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Maintaining high standards of professional practice

A key component of being a professional is the responsibility for ensuring that the care the NHS provides is of an appropriately high standard and that the interests of the patient and the wider public are put before the practitioner's own interest. The public and patients need to have confidence that this remains a realistic expectation of the healthcare professions. Key issues for consideration are listed here, under subject headings:

Appraisal and Assessment

1. Should doctors' performance be assessed in addition to, or as part of, the annual NHS appraisal? What purpose should appraisal of clinical practitioners have: should it be primarily for governance, with a mainly summative structure and handling, or should it be - as at present - primarily for developmental purposes, with a mainly formative structure and handling? Can it do both at the same time? How might small practices and departments be supported in this area? What form should assessment take?

2. What practical measures would assist with establishing that a doctor continues to be able to provide competent and safe services? Should 360° reporting be introduced by the NHS as part of appraisal? Should there be a confidential reporting system? Should doctors record their experience, learning or educational events in a log-book? Who should be involved in the assessment process?

3. How can patients and the public contribute to the maintenance of standards and competence? Should their views about their medical treatment be sought routinely? Or on a sample basis?

4. How should lessons learnt from patient complaints be fed into the appraisal system? How can staff be encouraged to identify and report poor performance or unacceptable conduct?

Revalidation

5. What should be the core purpose(s) of revalidation? Are the GMC correct when they say that the purposes are to contribute to raising standards by requiring doctors to demonstrate that they have reflected on their practice; and to protect patients by securing confirmation that doctors are up to date and fit to practise, by providing a backstop where local systems do not exist, or exist but are inadequate; and through robust quality assurance mechanisms?

An answer to this will be needed because it will influence data requirements, how 'success' and 'failure' are handled and how the process is presented to the public and to the profession. Should the emphasis be on securing public trust, on promoting Continuing Professional Development and the raising of standards, on detecting impairment, or on a combination of these aims?

6. In the light of this, what should the broad structure of revalidation be? Should it be a screening ('assessment level 1') process aimed at identifying practitioners at risk of having a fitness to practise problem; aimed at actually identifying dysfunctional practitioners (case finding, or 'assessment level 2'); or, as the legislation currently provides, aimed at evaluating fitness to practise (diagnostic or 'assessment level 3')?

7. What attributes (knowledge and skills), behaviours and attitudes should doctors have to demonstrate to maintain their registration? Are there any other relevant attributes which should be assessed?

8. How should the required standards be set? Should there be objective criteria? How should these be identified and measured?

9. Should there be a core evidence set for revalidation? How should it be defined?

10, How should 'failure to revalidate' be handled, in the light of topics I and II above?  How can we avoid 'double jeopardy', with repeated assessments?

Fitness to Practise

11. When a doctor's fitness to practise has been called into question what arrangements should there be to protect the public? How should the GMC monitor the compliance of conditions it has imposed on a doctor? Are there any extra safeguards for a doctor being retrained above those required for a doctor in training?

12. What arrangements are needed for doctors whose fitness to practise fails to meet the necessary standard? Is retraining a realistic option for all doctors? Who should pay for this? What arrangements should be for doctors to move to other duties and to provide exit strategies?

13. What else is needed to provide patients and the public with the assurance they need to maintain confidence in the competence and safety of medical practice?

14. How should information on practitioners' fitness to practise be held and made available, including information from appraisal, revalidation and fitness to practise (including local disciplinary procedures)? Should this be a single national database or a collation of local NHS and other databases (eg the GMC register)?

15. Should the GMC continue to be a complaints-handling body which receives complaints directly from any source, or should it be a body to which complaints are normally only referred by healthcare organisations and other public bodies where they have passed a threshold indicating that the doctor may be unfit to practise?

16. Will the complaints portal recommended by Dame Janet, together with appropriate public information about the differing aims of complaints procedures and fitness to practise procedures, resolve current public uncertainty about how and where to make a complaint; or is better role-definition for the various organisations involved, expressed where necessary in legislation, essential?

Future design of medical regulation

The medical profession is overseen by a range of bodies: the General Medical Council, the medical Royal Colleges, the Postgraduate Medical Education and Training Board (PMETB), NHS and other employers. The GMC is responsible for overseeing undergraduate medical education and for co-ordinating all stages of medical education; medical schools are responsible for delivering undergraduate medical education and the PMETB and postgraduate deans for the oversight of subsequent training. Taking into account your response to the above questions:

17. What should the regulation of the medical profession look like?

18. What should be the role and structure of the General Medical Council in the future? What should the primary purpose of the council, currently composed of 35 members, be: governance and policy development, ie more like a publicly accountable board, or delivery, ie directly involved in exercising the GMC's powers and functions? In either of these settings, what should its size be and how should members be appointed? If its function is governance and policy development, who should carry out the work of the council on delivery?  If its function is delivery, how should these powers be delivered? In fitness to practise, the following key components are currently delivered by the GMC: setting standards of conduct, policy and procedural rules, investigation of complaints, case presentation, adjudication. How should these elements be organised in the future?

19. Do we have the right balance between regulation and freedom to practise (including innovation)?

20. What alternative models are there in other fields of endeavour in the UK or elsewhere? How could these be adapted for the medical profession in the UK?

21. Should the regulation system be made more accountable and intelligible to the public? What should be the relationship between the GMC and Council for Healthcare Regulatory Excellence (CHRE)? How should the effectiveness of that relationship be evaluated? Should the GMC be made directly accountable to Parliament, as Dame Janet has recommended?

Members of the Advisory Group

• Dr Sheila Adam, Director of Public Health of the North East London Strategic Health Authority;
• Ms Janice Barber, Managing Partner at Hempsons Solicitors
• Professor Carol Black, President of the Royal College of Physicians
• Professor Sir Graeme Catto, President of the General Medical Council
• Mr Harry Cayton, Director for the Patients and Public, Department of Health
• Professor Angela Coulter, Chief Executive of the Picker Institute
• Malcolm Dean, Journalist at the Guardian Newspaper
• Niall Dickson, Director of the King's Fund
• Mr James Johnson, Chairman of the British Medical Association
• Professor Sir Ian Kennedy, Chairman of the Healthcare Commission
• Professor Sir Bruce Keogh, President-elect of the Society of Cardiothoracic Surgeons of Great Britain & Ireland
• Dr Mayur Lakhani, Chairman of Council at the Royal College of General Practitioners
• Dr Jock Lowe, (retired), Former Chief Pilot at British Airways
• Clara Mackay, Director of Policy and Research at Breast Cancer Care
• Ed Mayo, Chief Executive of the National Consumer Council
• Mr Michael Morgan, Director of the Change Partnership; former HR Director of Northern Food
• Jenny Simpson, Chief Executive of the British Association of Medical Managers
• Mrs Karen Straughair, Chief Executive Sunderland Teaching PCT
• Ms Jane Wesson, Chairman Council for Healthcare Regulatory Excellence