ࡱ> TVS#` ?bjbj\.\. ;h>D>D6LLLLLLL`8 `@.($nh^LGGGLLGLLGLL 0@4cH44LvjTDEX@GGGG```d $``` ```LLLLLL This report and its 44 recommendations could fundamentally change the way in which the medical profession is regulated: that is certainly its intention. So far reaching are the potential consequences for practice that all LMC members and their constituents were given the opportunity to contribute to Somerset LMCs response. We are pleased that the report states that of the 130, 000 registered doctors working in the UK only a small proportion practise in an unsatisfactory and unacceptable fashion, due to inadequate training, insufficient support, ill-health, lack of motivation or, very rarely, malice. We also agree that most doctors may at some time in their career have known of a colleague that, on balance, he or she would rather not treat a member of their own family. We agree that the profession has a duty to itself and to patients to identify and remedy poor practice when it is justified. The LMC agrees with the CMO that far more damage can be done from simple human error in the context of a weak system than by individual poorly performing doctors. That weak healthcare systems may have already been addressed in his report An organisation with a memory, but are by no means cured. Indeed there is evidence, for example from a Coroners inquest held in London in October, that new weak systems may still be being actively set up, in this case in an out of hours service. Somerset LMC shares many of the comments expressed by colleagues quoted in the report criticising past and present GMC practice and the different standards that exist in regulation. Thus it is recognised that some doctors can be deemed not good enough to continue to practise in a local service but not bad enough for the GMC to take action. Even when it does act the GMC may sometimes ineffectually allow bad practice to continue for years whilst, on other occasions, lack the flexibility to prevent overreaction to trivial misdemeanours. Both these are much resented by doctors but this regulatory gap also endangers patients. However we do not agree with Dame Janet Smiths intervention casting doubt on the GMCs plans for revalidation which were that they would necessarily have been an expensive rubber stamping exercise that would have misled the public. On the other hand there was much sympathy for the CMOs conclusion that the GMC cannot be expected to continue to be the recipient, processor, investigator, prosecutor, judge and jury of complaints. The LMC agrees that doctors are far less thoroughly regulated than professionals in high risk industries, such as civil aviation. It is true that once he or she achieves independent practice a doctor may have no formal assessment until retirement. However we also believe that it is controversial to say the least that direct lessons can be drawn from civil aviation let alone the nuclear power and oil industries. The LMC agrees with the CMO that it can be difficult to distinguish between misconduct, individual failure, human error provoked by a weak system and untoward outcomes that were really no bodys fault. We also deplore with him the off with their heads approach that can lead to more danger to patients as no one will admit ones own mistake nor will anyone wish to condemn a colleagues career to ruin. Recommendation 1 (R1) is line with Dame Janet Smiths assertion that medical regulation is a protective jurisdiction and so the civil standard of proof (on the balance of probabilities), rather than the current criminal standard (beyond all reasonable doubt) should apply. This is intended to reduce the number of doctors whose performance will not be bad enough to merit GMC action but still be a cause of concern locally. Somerset LMC asserts that the criminal standard of proof should apply to ultimately deprive a practitioner of his or her livelihood R2, that the GMCs role investigating concerns and complaints be extended by creating medically qualified licensed GMC affiliates (GMCA) in each organisation providing healthcare is broadly welcomed. Some concern was expressed that this will be a local clinician in active practice as there may be more objectivity to be found in such a doctor not working in the same area as he oversees for the GMC. Rigorous training, support and audit will be provided by the GMC (R10). The LMC has reservations concerning the selection and training for, and funding of, these posts. Will this be from an enhanced GMC registration fee? Since the new GMC will have a lay majority and self-regulation is discredited we do not believe that doctors should have to pay for the scheme. R3 for GMCAs being able to deal with some fitness to practise cases locally with the power to agree a recorded concern to stand on a doctors record is welcomed. It seems quite correct that if the doctor does not agree, or the GMCA judges the case too serious, it will be referred to the central GMC (R4). The new national committee of the GMC with a lay majority will routinely review all recorded concerns together with a report of all the other performance issues dealt with by GMCAs. Under R7 all healthcare organisations will be obliged to inform the GMCA of all complaints and concerns received. Because not all inquiries will lead to formal action the LMC is pleased that these will be anonymised in the reports to the central committee. It seems entirely reasonable that the HCA and Health Service Ombudsman shall also be able to refer doctors to the GMC (R12) to prevent performance concerns falling into loopholes. R8 allows for a dual method of making complaints in primary care. Patients or their representatives will be able to complain either to the practice or to the PCT. This should be publicised widely in surgeries. The LMC would regret any move that deprived practices of being the first port of call for concerns from patients or their representatives as a satisfactory conclusion can often be reached quickly by this route. Rightly or wrongly doctors will resent being made to publicise the means whereby complaints against them or their staff can be taken elsewhere without the opportunity to offer explanation or an apology, if appropriate. There will undoubtedly be resentment at the requirement to further publicise the process for making and encouraging complaints, perhaps to a-one-stop-shop-a-doc: a cartoon in Private Eye showed a doctor with a sign on his back, Hows my caring? Ring 0800 .. The separate and independent tribunal with lay, medical and legal representation that shall adjudicate (R11) in cases where a practitioner is uncooperative with a course of remedial action prescribed by the GMC under an interim order or where this has not improved the situation (R15) is tentatively welcomed, probably not because of any great confidence it the concept on the part of members as much as because of lack of confidence in the current GMC system. Doctors and the GMC being able to appeal to the High Court against decisions