Personal Views: Dame Janet's disappointments
Authors: Glyn Elwyn
Journal: BMJ (2006)

“Good riddance to blind faith in doctors,” was the opening line made by Dame Janet Smith at the “After Shipman” conference, held by the Royal Society of Medicine last week. The high court judge who chaired the Shipman Inquiry was reflecting on the manner in which the murders by the infamous general practitioner, and other more recent cases of medical misconduct, had broken the pillar of trust between the public and the profession. Her view was that blind faith should be replaced by transparent standards: doctors who fail against such measures “should be removed from practice”—reiterating the key argument she made in her final report on the inquiry.


Strong leadership in the medical profession could do more


Dame Janet then listed her disappointments, arguing that there had been little, if any, action taken by the government or the General Medical Council in response to her raft of recommendations. Death certification reforms have not been initiated. Improvements in the monitoring and handling of complaints have not occurred. Reporting colleagues' shortcomings (“whistle blowing”) is still a precarious step for individuals to take. There have been no decisions on the future of revalidation, even though 18 months have passed since publication of her report. There is still a majority of members elected by the profession at the helm of the General Medical Council (GMC)—reducing its credibility as a body accountable to the public. There is also a conspicuous lack of information about professional performance at the level of the individual clinician.

Dame Janet admitted that not everyone agreed with her proposals—but she was dismayed about the sometimes “offensive and destructive” discussions that followed her report. Some have argued against the “sledgehammer” approach, arguing that it's wrong to suggest so many changes in response to what is hoped to be a “one-off” serial murderer in the medical profession.

Dame Janet disagrees. A profession in which Shipman's activities could go unnoticed or unreported needs radical reform to reverse an accelerating erosion of trust, she argued.

But the changes she proposed are not progressing. Almost immediately after the publication of the final Shipman report 18 months ago, John Reid stopped the proposed GMC revalidation process in its tracks, requesting a review by the Chief Medical Officer. This delay is worrying. The Chief Medical Officer is taking a longer time to arrive at a view than Dame Janet took to sift the evidence and write her report.

But all could be forgiven if good decisions emerge, suggested Dame Janet. She hopes that all who support her arguments will apply more pressure “wherever and however you can.” What did her summary mean for me? I sat there reflecting on the changes over the past few years. Appraisal has been widely introduced. But most of the people I talk to say that, despite benefits achieved by formative feedback, the appraisal process is not sufficient to ensure that doctors meet minimum standards. The methods used are neither independent nor based on any valid reliable metrics.

There has been some movement towards collecting peers' and patients' views of practitioner performance. For instance, general practice contact—although this is not filtering through to secondary care. But these are ad hoc and unsystematic, and there are no attempts to address variance against benchmarks.

There is some evidence of a framework emerging to deal with poorly performing doctors—with a system of individual practitioner support in some regions, such as that found in South Wales—but although extremely valuable, this could not be used as part of a quality control system.

Perhaps we have to wait for the government to declare its hand on this issue and take our lead from their next set of policy documents. But I suspect that, as a profession, we will remain passive, unable to demand that our professional bodies—various colleges and the General Medical Council—rise to the challenge of creating systems that monitor and measure performance rigorously and systematically.

I fear that Dame Janet may well continue to be disappointed, not just in the decisions being taken on the issue by the Chief Medical Officer but also in the continuing complacency. Strong leadership in the medical profession could do more.

The task of creating fair methods of assessment of performance that are valid across the many different facets of the diverse workforce in medicine is difficult. Drawing on clinical approaches to diagnose disease, perhaps we should devise a screening method for detecting variance in performance before asking outliers to take diagnostic tests such as discipline adapted simulated clinics, which many consider to be a gold standard.

It may be difficult but we must not give up. We should address the task with the care, urgency, and resources that it deserves.