Regulating doctors

It would be absurd to try to organise health services on the assumption that any doctor could turn out to be a serial killer, argues Dr Michael Fitzpatrick

In my column in LM last April, I wrote that 'the continuing proceedings against Dr Harold Shipman could not have come at a better time for the medical establishment'. This is even more true of his conviction of the murder of 15 of his patients on 31 January.

Ever since he became president of the General Medical Council in 1995, Sir Donald Irvine, formerly a GP, has been pressing for a tighter system of regulating medical practice. Under his direction, the GMC has taken a much more proactive role in regulating the profession, publishing a series of detailed guides to good practice. Other medical bodies, including the British Medical Association and the royal colleges governing specialities, have pursued a broadly similar agenda.

In 1998, Irvine seized on the case of the Bristol children's heart surgeons - which he chaired personally - as an opportunity to promote the reform agenda. In early 1999, the GMC agreed to introduce a system of regular revalidation of all doctors in Britain. Towards the end of the year, a flurry of documents appeared in response - from the BMA, the RCGP and from the government. These attempted to define acceptable and unacceptable standards of practice, proposed ways of dealing with 'underperforming' doctors and outlined a timetable for introducing revalidation.

Tony Blair has seized on the issue of health service reform as a symbol of his modernising crusade against the 'forces of conservatism'. Blair has singled out the BMA as an example of such a force, which is rather unfair as it has broadly supported the government's reforms and has particularly approved moves towards tighter regulation. Indeed, it is difficult to identify any opposition to all these proposals, conservative or otherwise. The only reason for delay seems to be the major organisational (and financial) investment required to implement any comprehensive system of revalidation.

Though the Shipman conviction has provided the occasion for a renewed clamour for tighter controls over GPs, it is strictly irrelevant to the issue of professional regulation. As the Guardian's health correspondent noted, 'none of these measures would have been likely to have caught Shipman, who was a multiple murderer, but not a failing GP' (1 February). Indeed Shipman appears to have been a capable and conscientious GP, who was generally well regarded by his patients. It would be absurd to try to organise health services on the assumption that any doctor could turn out to be a serial killer.

Yet the ultra reformers are in full cry. New Labour GP Sam Everington appeared on Newsnight within hours of the verdict to suggest that the GMC should have a lay majority, thus abandoning the principle of professional self-regulation that has prevailed since 1858. Given the series of recent exposures, it is worth noting that there have always been medical rogues - and the GMC has long been criticised as an ineffectual watchdog. What is new in recent years is a declining trust in doctors, which is part of a wider breakdown of trust in society. The most striking recent development is the medical profession's loss of confidence in itself, which is expressed in the quest for reassurance through some form of audit or assessment. One irony of recent trends towards professional self-abasement is that they are taking place after a period of general improvement in medical standards (particularly in general practice) and after the GMC has become more dynamic than at any time in its history.

The tradition of self-regulation reflected the early medical profession's confidence in its capacity to maintain its own standards. Doctors asserted their independence of both market forces and the state. Whereas the market ideal is that the consumer rules, the professional answers to a higher standard - that of the authoritative judgement of fellow professionals. Everington's notion that lay people should sit in judgement over doctors is a New Labour populist gesture which merely expresses a lack of professional self-respect. The fact that some doctors have fallen below an acceptable standard, and that the GMC has been dilatory in maintaining it, seems a poor justification for abandoning a tradition of autonomy which remains an important protection for patients and doctors and of the integrity of the relationship between them.