The present and future standing of self-regulation in the pharmaceutical,
medical and nursing professions
and the need for revalidation for continued registration were discussed in the
first “great debate” session
at the British Pharmaceutical Conference on September 13. The voice of the patient
was also heard
For modern health services, quality was an essential ingredient not an add-on,
Miss ANN LEWIS (Secretary and Registrar, Royal Pharmaceutical Society) said,
opening her contribution to the debate. Not all health care professionals were
committed and conscientious about their duty to keep up to date. Attitudes of
arrogance, adequacy and “that will do” still persisted.
A profession represented a body of knowledge and an expression of intent. The
body of knowledge changed over time with new developments and discoveries. The
expression of intent was normally found in the form of a code of ethics or professional
guidance. This had to be seen to be acting in the interests of the public.
Miss Lewis said that the Royal Pharmaceutical Society had a tripartite function
as a registration, regulatory and enforcement body for pharmacy. It took these
roles seriously and was not complacent about them. She outlined a number of
changes that the Society was seeking to make to its disciplinary procedures.
“The Order-making powers contained in the Health Act 1999 give us greater
scope for making changes. We are now seeking to address much wider issues, including
the need for pharmacists to maintain competence through professional development
and the establishment of a ‘practising register’ of pharmacists.”
Standards tribunal
The Society was also seeking powers to look into allegations of poor professional
performance and to be able to put things right,
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| Ann Lewis: the issues of continuing professional development and a “practising register” of pharmacists are being addressed by the Society |
Miss Lewis said. These would be dealt with through the new standards tribunal.
Powers to deal with pharmacists whose performance was affected by mental or
physical ill-health were also sought, including an ability to suspend pharmacists
from the register where public safety might be at risk.
“We want to see proportionality: the availability of meaningful sanctions
from support and encouragement through to striking off — the punishment
must fit the crime.”
Miss Lewis said that she had been pleased to hear that the Department of Health
would be taking these proposals forward over the next year.
A major revision of the Society’s Code of Ethics was under way, she said.
The Society’s annual general meeting had approved Parts 1 and 2 of the
new Code in May and Part 3 and new standards guidance would be put forward in
2001.
Miss Lewis said that entry to the Register of Pharmaceutical Chemists was rigorously
controlled through accreditation of the schools of pharmacy and through competence-based
preregistration training and the registration examination.
A new system of continuous professional development was being developed for
existing practitioners and a pilot trial had been undertaken. The system would
form the basis of competence assurance, but it would not come cheap, Miss Lewis
warned.
The Society had been examining and revising the way in which it worked. There
was an expectation of increasing lay involvement on the Council and the Statutory
Committee. It had been said that professions were a conspiracy against the laity.
She did not believe that, but she could see how it might be seen as such.
“Effective self-regulation must be a dynamic process which is transparent
and accountable,” Miss Lewis said in conclusion.
Mr NIALL DICKSON (health and social affairs editor, BBC), chairing the debate,
asked Miss Lewis if she was optimistic about the future of professional self-regulation
in view of the formation of bodies such as the UK Council of Health Regulators.
Miss LEWIS said that she was. The Society was looking forward to playing its
part on the new council. There were principles of accountability and consistency
which could be applied to all professions, but it had to be remembered that
individual professional practices were different.
Self-regulation in medicine
Mr FINDLAY SCOTT (chief executive, General Medical Council) said that there
was a recurrent view that the work of the GMC was about protecting not punishing
doctors and that it was all done behind closed doors.
There had been a number of common features in recent high-profile cases which
had come before the GMC. These included damage being done to patients over a
long period of time; a lack of insight or humility among the practitioners;
a betrayal of public trust; late or ineffective management action; and an assumption
that these cases represented “outliers” from normal practice.
Some of the criticism of the GMC had been ill-informed, Mr Scott said, but the
GMC had been slow to wake up to the demands of patients and slow to ask politicians
for new powers.
“We did not act to seek new powers and we did not point out the problems
of not receiving them,” he said.
Some of the faults of the GMC had been that it had been too polite with politicians,
too slow to change, too narrow in its view of what regulation encompassed, too
reluctant to communicate and explain and that it had been unwilling to recognise
or set out the limits of what it could do.
However, things were beginning to change. A new medical curriculum, introduced
in 1993, was starting to take effect with newly qualified doctors. Standards
of good medical practice had been introduced and performance procedure to deal
with recurrent poor practice established.
