Aspiring to “right-touch” regulation

PROFESSOR Terence Stephenson took up the role as Chair of the GMC’s Council in January 2015. He has spent most of his career specialising in paediatrics, having studied medicine at Oxford Medical School. He is currently Nuffield Professor of Child Health at University College London and an honorary consultant paediatrician at University College Hospital London and Great Ormond Street Hospital.

He only recently stood down as chair of the Academy of Medical Royal Colleges and is a former president of the Royal College of Paediatrics and Child Health.

Professor Stephenson is not involved in the day-to-day running of the GMC. The role of the Council – with its six lay and six medical members – is one of strategic oversight: making sure the regulator is properly managed by its executive team and fulfils its statutory duty to protect, promote and maintain the health and safety of the public by ensuring proper standards in the practice of medicine.

What do you see as the main challenge facing UK healthcare and the GMC as a regulator in coming years?

I think the biggest challenge facing any regulator is the fairly relentless increase in complaints over the last decade. And it’s not particular to doctors – if you look outside healthcare it also applies to lawyers and other professionals. Allied with this is the fact that healthcare in the UK is in a very stressed state – most doctors, nurses and other professionals would say there is a lot of pressure on. We’ve had a recession, finances are tight and there are concerns over recruitment into particular specialties.

But I think for regulators the big challenge is the rise in complaints. One of the reforms ideally we would like to see is that only relevant complaints make it to the GMC. We get about 10,000 complaints a year and probably about half of those get very quickly referred back to the employer: contractual or other issues we don’t really want coming to a national body like the GMC. We think they should be kept locally. They may have some substance, some issue needing investigation, but are not appropriate for the GMC.

Why are complaints against doctors rising?

I think it’s a societal thing and, like I said, that’s true in all professions. We have a more well-informed population and a less deferential relationship between the public and professionals like lawyers, accountants, dentists and doctors. We also have a more litigious society in general, with people more willing to make complaints across the board.

Medicine has also become more complex. It was Sir Cyril Chantler who said medicine used to be ‘simple, ineffective and relatively safe’. Now it’s complex and often carries risk, but saves lives. It’s certainly more complex than when I was a student, with more complex therapies, more complex treatments.

Do you think there is a danger of doctors becoming over-regulated?

I think that is a very fair question and it behoves all regulators to make sure that the burden of regulation is proportionate and risk-based. We are overseen by another body called the Professional Standards Authority and they produce a regular report on the nine healthcare regulators. They have complimented us on what they called our ‘right-touch’ regulation – and that implies proportionality; that you are light touch where you can be but have heavy boots on the ground where it’s required. And I think that is what we aspire to.

I’m a practising doctor and have twice been reported to the GMC. Nobody likes it and you feel the sword of Damocles as you go through the procedure. But I would say we are working hard to make the process more proportionate. Perhaps we haven’t been as good at getting the message across to all our 267,000 doctors that the GMC has an obligation by Act of Parliament to investigate every single complaint that is brought to us. So we can be ‘right touch’ for the downstream of what we do but there is no discretion to say “actually that doesn’t sound very serious so we won’t look at that”. We definitely have to look at all of those 10,000 complaints.

Has revalidation had any demonstrable effect on quality of care?

This is a common question and, in truth, there is no way you can show causality between revalidation and quality of care because there are a huge number of other things going on over a five-year period [of revalidation] that might affect quality of care.

I would turn the question around. I think most people would be astonished with the idea that doctors didn’t somehow have to demonstrate that they were still fit to practise. I last took a professional exam in 1986 and until I revalidated in 2013, there had never really been a formal process by which I could be called to account and asked to demonstrate I was still a fit doctor to be seeing patients. So I think that is the role of revalidation.

Trying to show that it has had an impact on quality of care would be quite difficult but we do know that we have already declined licences for a significant number of doctors; so it does again have teeth. It’s not a tick box; it’s not a shoe-in that everybody automatically revalidates.

Is the organisation any closer to understanding the cultural disparity among doctors subject to GMC investigations?

I think we are getting closer but are not yet at the bottom of it. We are continuing to work with organisations like the BMA and BAPIO to try and understand it better. I think if I went tomorrow to work in another country where English wasn’t the main language, with a different culture and context, I would probably be more likely to get into difficulties. I don’t think that is so surprising. What we want to understand better is if BME (black and minority ethnic) doctors who are born in the UK and educated and trained here seem to be over represented in our procedures – and I think we have some more work to do on that particular point.

Researchers at Plymouth University recently published an independent review of 187 randomly selected cases and concluded that the process was fair. It was a detailed study of our decision-making during investigations. What we did find was that we didn’t always spell out our reasons clearly enough. So if we found somebody’s language or cultural context was wrong we should be spelling that out better.

Do you think the GMC has a duty of care to doctors being investigated?

I acknowledged to you before that I have been twice investigated and I found that very stressful, so we completely recognise that these procedures are of course an added stress and indeed could sometimes be the cause of stress. We don’t doubt that for a moment. We are reviewing the tone of all our communications with doctors who are under our procedures. We don’t want it to be unduly officious or heavyhanded but they are legal documents and we are obliged to investigate every complaint so can’t duck our responsibility either. We just have to try and strike a balance. We need to walk that line between taking the complaint seriously and investigating but also taking a doctor’s health problems into account and try and manage that as best we can.

How do you think a national licensing exam would improve patient safety?

I think there are two answers to that. First, if someone were to ask - can you assure me that every doctor graduating in all 32 medical schools in the UK is reaching a common standard, passing the same exam like a driving test or pilot’s licence – I wouldn’t be able to say that. I would have to say that universities examine their own students, as they do in a modern languages or a physics degree. There are some checks and balances in there: they have external examiners, they have a shared question bank. But nevertheless these are university exams. So I think we could better reassure the public with a single licensing assessment to ensure that all UK doctors reach a common standard.

Second, at the moment some doctors coming from outside the EU take something called the PLAB exam, which is set at the level expected at the end of Foundation Year 1. But, if we had a single exam, that all our doctors have to take wherever they qualified in the world, it would make it simpler to reassure the public that doctors coming from overseas countries were reaching the same standards as our own graduates.

It would also be an exam in English – and in the context of UK practice. So all the medicines and the treatments, the consent and capacity issues, the medical, ethical and legal issues would reflect British practice.

Interview by Jim Killgore