Quis custodiet ipsos custodes?


You may have seen or heard this question many times in various guises, as it concisely captures the question of our generation; who's watching the people in charge? Juvenal could not have anticipated its numerous applications (or longevity) when he wrote his satires on the Roman Empire. He was originally describing the problems inherent in monitoring marital fidelity, but these days we could use it when talking about governments, the church, banking or (virtually) any regulatory body.

So, let's talk about the GMC. It was established in 1858, primarily for registering who was licensed to practise medicine, as legal principles of autonomy and consent actually allow any person to offer medical treatment. The incentive to register was to receive 'privileges', but the result enabled sanctions to be brought against those who were not registered. In recent times the GMC has also pledged to 'protect, promote and maintain the health of the public' (1983), set standards of professional conduct (1995) and administrate revalidation (2012).

The GMC sits in a difficult spot - between public and medics. The public wants to be reassured that medics are all fit for purpose and accuses the GMC of leniency and collusion, but the medics complain that they have been persecuted out of keeping with the scale of their alleged wrong-doing. Levels of morbidity and mortality among doctors going through fitness to practise proceedings are high. Sixty-eight doctors in total, or 4-5% between 2003/4, have died during enquiries, prompting queries as to whether the process is fair and proportionate.

A recent high-profile case involved allegations against a GP that have been reported as 'inconsistent' and 'increasingly wild'. Struck off by the GMC, the GP has now been cleared of the charges by the high court, but will never be recompensed for the three years of hell he probably endured, or the financial consequences. He is said to be pursuing a claim of his own against the GMC.

Perhaps greater transparency in their regulatory proceedings would calm the storm. Several cases from the last decade mention the reluctance of the GMC to explain its actions, or admit when errors have been made. Research has shown that in the face of increased regulation and media scandals, doctors are practising more defensively.

This is not good news for the UK health budget (more investigations and referrals), or for the patients (increased health-related anxiety). Clare Gerada, talking about over-regulation, said: "We already spend up to £1bn regulating doctors. We are one of the most over-regulated professions around and there will always be people who fall through. If we pile on more and more regulation we will never win."

Which brings me to revalidation. There were reports last week that of the first 10,000 doctors revalidated only ONE had been found to need remediation. Commentators rightly pointed out that the first cohort contained many 'leaders' and high-profile doctors, who would be highly motivated and that subsequently numbers needing remediation would be likely to rise.

Time will tell, but at what cost? Current estimates run at revalidation costing around £100 million per year and this figure excludes the hidden costs, such as time taken to produce your evidence, time lost out of practice and the skills drain, as senior GPs decide 'it's time to go', unwilling to jump hoop.

The GMC is regulated by the government (through the Health Select Committee) and also has its fitness to practise verdicts reviewed by the Council for Healthcare Regulatory Excellence (CHRE -renamed after the Health and Social Care Act, 2012). Inevitably, mechanisms do exist to review the performance of the GMC, but do they have teeth? In their report of 2011/12 the CHRE states: "The GMC continues to meet the Standards of Good Regulation for fitness to practise. It has maintained an effective, transparent, proportionate and secure fitness to practise process, whilst undertaking enhancement work." Reassuring to read, but cold comfort for those at the sharp end. If revalidation aims to show 100% of doctors are fit to practise, shouldn't they aim to manage 100% of fitness to practise proceedings, without fatalities?

To help you tread the fine line between patient-centred practice and defensive medicine, our latest, evidence-based articles can be found here.