Charlie Massey Westminster Health Forum speech - Regulatory reform

Introduction

In 1983, the Medical Act, which governs the GMC and its functions, was passed. It is a time that looks utterly foreign to today’s eyes.

In the 1980s, personal computers, which most of us have been glued to for the past year, were still a novel concept.

Smoking was so common in public spaces that even non-smokers had measurable concentrations of smoke products in their bodies.

And paternalism pervaded the doctor-patient relationship, with self-regulation the order of the day up until the late 1970s.

Like the world in which it operated, the nature and tenor of the GMC’s work was also vastly different.

In 1983, the GMC was dealing with less than one complaint a day, compared to around 10,000 a year when I arrived as CEO.

Around 2,200 PLAB exams, which overseas candidates must pass to join the register, were taken in 1983 . By 2019 this figure had risen to nearly 20,000.

And less than 10% of our Council were women , compared to over 50% today . It would be another 35 years before we had our first female Chair.

Meanwhile, cancer survival rates were 20% worse , life expectancy was around half a decade lower and innovations to improve patient experience, like day surgery , were in their infancy.

Nearly 40 years later, medical practice has been transformed. But while the needs of patients and the profession have shifted dramatically, regulation has remained more or less static.

This is an issue that goes beyond mere rules and processes. It’s about the needs of today’s health service, the doctors who work in it and the patients who rely on it.

The good news is that change is on the horizon.

More than a year of dealing with the pandemic has reinforced the case for fundamental change in the health system. With waiting lists now at a 14-year high , patient care will continue to dominate public consciousness. Good regulation has never been more important – in addressing the challenges we face today and in meeting the UK’s healthcare needs in the years ahead.

That’s why the GMC welcomes the government’s proposed reforms to professional regulation. From fitness to practise to workforce supply, they represent a once-in-a-generation chance to bring regulation in line with modern needs. We must not let the opportunity pass us by.

Fitness to practise

Patient safety is at the heart of good regulation. Upholding standards and acting swiftly against bad practice is fundamental to our role.

But the GMC exists to protect the public, not to punish the profession.

The route to delivering first-class care lies in supporting doctors so they do their job well. And that’s where we want to spend the bulk of our time and resource.

That means being decisive where there is risk of public harm and proportionate where the situation calls for it. Rather than using a hammer to crack a nut, we need a more nuanced approach.

The trouble is that current legislation means the emphasis of our activities is in the wrong place.

Under the Medical Act, we are obliged to hold hearings even in cases where it’s clear a doctor will be struck off, including when they have been convicted of murder or rape. That doctors convicted of these crimes are not erased from the register automatically must seem bizarre to the public.

At the same time, we are required to fully assess every complaint we receive, even if it doesn’t raise serious fitness to practise concerns and won’t meet our legal thresholds. Reform will allow us to be much more focused in deciding which cases we investigate, and how we do it – ensuring fairer and faster outcomes.

It will also give us better options for concluding cases in a way that takes account of the needs of all parties. Defaulting to an adversarial panel hearing can be deeply stressful. Not only for the doctor but also for the complainant, especially for those who don’t want to give evidence in public.

What we need is a more a proportionate approach, where the course of action is determined by the case at hand, not legislative diktat.

Reform will help us address this, by allowing for the greater use of ‘accepted outcomes’ in some cases. This will give doctors the option to accept that their practice is impaired and that a sanction is necessary, without having to go through a full tribunal process. It will do away with the lengthy, legalistic process, replacing it with swifter resolution where that is in the interest of all parties. By doing so, it will allow safe practitioners to continue in or return to the workforce more quickly.

As well as faster outcomes, the public and the profession should be able to expect openness and transparency. Whatever side of the complaint you’re on, an investigation process is hardly a trivial matter. And it’s reasonable to want to be kept informed. That’s why the reforms include a stipulation that decisions are published by default unless there is an exceptional reason not to. They also require the complainant to be updated at key decision points if requested. Transparency should be at the heart of our regulatory processes, so this is something I very much welcome.

Workforce

Greater flexibility in fitness to practise cases is long-overdue. But there’s another long-standing issue the reforms have the potential to address – the balance between supply and demand of healthcare professionals in the NHS.

Workforce shortages constrain doctors’ ability to deliver care to those who need it. And the health service needs more doctors.

Yet outdated legislation and onerous bureaucracy hampers the flow of senior medical talent to UK health services. As it stands, if a doctor from outside the EU wants to work as a consultant or GP here they have to go through a process that will require them to supply over 2,000 pages of evidence. This process often takes close to a year, with a failure rate of around 50%.

As a result, the UK becomes a much less attractive destination for experienced international specialists. Equally importantly, it blocks the progression of many SAS doctors already in the country who want to step into consultant roles. That means that patients too often aren’t getting the benefit of clinicians working to their full potential.

Reform will make routes to the register more straightforward and streamlined. It will give the GMC greater discretion, so doctors are assessed on their abilities, not the number of pages they can pull together. And it will speed up the process for senior doctors to join the workforce and enhance patient care with their expertise.

As well as growing the pipeline of senior doctors, reform will support the development of new medical roles. Numbers of Medical Associate Professions (MAPs), such as physician associates and anaesthesia associates, are small now but on the rise. Bringing these new roles into formal regulation will allow us to get the most out of them, whilst also giving patients assurance over their education and practice. In turn, it will help these professions to flourish, helping to address healthcare needs across the UK.

Regulation that enables

The golden thread running through all these proposals is the freedom to focus on the things that really matter in today’s health service.

More autonomy and less red tape mean we can use our resources to drive improvements in culture, training and education. It means we can ensure support is there for doctors at the start, rather than simply stepping in when things go wrong. And it means regulation can be responsive, flexible enough to meet future challenges.

A good example is the urgent imperative to tackle discrimination and inequality within the healthcare professions. The pandemic has showcased the deep pride we all hold in our health services. But it has exposed a shameful side too – that too many doctors from ethnic minorities continue to experience disadvantage. This ranges from educational attainment and career progression, to their likelihood of being referred to their regulator.

Creating an even playing field requires effort from us all, across the healthcare system. And regulatory reform will have a crucial role to play. Not only will it enable us to break the glass ceiling for so many doctors unable to fulfil their potential. It will also allow us to focus our attention and resource on the areas we can have the greatest impact.

In short, reform means regulation can be a real force for good – contributing to the solution, not being part of the problem. In the big strategic challenges the health service faces – from workforce supply to staff wellbeing – regulation has a role to play. It is our duty, and our desire, to play it.

Conclusion

When the Medical Act was written into law in 1983, its authors surely didn’t expect its prescriptions would still be defining how things were done more than a generation later.

The health system in 2021 is a world away from what it was 40 years ago. Patient and doctor needs alike have evolved as medical practice has entered the digital age. But regulation has remained static, restricted by red tape.

Change is sorely needed. And if there was ever a re-set moment for healthcare – this is it.

More than a year since the pandemic began and the health service has never been more revered. But the problems that existed before 2020 haven’t gone away. Indeed, in the case of waiting lists they’ve only been exacerbated.

Tinkering round the edges won’t cut it. What is required now is wholesale reform. A new model of regulation to meet 21st century needs.

Galvanized by the pandemic, the chance for meaningful change is finally on the table.

The reforms will allow us to do away with the anachronisms of the Medical Act, so regulation can do what it’s meant to do – protect patients and support its registrants to be good doctors. We must not squander the opportunity.