International Journal for Quality in Health Care 15:375-376 (2003)
© 2003 International Society for Quality in Health Care
Conference Paper |
Improving professional competence—the way ahead?
Guy’s, King’s College and St Thomas’ Hospitals’ Medical & Dental School, London, UK
Globally, there has been considerable interest from the public, medical profession, and governments in ensuring that doctors are fit for practice. Appropriate accountability for the profession has become an important contemporary issue. With doubts emerging on the effectiveness of professionally led regulation, a variety of different mechanisms have been devised to ensure that patients receive appropriate and good quality care. This paper reviews regulation of the medical profession and indicates the way in which doctors in the UK are held accountable for their practice.
Keywords: competence, fitness for practice, medical education, quality standards, professional regulation
Address reprint requests to Professor Sir Graeme Catto, MD DSc FRCP FmedSci, FRSE, Dean, Guy’s, King’s College and St Thomas’ Hospitals’ Medical & Dental School, 57 Waterloo Road, London SE1 8WA, UK. E-mail: graeme.catto{at}kcl.ac.uk
Based on a Plenary Address to the 19th International Conference of The International Society for Quality in Health Care, Paris, France, 7 November 2002.
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Medical regulation |
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 Top Medical regulation CompetenceRevalidationFutureReferences |
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The General Medical Council (GMC), founded in 1858, is a typical medical regulator. It is a statutory body comprising lay members and doctors, and membership will shortly decrease from 104 to 35, 40% of whom will be lay people. The Council has a number of linked functions.
- Drawing on widespread consultation with the public and the medical profession, the GMC sets the standards expected of all doctors [1].
- The Council has the statutory responsibility to coordinate and to promote high standards in all stages of medical education, thereby ensuring that all doctors working in the UK are able to meet the prescribed standards [2].
- Through its Fitness to Practise procedures, the Council can take action against any doctors whose practice is considered to have fallen below these standards.
- Finally, it retains a Register of qualified doctors able to work in the UK.
From 2003 all doctors working in the UK will be required to provide information on their clinical practice, their relationships with colleagues and patients, and on how they keep up to date in order to acquire a Licence to Practise. This process is known as ‘revalidation’ and the licence will normally be awarded for a period of 5 years.
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Competence |
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Over the last few years there has been considerable interest in determining how best to assess doctors. A variety of computer-based techniques have been devised to assess knowledge and skills; these include multiple choice questions and variants such as extended matching questions. These techniques are reliable and some of the models are now used for undergraduate and postgraduate assessments in different countries.
Similarly, more sophisticated techniques are now available to assess a doctor’s competence, often in a simulated clinical environment. There is now increasing evidence that a doctor lacking the requisite knowledge, skills, and competence is unlikely to perform satisfactorily in clinical practice. The converse, however, may not be true. Many doctors whose clinical care is found to be below accepted standards are both competent and have adequate knowledge and skills. In day-to-day practice, however, they do not, for whatever reason, deliver care to acceptable standards.
The concept that the public, profession, and governments would wish a doctor’s professional practice to be assessed is widely accepted. This interest has been stimulated over the last decade or so by a number of medical scandals in both the UK and abroad; all have led to a marked change in the way in which the medical profession is both organized and held accountable. Within the UK, individual doctors are accountable to the medical regulator (GMC), which in turn is directly accountable to Parliament. The GMC is thus responsible for ensuring that all doctors on the Register (or in future with a Licence to Practise) are fit for practice.
Other countries have adopted different approaches. In the USA, for example, a ‘Physician’s Profile’ is available on the Internet. In this situation, a physician provides a complete note of his or her qualifications, working practices and any proved complaints. The information is substantial and it is difficult for any individual not well versed in medicine to distinguish what matters from what does not. Such unfettered access to information is not a new phenomenon. Prior to the middle of the 19th century, patients and potential patients had access to a good deal of information. At that time the medical profession was not held in particularly high regard. Quacks and patent medicines abounded while the treatment offered frequently did as much harm as good. The information available was generally of poor quality, based on advertisements, and the public had no ready way of determining fact from fiction. Medical regulation was introduced both to protect patients and to guide doctors.
The methodology for assessing the clinical performance of doctors is not yet well developed and at present involves a laborious, time-consuming, and expensive work-based assessment and more objective tests of knowledge, skills, and competence. Such an approach may be justified for assessing individual doctors whose clinical practice has caused concern; however, it is totally inappropriate for assessing the quality of practice provided by the medical profession generally. Many countries are introducing some form of recertification; in the UK this is known as revalidation.
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Revalidation |
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Revalidation is the regular demonstration by all practising doctors that they remain up to date and fit to practice medicine. It is one method of attempting to assess performance, leading to the provision of a licence to practice. In 1995, the first edition of the GMC Standards document Good Medical Practice [1] was published. Each doctor will be required to provide information under the seven major headings in that document:
- Good professional practice.
- Relationship with patients.
- Working with colleagues.
- Maintaining good practice (keeping up to date).
- Teaching and training.
- Health.
- Conduct.
The public enquiry that followed the revelations of the poor outcome for children requiring complex cardiac surgery in Bristol [3] recommended a number of important changes for the regulation of doctors and other health care professionals, including the following:
- Continuing professional development (CPD) should be compulsory for all healthcare professionals.
- Appraisal should be compulsory for all healthcare professionals.
- Revalidation should be compulsory for all healthcare professionals.
- The public, as well as the employer, and the relevant professional group must be involved in the process of revalidation.
In order to assess professional performance, a number of factors will have to be brought together. The information on a doctor’s practice will be used for the annual appraisal process and also for the revalidation procedure, to be undertaken normally every 5 years. Based on the data presented by the doctor, revalidation groups will revalidate the doctor or refer the matter back to the GMC. The revalidation groups will be trained by and integral to the GMC, and we envisage they will include lay members. In summary, the process will involve the following factors:
- Portfolios: doctors and organizations will collect information about performance generated by day to day practice, including evidence from patients.
- Appraisal: information will be used for annual appraisal.
- Revalidation: revalidation groups will review folder or appraisal summaries every 5 years.
- Licence to Practice: the GMC will revalidate or refer to the Fitness to Practice or Revalidation Evidence Committee.
Similar approaches are being evaluated in a number of different countries. With the increasing mobility of doctors it is essential that the regulatory bodies cooperate effectively. The International Association of Medical Regulatory Authorities has initiated this type of cooperation.
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Future |
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If the medical regulators are to sustain the confidence of the public, the medical profession, and the government, they must ensure that they too are competent and fit for purpose, and have the interests of the patient at the heart of everything they do. They must work closely with others, both in their own country and abroad. The responsibility for good quality practice will, however, continue to depend on the professional standards of the individual doctor.
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References |
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- Good Medical Practice. London, UK: General Medical Council, 2001. Http://www.gmc-uk.org/standards (accessed April 10, 2003).
- Tomorrow’s Doctors. London, UK: General Medical Council, 2001. Http://www.gmc-uk.org/med_ed (accessed April 10, 2003).
- Learning from Bristol. The Report of the Public Inquiry into Children’s Heart Surgery at the Bristol Royal Infirmary 1984–1995. Http://www.bristol-inquiry.org.uk (accessed April 10, 2003).
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