large-scale organisation, and has at its command powerful tools, requiring skilled and sensitive use. Furthermore, patients know a great deal more about medicine than they did. Has the GMC kept up with these changes?
A SOCIOLOGIST LOOKS AT THE GMC CRITICISM
Department of Sociology, University of Warwick, Coventry CV4 7AL MEDICINE in Britain is currently exempt from the legislation that curtails restrictive practices; and much of the power, prestige, and cohesiveness of the profession rests upon this privileged position. These privileges will cease if legislation follows the lines proposed in the Government’s review of restrictive trade practices policy. The circumstances in which doctors practise are increasingly subject to managerial control, and the NHS review proposes further extensive changes towards a market model of health care delivery. As regulator of the profession, how will the General Medical Council cope with the impending changes? I was a lay member from 1976 to 1984, and have since been doing research on the working of the Council. The new President, Sir Robert Kilpatrick, has taken office at a testing time. A little over 20 years ago the "rebellion" began that led to the 1975 Merrison Report and the 1978 Medical Act. A miscellaneous group of radical youngish doctors finally rallied the profession to reform behind the cry "no taxation without representation"-the introduction of the annual retention fee being the precipitating cause of the trouble. Michael O’Donnell alone of those rebels survives as a GMC member. The 1970s reforms were profession-led, but changes of the 1980s-as well as those likely to come in the 1990s-have been encouraged by consumer criticism expressed through patients’ associations and the media, and by a right-radical, apparently pro-consumer, government. How the profession is regulated, by whom, and whether it continues to be self-regulated are crucial questions. When the Medical Register was first established in 1858, the GMC was charged with regulating the profession in the public interest. In exchange for protection and privilege in the market over and against all other healers, the profession assured the State that members of the public would get satisfactory treatment if they consulted practitioners registered with the GMC. There have been immense social, economic, and political changes in the past 130 years; medicine is an altogether different activity, involving a complex division of labour and
25. Crapper DR, Krishnan SS, Quittkat S. Aluminum, neurofibrillary degeneration and Alzheimer’s disease. Brain 1976, 99: 67-80. 26. Perl DP, Brody AR. Alzheimer’s disease: X-ray spectrometric evidence of aluminum accumulation in neurofibrillary tangle neurons. Science 1980; 208: 297-99. 27. Perl DP, Brody AR. Detection of aluminum by SEM S-ray spectrometry within neurofibrillary tangle-bearing neurons of Alzheimer’s disease. Neurotoxicology 1980; 1: 113-37. 28. Perl DR, Gadjusek DC, Garruto RM, Yanagihara RT, Gibbs CJ. Intraneuronal aluminum accumulation in amytrophic lateral sclerosis and parkinsonismdementia of Guam. Science 1982; 217: 1053-55. 29. Yoshimasu F.Aluminum in amyotrophic lateral sclerosis and parkinsonism-dementia in Japan and Guam. Amyotrophic Lateral Sclerosis in Asia and Oceania. In. Chen KM, Yase Y, eds. Proceedings of the Sixth Asian and Oceanian Congress of Neurology: Amyotrophic Lateral Sclerosis Workshop. Shyan-Fu Chou, National Taiwan University, 1983: 357-69. 30. Spencer PS, Ohta M, Palmer VS. Cycad use and motor neurone disease in Kii peninsula of Japan. Lancet 1987; ii: 1462-63. 31. Spencer PS, Nunn PB, Hugon J, et al. Guam amyotrophic lateral sclerosisparkinsonism-dementia linked to a plant excitant neurotoxin. Science 1987; 237: 517-22.
Some doctors trivialise the GMC, pointing to the greater importance of the Royal Colleges, the BMA, and other bodies in setting and maintaining medical standards. Others see the Council as composed of "fuddy-duddies" or
"politicos" and not really relevant to everyday medical practice. However, the GMC is undoubtedly important, not only because of the powers vested in it, but also because it is the gatekeeper between State and profession and between profession and public. It may follow rather than lead, but it defines the bottom line of acceptable medical practice, in which it alone speaks for the whole profession. Other critics think the GMC harsh or quixotic in its disciplinary activities. A lay member of the Council, Jean Robinson, accuses the GMC of being soft on doctors who behave unprofessionally and of allowing incompetent practitioners to slip through the net, thus putting the public at risk.! Many medical practitioners are themselves convinced that more attention should be paid to continued medical competence whether through the GMC or some form of peer review. Some medical members of the Council worry about the opacity of many GMC procedures and about the power which, by statute and practice, resides in the President. Underlying the principle of self-regulation is the profession’s request to the public: "Trust us". Jean Robinson’s message is "We, the public, don’t feel we can trust you; not only do we have evidence of things that go wrong (to be expected in any occupation) but we have evidence that they are not always properly investigated, nor are adequate measures taken to prevent a recurrence". I must add that most of the other lay members dissociated themselves from her critique. REFORMS
My research shows movement in the GMC’s "blue pamphlet" (which spells out what is acceptable professional practice) from an almost exclusive intraprofessional focus towards issues about the quality of patient care. However, I also found that most of the changes came as a result of external pressure, albeit pressure that gave forward-looking members of Council opportunities to propose reform. How one judges the reforms must depend on what one thinks the GMC is or should be doing. If we are looking for a body that not only lays down clear guidelines about acceptable practice, including clinical matters, but also pursues miscreants relentlessly-and is seen to be doing so-then the changes made must seem minuscule. If one believes the GMC should be ensuring that doctors who are incompetent are found out (perhaps through a system of privileged reporting to peers), given opportunities for retraining or whatever, and ultimately removed from the Register only if they do not comply, then again the reforms to date do not seem very large.
