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PJ Online | News feature: How other health professions are coping with the regulatory reforms (2)

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The Pharmaceutical Journal
Vol 268 No 7194 p529-530
20 April 2002

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News feature

How other health professions are coping with the regulatory reforms (2)

It is not only the Royal Pharmaceutical Society that is having to face up to regulatory reform. Other health care professional bodies are, too. In this second article, Wendy Moore looks at the impact of changes on doctors, dentists and opticians who are still working on reform

Some key health professionals have already embraced the new world of regulatory reform and others are now teetering on the brink of change.

Two new regulatory bodies — the Nursing and Midwifery Council (NMC) and the Health Professions Council (HPC) — emerged from a year of dress rehearsals on 1 April (PJ, 6 April, p460) (PDF* 130K). Other health professionals — including doctors, dentists and opticians — are waiting in the wings. For them, this year will be a crucial time for change.

Unlike the NMC and HPC, which are entirely new bodies replacing their predecessors, the bodies regulating doctors, dentists and opticians will be revamped rather than replaced. The process, however, will still result in a sea change.

Focus of reform

In the wake of the Bristol inquiry and other high profile cases involving doctors, attention has inevitably focused on reform of the General Medical Council (GMC). The thrust of the changes to the GMC — in line with Government thinking ? is to slim down and streamline the organisation while also bringing in new fitness to practise rules and making continuing professional development (CPD) compulsory as part of a new system of revalidation for doctors.

Initial plans put forward in 2000 for transforming the GMC, currently a weighty body of 104 members, into a two-tiered organisation met general disagreement. The GMC regrouped and came up with plan B — to slim down to a council of 35 with 40 per cent lay representation, backed by a large number of medical and lay people who could sit on committees and panels. The new council would comprise 19 elected medical representatives, two appointed medical members and 14 lay people. Although still a bulky structure, this blueprint has won consensus from medical and consumer lobbies alike.

"It is a great advance," says Angela Coulter, chief executive of the Picker Institute Europe, which promotes patient participation. She would have preferred to see majority lay membership on the GMC but acknowledges doctors' eagerness to retain control over self-regulation. "I do see the 40 per cent as an advance," she says, although she points out the GMC will also need to introduce other changes to ensure better feedback from patients.

The GMC is currently awaiting a Government response to its plans. "A strong element of the proposals we have put forward is that they are the result of a consensus," says Mark Paulson, the GMC's governance project manager. "We hope the response from the Government does not unstitch that consensus."

The dramatic drop in medical members from the current 79 to 19 may evoke fears among some doctors that they are being sidelined and that minority interests will be excluded. But the GMC promises to find new ways to be inclusive — both for doctors and patients. "It is not about representatives. It is not just about seats at the table," says Mr Paulson. "We are going to have to have other ways of involving and including people."

The current pool of 150 lay and medical people who sit on fitness to practise panels already goes some way towards encouraging inclusiveness. The GMC has just opened a hearings centre — soon to become a regional office — in Manchester. The revamped body will also attempt to reach out to its far-flung constituents through conferences and meetings.

It is also hoped that a smaller GMC, similar to a board rather than the current huge "parliament", will be more efficient. "A smaller body meeting more often has got to be more effective," says Mr Paulson.

Electoral system needed

Before the new body can be constituted, an electoral system has to be set up for the 19 medical members. At the last GMC election in 1999, voters were asked to choose from a colossal 336 candidates on a 60-page ballot paper. Now it is planned to divide England into five regions so voters will be able to make more manageable decisions. Under current proposals there will be 15 members elected in England, two in Scotland and one each in Wales and Northern Ireland.

Lay members will be appointed by the Privy Council under the existing system for all regulatory bodies. Although the current lay membership will be reduced from 25 to 14 under the reorganisation, it represents a boost from 25 per cent to 40 per cent. Since the new nurses' and therapists' councils have been set up with almost 50 per cent lay membership, this may still be considered less than generous. However, Mr Paulson says: "What we have come up with is something we are comfortable with and leading patient and consumer and medical bodies are comfortable with too."


He argues that the size and shape of the organisation is far less important than the reforms it must implement. "What will make a difference to patients and have a big impact on doctors are issues like revalidation and our fitness to practise proposals," he says.

The GMC has spent two years thrashing out revalidation reforms. The proposals will mean in future all UK doctors will record and review their practice and professional development. Mostly this will be done in conjunction with NHS employers as annual appraisal. Every five years this record will be reviewed by the GMC, initially through local revalidation groups. Unless problems emerge this should lead to revalidation. When concerns are raised, the GMC will investigate further. Subject to legislation being approved this year, the first revalidation process will take place in 2005.

Reforms of the GMC's fitness to practise procedures have also been brought forward. As with the other regulatory bodies, one aim is to separate investigating from adjudicating complaints, in line with recent human rights legislation. Cases coming to the GMC have risen so much in recent years that as many as six adjudication panels are meeting every day. Already, however, the panels of five include lay members and some even have a lay majority.

Investigations committee

Under new plans, cases will be first considered by a new investigations committee. This will consider whether a complaint indicates that a doctor's fitness to practise is impaired by misconduct, poor health or — a new category — poor performance. Where there is a case to answer, complaints will be referred to adjudication panels drawn from the pool of medical and lay members. No members of the GMC will be members of the pool.

Although hearings panels will normally still consist of five people, the quorum will be reduced to three enabling more hearings to go ahead. The GMC will also investigate concerns which fall short of serious misconduct when it may issue warnings.

