Entering the danger zone

The timing of the trial of Dr Shipman could not have been better. Regulation of the medical profession – meaning control of a high-spending group of civil servants prone to very variable performance – is a government ambition, now apparently justified by a medical serial killer, surgeons unable to distinguish right from left and the seemingly cavalier extraction of dead children’s organs. Although the introduction to the recently published document Supporting doctors, protecting patients says that it has been prepared ‘to address the small minority of problem doctors’, it has a much wider remit and there are many implications for the NHS.

There are three themes which seem to be central to government thinking. The clinical performance of all practitioners can diminish over time, because of the rate of change of scientific knowledge and practice. There is evidence that this is happening, and that existing systems for maintaining standards of clinical performance are insufficient to the task. New ones are needed, and will include revalidation, as a form of summative assessment (deciding on continuation of practice), probably set for doctors by the General Medical Council; and appraisal, as formative assessment (shaping performance, allowing for remedial action) but also contributing to revalidation. Significantly, poor performance will include failure to engage with quality improvement initiatives (under the title ‘clinical governance’) and to participate in clinical audit.

No doubt there will be professional lobbies interested in promoting conflict here, for failure to conform to current management directives and poor practice are arguably different. But the net effect of such changes could be to enhance the competence of practitioners, boost their sense of control over the work process, and increase their job satisfaction. The task for NHS management is to ensure the positive engagement of practitioners in quality improvement locally, and to set a realistic timetable for change and avoid imposing unnecessary tasks nationally. On past experience, this will be difficult for the NHS to achieve, driven as it is by short-term agendas set by Ministers, and low-trust relationships with professionals.

Dangerous performance is the extreme form of diminishing performance, and is important not only because of the consequences for patients, but also because of the high levels of psychological morbidity in the medical profession. The case for reform looks strong if the issue of dangerous practice is seen as a consequence of a system failure, in which vulnerable individuals enter and remain in a ‘zone’ of hazardous performance. Shipman may have decided to end the lives of many of his patients, but although working alone he did not work in isolation, and many around him did not act until very late in his career.

The current management structure of the NHS is unable to deal with this effectively or consistently. ‘General management’ has not been the solution that was promised, and clinical directorships have reached the limits of their powers. A large number of organisations have an interest in education, measuring performance and accreditation, and their roles are unclear. Supporting doctors, protecting patients proposes an autonomous regulatory system of assessment centres that will put problematic practitioners on the right track if local efforts fail, and speed up the process of excluding the irremediably poor performers.

These are necessary steps, but perhaps not enough. Spotting the truly villainous professional is difficult, for their skill lies in concealment. Identifying the beginnings of poor performance and acting on it are different issues. Although the professions may resist, appraisal and revalidation need strengthening with rolling short-term contracts that provide both security of employment and the possibility of dismissal.

Nevertheless, the limitation of professional autonomy is necessary, despite its risks and disadvantages, and the professions seeking public money cannot evade it for much longer.