ultimately made by the tribunal is fair but, again, the LMC regrets that the civil court burden of proof is not sufficient to deprive a man or woman of their livelihood. R14, that the NCAS should develop methods to assess the small number of doctors with mental health and addiction problems and that the NHS should commission a specialised addiction treatment service for health professionals, is to be welcomed. R16 is that the GMC and (Postgraduate) Medical Education & Training Board (PMETB) devise a clear set of standards for generic medical practice and that this be placed into the contracts of all doctors. This seems unnecessary as the duties of a doctor extend beyond his or her employment at any given time. NHS appraisal should be standardised, audited and make explicit judgements about performance judged against the generic standard in the doctors contract (R18). We have grave concerns about how such standardisation could cope with the wide variety of circumstances under which good general practice thrives, yet with so very few doctors being substandard. Celebration of diversity is something dear to the governments heart but this seems at odds with the drive to standardisation. R24 & 25 state that all locum agencies should be registered with the Healthcare Commission for the purpose of access to a GMCA and that contracting organisations should make a brief standardised return to him or her at the conclusion of every locum appointment. The LMC welcomes the inclusion of non-principals into the regulation process but believes that, in general practice, this could be a needlessly burdensome and pointless exercise as some locum appointments in general practice might be for a single session. It is hard to see how useful information would be gained in these instances. R26 deals with revalidation, a two stage process: re-licensure (the renewal of the right to remain on the Medical Register) and re-certification (the right to remain on a specialist register). The process should be affirmative rather than confirming the absence of concerns. Re-licensing will be based on the revised system of NHS appraisal and any concerns known to the GMCA. The GMCA will be responsible with the CEO for making a confirmatory statement to a statutory clinical governance and patient safety committee (R28). The GMCA will only be able to make a confirmatory statement if the doctor is engaged in annual appraisal and has participated in an independent 360 degree feedback exercise in the workplace (which will be designed and commissioned by an independent organisation (R30)) and that any issues concerning the GMC have been resolved (R28) employer as a reference (R29). The LMC has doubts about the evidence base for 360 degree appraisal and also in the ability of those in small practices and non-principals to undertake it. Doctors approaching retirement will be invited to review with the GMCA whether a further five year re-licensure is desirable. A working group should consider the setting up of a register of retired doctors to enable a defined period of limited practice (R27). A representation has been made to the LMC pointing out that older doctors are a valued source of part time, sessional, out of hours and locum doctors. It is clear that any obstacle to continuation in work will encourage a proportion of these doctors to abandon practice altogether despite the overwhelming majority being good, competent and experienced doctors. This will have serious workforce ramifications. Specialist re-certification will occur no less often than every five years and will rely upon membership of, or association with, the relevant Royal College which will make a positive assurance after a comprehensive assessment against the standards set by that College (R31). General practice is somewhat unusual amongst medical specialities in that many practitioners have, to say the least, an ambiguous attitude to their Royal College. It will be interesting to see how these difficulties will be addressed. R33 is for a national clinical audit advisory group to drive local programmes and provide publicly available data. Significant event monitoring should be a contractual obligation on GPs and that there should be piloting of a national system for death monitoring. Furthermore the RCGP and the NHS Business Service Authority (ex PPA) should work together to see what prescribing data could be used to scrutinise performance of doctors (R34). The LMC recognises that these data may be useful but hopes that local knowledge and commonsense will be applied their interpretation. PCTs will be obliged to assure that lessons are learned from errors and complaints (R35) and attention should be paid to ensuring the formal and personal accountability of individual GPs to their PCTin particular, PCTs should be guaranteed unfettered access to all patient records (R36). This caused some concern to the LMC and was thought to risk the continuation of the much vaunted doctor-patient relationship as a basis for general practice. Insurance premiums paid by NHS organisations and by practitioners to their defence organisations should reflect clinical governance processes applied, thus creating a financial incentive to promote safe practice (R37). An expert group should consider this. The LMC would welcome this but does not hold its collective breath about saving money. R41 is that there should be a system whereby, if a patient registers with a new GP without changing address, the PCT should offer a confidential interview at a place of the patients choice in order to capture a potentially vital source of information on patient experience This is strongly thought to be unlikely to be the case: patients may change doctors for positive as well as negative reasons and it is also pointed out that patients are now registered with practices rather than individual doctors. The LMC doubts that the effort involved would represent value for money in identifying real concern. The CMO quotes, apparently approvingly, the ethicist Onora ONeill, The efforts to prevent abuse of trust are gigantic, relentless and expensive: their results are always less than perfect. Baroness ONeill, the best Reith lecturer of recent years, argued that this was a cause for more trust in society, not more regulation. The LMC questions whether the parade of proposed working, groups, expert panels, committees for public safety and numerous other quangos represents an unwieldy and unworkable over reaction to a problem that has been exaggerated out of all proportion? The LMC, in making these comments, notes with some trepidation the undoubted authoritarian undertone in this document. It is also be concerned by the CMOs statement, that lighter-touch regulation of doctors - whether on grounds of cost, ideology or professional acceptability - would mean the acceptance of risks to patients being tolerated... and what this means for the validity of the consultation process.     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