Angela Coulter welcomes the planned changes to the disciplinary system, which has come under fire for its slowness in hearing cases and inadequate redress. "There does need to be reforms," she says. But she believes doctors could dramatically reduce formal complaints by generally being more open when clinical errors occur. "Patients say what they want above all is for doctors to be open when errors occur, not to be defensive but to provide explanations," she says.

Timing of the GMC reforms remains unresolved. Legislation is expected by the end of this year to establish a revised GMC in 2003. The further changes are likely to be phased in rather than going ahead with a "big bang".

Dentists further ahead

Meanwhile, dentists are further ahead than many in reforming their regulatory body and introducing key advances, including compulsory CPD and new disciplinary procedures.

Plans for a smaller, streamlined General Dental Council (GDC) with greater lay representation were approved by Parliament last November. Currently, the GDC has 50 members, comprising the president, 18 elected and 17 nominated dentists, four chief dental officers, one dental auxiliary, three members of the GMC and six lay members.

The new-look body will be made up of 29 members comprising 15 dentists — including the president — four members from the professions complementary to dentistry and 10 lay members. All 19 dental team members will be elected and the president will be a registered dentist who will serve for five years.

But although the legislative framework is now in place to change the GDC several processes need to be completed before the body can emerge from its chrysalis. "The council would like to see the new body in place as soon as practicable and efficient," says GDC recertification director Chris Collins, who has been heavily involved in the reforms. In practice, the new GDC is unlikely to emerge before the end of this year. It will be a busy transitional period.

Before the reformed GDC can evolve, procedures need to be agreed for the election of the 19 dental team members at five-yearly intervals. There also needs to be agreement over the setting up of an appointments body whose job will be selecting people, both lay and professional, to make up a new fitness to practise panel which — as with the GMC — will be separate from the council itself.

The changes are driven by the need to make the future GDC a more strategic body. The new council will concentrate on the "big picture" — determining direction and policy, rather than dealing with detail, according to Mr Collins. As with the GMC, investigating complaints will be separated from deciding cases.

Currently, the GDC — like the GMC — both investigates and decides the outcome of cases where breaches of conduct are alleged. Under existing rules, the GDC's preliminary proceedings committee considers initial complaints about dentists. If it determines there is a case to answer it refers the complaint to the professional conduct committee — or to the health committee if the dentist's health is in question.

Under future plans, if the preliminary proceedings committee decides there is a case to answer it will refer the complaint to a new independent fitness to practise panel. The panel will be made up of lay people and members of the dental team who are not Council members.

But creating the new panel is a lengthy process. A shadow chair of the appointing body, Sir Graham Hart, has been appointed and plans are now being finalised to appoint the other members. Once they are in place, the appointing body will develop plans to recruit members of the fitness to practise panel. Once up and running, panels of normally five people — with a quorum of three — will hear individual cases. The new system is also being designed to deal with dentists whose performance is below acceptable levels, even though they are not charged with serious professional misconduct.

Long delays

Complaints are already a major burden for the GDC. Complaints have risen steadily — to about 900 in 2001 — so that there were 51 days of hearings last year compared to 13 in 1996. The workload means some long delays before hearings go ahead. Partly to help clear the backlog, the GDC agreed last month (March) to raise its annual retention fee.

Dentists have already made significant progress towards compulsory CPD compared with many health professionals. In January this year CPD became mandatory for a third of all dentists — those who registered between January 1990 and December 2001. The next tranche of dentists, registered in the 1980s, will begin compulsory CPD in January 2003. The final group, registered before December 1979, will join the scheme in January 2004.

Under the system, dentists must complete 250 hours' CPD within each five-year cycle. They must maintain their own records and make an annual statement to the GDC. At the end of each cycle returns will be checked to ensure they meet the required hours. A random selection of records will be audited. Failure to complete the necessary CPD could result in dentists being removed from the register.

"All dentists should be aware of statutory CPD and the requirements," says Mr Collins. The scheme was in development for four years before going live in 2002, he says. Although minor difficulties have emerged — in queries over forms and so on — there have been no major flaws. Ultimately, dentists — like other health care professionals — expect to undergo a process of revalidation and CPD is likely to form a major component of that.

Meanwhile, the GDC is working towards registration for all members of the dental team. Currently, more than 33,000 dentists are on the register, plus about 4,000 dental hygienists and 400 dental therapists. The GDC aims to extend its register to include dental nurses and dental technicians.

Long term process

For opticians, change has been a long-term process. The opticians' regulatory body, the General Optical Council, was transformed in January this year after two years of planning, into a slimmer, streamlined body of 28 with 15 professional and 13 lay members. The 15 registrant members are divided into nine optometrists and six dispensing opticians.

Driven by the reforms in other regulatory bodies, the GOC also aims to change its fitness to practise procedures and make continuing education and training (CET), as the opticians call CPD, compulsory. Currently, the GOC has no powers to deal with allegations of incompetence or health problems against opticians. Cases are normally dealt with through an informal procedure. It now wants to formalise proceedings, including setting up a health committee to hear cases where an optician's health is considered a problem.

Proposals for reform were submitted to the Department of Health last year. Details of the changes, however, are still "in the melting pot", according to acting head of conduct Roderick Clarkson. He says: "Hopefully we will see some changes this year."

This view will, no doubt, be echoed by the other regulatory bodies as they contemplate the rest of 2002.

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Wendy Moore is a freelance journalist

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