1. Robinson J A patient voice at the GMC: a lay member’s view of the General Medical Council. London: Health Rights, 1988.
the GMC as the most important piece of complaints machinery for aggrieved patients-and the only one available for private patients-short of the law courts. The GMC was, of course, not designed as such. It was really set up to protect the profession. Those doctors who still see this as its main task will think the changes have gone too far.
COMPETENCE AND DISCIPLINE
The GMC’s control of entry to the Register is crucial to its effective performance. There are two aspects here-the quality of training that medical students receive and the standards achieved by those who are deemed to be qualified. For both, the Education Committee has to rely on the competence of the universities that it is charged to oversee. Furthermore, in any grading system, including those used for medical students, some candidates only just fail and some only just pass. Such systems rely on the line being drawn high enough. Having ensured, as far as possible, that newly qualified doctors are competent when they are registered, the GMC has then to maintain a "register of the competent". This it patently cannot do unless it has either an inspectorate (something which the profession has always refused) or another system whereby doctors who have become incompetent, careless, or in some other way a hazard to patients are found out and action is taken. Doctors, like all other workers, are reluctant to "shop" their colleagues; and to that understandable distaste is added the strong indoctrination about the unity of the profession which played such an important part in its establishment. But covering up for incompetent or unfortunate colleagues is no longer in the best interests of the profession; it has never been in the best interests of the patient. My research suggests that, up to now, in the inevitable tension between maintaining professional unity and protecting the public, the balance has been tipped to the profession. One medical member suggested that the GMC should concentrate on improving its handling of obviously incompetent doctors because that, in the public view, is its most important service: "that’s what people think it does". Disappointment is immense when lay people discover that incompetence has not been a main concern of the Council. In the past doctors have thought it would be quite wrong for the Council to interfere in clinical matters, except in the grossest cases. The 1983 guidelines, in moving nearer to the area of competence, spelled this out: errors of diagnosis and treatment were of concern to the Council only when they raised a question of serious professional misconduct. Can a doctor-dominated body ever adequately discipline doctors in the public interest? Three sorts of proposals are made by those who think not. One suggests that the disciplinary functions of the GMC should be handed over to the law. The trouble with that is that lawyers (whose own profession is judged in need of considerable reform) are no nearer to understanding the ordinary patient’s point of view than medical people-and they are expensive. The second, a right-radical proposal, is that entire control should pass to a
totally lay body.2 A more moderate proposal, which in some versions includes separating the disciplinary from other functions of the GMC, suggests a large increase in the numbers of lay members of the Council. The GMC has recently increased their number (the proportion actually decreased after the 2. Green D. Which doctor? A critical analysis of the professional barriers in health care. London: Institute of Economic Affairs, 1985
Although doctors always feel beleaguered and vulnerable, they are individually and collectively in a much stronger position than patients.3 There is a case for at least a majority of lay members on the Council-a notion that many doctors will find anathema, although some have actually proposed it. Most doctors believe profoundly in the doctrine that only peers can judge peers. Clearly, lay persons require guidance as to what, in any given circumstance, appropriate medical behaviour might be, but in my experience they are perfectly able to understand the kernel of medical judgments and weigh up conflicting advice. 1978 reform).
We live in an age of radical and iconoclastic reform. If it becomes accepted that the profession is not regulating itself adequately, the task of control could well be given to others. Proposals from the profession will need to be examined carefully since even well-intentioned doctors will find it hard to devise a system equally fair to doctor and patient. Better that, from the start, doctors, patients, and potential patients work openly together to improve the system. This paper is based on an address to the annual conference of the British Association on March 20. I thank the Economic and Social Research Council for financial support and officers and members of the GMC for their help.
We continue our series of responses to the British Government’s working paper on medical audit. A GENERAL SURGEON
SURGEONS are pastmasters at audit, although until lately they may not have known that was the word for what they were doing. The successes, failures, and complications of surgical management have nourished countless hospital, regional, and national meetings; and Working Paper 6 pays tribute both to CEPOD and to the clear commitment to audit already made by the surgical Royal Colleges. It is shameful, however, that few NHS hospitals know the cost of even their commonest surgical procedures. There is room for improvements. Just because the work of a surgeon lends itself to measurement, and thus to information processing, we do not have to believe that measurement will always be a good thing. The beguiling charm of statistics can lead to inappropriate conclusions. Rather than the mighty leviathan that may emerge from the glossy cover of Working Paper 6, many of us would opt for a more limited investment, with provision of equipment, secretarial time, and consultant sessions to develop local audit, we could at least await the outcome of well planned pilot studies. Let there be a national, regional, district framework translated into local "norms" to which surgeons might aim to work. If every doctor is to be reviewed by his "peers" then the entire surgical plant of a hospital will have to shut down for at least one session a month; perhaps this could be integrated with other postgraduate educational activity to provide a profitable afternoon for all, but does it not at the same time raise the spectre of inefficiency? There is a danger that the entire process could even become a grotesquely enlarged 3. Watkins S. Medicine and labour: the politics of a profession. London: Lawrence and