By Melanie McDonald
My timing is probably not the best: a few days before Channel 4 had broadcast the Dispatches documentary, “Can you Trust you’re Doctor?” After sending in undercover reporters to GPs’ surgeries so that they could fail to be diagnosed with various life-threatening conditions and highlighting several genuine cases of misdiagnosis with predictably tragic consequences, there was a fleeting shot of Dame Janet Smith bemoaning the lack of an independent adjudicatory body before Jon Snow was shown interviewing a rather cautious Niall Dickson resolutely picking his way through the points being put and not giving much away. Neither Snow nor Dickson seemed to have much relish for the discussion. It was difficult, Dickson said, for the GMC to investigate poor clinical practice unless the case was referred to the GMC. Patient protection, he emphasised, was what the regulatory process was about, not the punishment of erring doctors.
Now here I am at the GMC to interview him about the future of healthcare professional regulation, walking past the bronze Anthony Gormley figures staring blankly through the plate glass windows on to Euston Road. Stephanie, a cheerful Australian girl and the GMC’s press officer comes swinging towards me, clipboard in hand. I have been asked to submit my questions beforehand so there are not going to be any surprises. The whole operation is as slick and polished as you would expect it to be given the high profile of the organization. She asks me in a lowered voice whether I saw the Dispatches programme. I say yes and she shakes her head grimly, giving a low whistle of exasperation.
On the way up Stephanie briefs me about procedure. I have been allocated an hour. She will remain present throughout and the interview will be recorded. She will send a copy of the recording over to my chambers the next day. Then we are in the room, Niall Dickson rising from a desk and walking to join us at a large round conference table. Stephanie arranges herself and her papers across the table from me and places the Dictaphone in the middle. Of the three of us, Niall Dickson is by far the most seasoned at this kind of thing, having moved from the editorship of the Nursing Times to be health correspondent and, eventually, Social Affairs Editor at the BBC before leaving journalism to become Chief Executive of the Kings Fund in 2004. He was appointed Chief Executive of the GMC in January 2010.
In many ways the GMC has been the winner in the reorganization of healthcare professional regulation signaled by the arrival of the Coalition. The government’s chosen route of abolition of OHPA but making (or at least encouraging) some changes to the current regulatory framework depended heavily of the ability of the regulators to take matters forward and the GMC with its recently completed suite of hearing rooms in Manchester was well placed to step into the vacuum created by the abolition of the Office of the Health Professions Adjudicator (OHPA). The Shipman reports with their trenchant criticism of the GMC seem a long way away now. The GMC very much leads the fleet of healthcare regulators and the man at the helm has an air of quiet purpose about him. He gives the impression of being entirely comfortable in his role and confident in the direction he is taking. From the brief conversation I’ve had with Stephanie it’s obvious that she thinks that the arrival of Niall Dickson has been altogether a very good thing for the GMC.
So to the interview. In the agenda prepared and submitted in advance, I have made it clear that I was interested in fitness to practice proceedings (FTP) rather than the current hot topic of revalidation, so I am slightly taken aback when Dickson immediately launches into a fluent monologue on the latter, “But” he says, smiling as he comes to the end, “That doesn’t answer your question does it?”.
In a way, though, it does because it is obvious that what Niall Dickson has in mind is a policy of prevention rather than cure, a plan to reduce significantly the number of referrals to the GMC on the basis that clinical issues will be picked up and addressed at local level through revalidation. This seems to be part of a new holistic approach to regulation. Self-regulation is, he explains, the key, and to that extent the policy is very much in line with current government thinking on healthcare regulation.
Several times during the interview he emphasises the importance of going back to the beginning: to the medical schools and engaging the understanding of student doctors, catching them both at undergraduate and postgraduate level so that, through programmes of study, they gain an understanding of the issues surrounding civil and criminal liability as well as professional misconduct, and gain confidence in their ability to exercise professional judgment. The ultimate objective, it seems, is for doctors to have from the outset a more mature relationship with their professional body.
Patient protection, he says confidently, will be reinforced by the cultural changes taking place within the GMC, and it is this bigger picture which engages Dickson’s interest. Training and performance management are centre stage to his vision of regulation and he talks dismissively of “FTP wagging the GMC dog,” while he confesses to having found professional regulation “more interesting than I expected.”
Of course as far as fitness to practice proceedings are concerned nothing too radical is going to happen any time soon. With the Law Commission not due to report back on healthcare professional regulation before 2013 and many of the structural changes dependent on s.60 rule changes with a period of consultation, the reforms proposed in respect of case management and consensual meetings are still a long way off. Legally qualified chairs of FTP panels may be appropriate for more complex cases, but it’s difficult to discern any real enthusiasm for their introduction. Dickson points to the fact that the GMC already has a pool of long serving lay chairs to draw on whose experience would be missed.
The main change will involve the introduction of the Medical Practitioner’s Tribunal Service (MPTS) which ultimately will take shape as a separate statutory committee dealing with the adjudication of cases investigated by the GMC. In anticipation of this from summer 2012 FTP hearings will take place under the auspices of the MPTS. The appointment of its first president, David Pearl, was announced in December 2011. The MPTS comes into existence on the back of the OHPA drawing with it some of the procedural reforms that the OHPA proposed but evolving out of the existing system. So how properly independent will it be? Dickson points to the fact that the GMC is seeking legislative changes to incorporate a right of appeal for the GMC against MPTS decisions. Doesn’t the CHRE s.29 right of review and appeal provide sufficient protection against perversely lenient FTP panel decisions? Apparently not- Dickson acknowledges s.29 has a role to play as a back stop but clearly relishes the prospect of the GMC having the opportunity to challenge decisions made by its adjudicatory arm.
The main focus of our discussion on FTP proceedings is the possibility of resolving many FTP complaints through consensual discussions with the doctor concerned at the conclusion of the investigation. This is predicated on a cultural change, encouraging a climate of full and frank disclosure on the part of the practitioner which, he says, may be particularly effective in addressing financial, organizational or performance issues. Concerns that this may lead to a perception of the whole thing being sewn up behind closed doors, ignore, he says, the continued input from case examiners and the requirement for full disclosure from those doctors involved should reassure the public that the regulatory process will remain a robust mechanism for dealing with complaints.
In the end the discussion comes full circle, back to revalidation, to joined-up regulation; keeping things at local level wherever possible, with the GMC a necessary but background presence liaising with employers, providing advice to medical directors. It’s a persuasive pitch and if the big picture is slightly lacking in detail that’s because it is, well, the big picture. I have no doubt of the coherence of Dickson’s vision or his determination to translate it into a working model. He is in every sense a grounded and pragmatic visionary, well used to working within the restraints of the current political landscape and able to focus on what is probably achievable.
So all in all a safe pair of hands at the helm of what has, in the past, often proved to be an unwieldy ship. Revalidation and improved training on professional regulation may well – in the long term – be effective in reducing the number of complaints about doctors, but it is very much a long term fix. In the meantime the extent to which the MPTS can provide an effective substitute for the modernisation of healthcare professional regulation which the OHPA promised, remains a more uncertain proposition. It is unclear how the MPTS proceedings will differ in substance from current FTP practice and procedure. Despite the upbeat tone of the discussion I leave feeling slightly subdued, and become more so when, a few days later, Stephanie sends an apologetic email. It seems that the promised recording of the interview has been accidentally wiped, so perhaps not such a slick publicity machine after all.