should, they must cease pouring scorn on those who are trying to guide them into calmer and more constructive waters.

What of the future? The old notions of autonomy and prestige that have characterised medical professionalism are now being eroded in many western countries, not only the UK. Matthew Wynia and colleagues argued that in the USA "most physicians are ill equipped to deal with these threats".¹⁰ They appealed to the traditional concepts of "devotion to service, profession of values, and negotiation [of these values] within society" as the "core elements of medical professionalism". In a more compelling analysis, William Sullivan concluded that "medicine must take the lead in a public conversation about the profession's contract with society".¹¹ He wrote of the need for a "civic professionalism" that was "specifically public-regarding". And he cited a shift in the role of a doctor from social agent to technical expert as one that "made professionalism less effective as a claim to public legitimacy and at the same time has diminished the importance of the professional voice in public debate".

Sullivan's view seems a plausible interpretation of the saga of events that has overtaken UK medicine. In a perverse way, therefore, the toppling of medicine from its professional pedestal--break-up of the GMC, revised and more demanding responsibilities for Royal Colleges, and less political pandering to the BMA--may be the only way for doctors to re-establish their covenant of trust with the public. This professional recalibration may simply be an inevitable step in the process of medical rehabilitation.

During the coming months, there will be further talk, much of it predictable and tribal, about continued professional development, revalidation, audit, clinical governance, performance criteria, guidelines, and leadership. But a crucial element is missing from this debate: time. Ian Morrison, in an essay on the future functions of a doctor,¹² identified at least eight competing roles: clinical data collector, proceduralist, diagnostician, knowledge navigator, health advisor, quality-assurance specialist, physician manager, and shaman. Morrison's assessment of a doctor's predicament is blunt: "Physicians today are floundering . . . [they] must envision a future that offers them something better than being a hamster on a wheel". Doctors need time to fulfil the roles Morrison identifies and the public now expects. Building more time into a doctor's professional life, on the grounds that it is time above all that a patient seeks, is not high among government priorities. But time and a renewed civic professionalism together make up a powerful counter-argument to those who believe that medicine can be modernised only by adding one suffocating layer of regulation on top of another.

Richard Horton

1 Editorial. It's time to get rid of the GMC. Independent on Sunday June 4, 2000, p 26.

2 Editorial. Bad medicine. Sunday Times June 4, 2000, p 18.

3 Horton R. How should doctors respond to the GMC's judgments on Bristol? Lancet 1998: 351: 1900-01.

4 Laurance J. "Arrogant doctors" attacked by organ inquiry. Independent May 11, 2000, p 1.

5 Irvine D. The performance of doctors: the new professionalism. Lancet 1999; 353: 1174-77.

6 Johnson J. Can revalidation really be put into practice? Hospital Doctor May 25, 2000, p 61.

7 Pringle M. The Shipman inquiry: implications for the public's trust in doctors. Br J Gen Pract 2000; 50: 355-56 [PubMed].

8 Alberti G. Message for the millennium. Bull R Coll Physicians Lond 2000; Jan/Feb: 1-3.

9 Jarman B. The quality of care in hospitals. J R Coll Physicians Lond 2000; 34: 75-91 [PubMed].

10 Wynia MK, Latham SR, Kao AC, Berg JW, Emanuel LL. Medical professionalism in society. N Engl J Med 1999; 341: 1612-16 [PubMed].

11 Sullivan WM. Medicine under threat: professionalism and professional identity. CMAJ 2000; 162: 673-75 [PubMed].

12 Morrison I. The future of physicians' time. Ann Intern Med 2000; 132: 80-84 [PubMed].