Following the case of Dr Harold Shipman earlier this year, new interim powers
of suspension from the medical register had been introduced. A tougher approach
on restoration was being taken, with a minimum striking-off period of five years,
although the GMC had argued against the idea of “life bans”.
The way in which the GMC worked was also being overhauled. Mr Scott said that
a council of 104 members was “good for debates but poor for action”.
The number of disciplinary hearings had been increased, moving from one panel
sitting for 20 weeks per year to four or five parallel panels in 2001 in order
to clear a backlog of cases.
The medical profession had also made a start on revalidation for continued registration.
This would begin to take effect next year.
Mr DICKSON asked Mr Scott about professional disquiet about medical regulation,
including a recent vote of no confidence in the GMC at the British Medical Association’s
annual conference.
Mr SCOTT answered that the BMA had voted against the GMC as it was presently
constituted and not against self-regulation per se. There was a feeling among
doctors that the GMC was imposing extra burdens on a profession which was already
struggling. Mr Scott noted that the same meeting had also voted in favour of
revalidation, something which would have been inconceivable a few years ago.
Volume approach in nursing
With over 643,000 registrants, the UK Central Council for Nursing, Midwifery
and Health Visitors had to take a volume approach to its work, Ms SUE NORMAN
(chief executive, UKCC) said. Since 99.9 per cent of registrants were employees,
employers’ disciplinary and appraisal processes played a big part in the
UKCC’s work.
Ms Norman said that professionals often saw the registration process as simply
an administrative one, but being registered conveyed to employers and the public
that a suitable standard had been reached by practitioners. It was a licence
to practise. The register was not simply a list, it was an important tool for
public protection. The UKCC urged employers to check the registration of new
employees and to recheck existing employees regularly. The UKCC register was
available online to allow this.
Continuing professional development had been mandatory for nurses since 1995,
with renewal of registration taking place every three years. The UKCC had not
increased its registration fee (£36 for three years) since then. Registrants
had to complete at least 35 hours of learning over each three-year period within
their chosen area of practice. This had to be documented in a personal portfolio.
The UKCC was about to start an audit process on compliance with CPD, based on
a 10 per cent sample. Those found not to be complying would be deemed to have
let their registration lapse.
The problem with CPD was that it did not demonstrate competency in practice.
Employers had a big part to play in ensuring competence.
“Professional regulators do not have a monopoly of the responsibility for
protecting the public,” Ms Norman said. “It is also a responsibility
of employers, practitioners themselves and the Government, both in setting the
rules and providing the resources for the places of work.”
Clinical governance was shifting the focus of professional self-regulation on
to practitioners in practice. Ms Norman ended her presentation with four questions
which she felt needed to be answered in order to determine the future of professional
self-regulation: How could peer review and public involvement be balanced? How
could the competence of practitioners be guaranteed? How could professional
self-regulation be consistent with the public interest? Who would pay for regulation
if it was not self-regulation?
The view from the street
The public had great respect for the individual health care professionals whom
they
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| Sue Norman: professional regulators do not have a monopoly of the responsibility for protecting the public |
dealt with on a day-to-day basis, but they were influenced by recent headline
cases, Ms DONNA COVEY (director, Association of Community Health Councils in
England and Wales) told the Conference.
“Not that they think ‘My doctor is going to murder me’, but they
are worried about the way cases seem to drag on and what would happen if they
had a problem.”
Members of the public were concerned more about day-to-day injustices; about
the way that they were passed around the system and patronised if they did complain.
This escalated their complaints from the trivial to the serious. They were also
concerned about a “cover up culture” and “professional mafias”
which led to a real sense of “them and us”.
Ms Covey said that she was all in favour of revalidation for health care professionals
and for annual performance appraisals. These were already the norm in most companies
and public sector organisations.
There was a real issue about independent contractor status. If it was to survive
then there had to be an assurance that people would not “fall through the
gaps”. One thing that the National Health Service lacked was a good early
warning system.
She wanted to see a critical mass, and preferably a majority, of lay members
on regulatory bodies. It was not acceptable to have just one or two with a large
group of professionals. Even more important was having lay members on all the
committees where decisions were being taken. In addition, the lay members should
preferably have a record of patient rights activities and not just be members
of “the great and the good”. They had to be representative of the
population being served.
Regulatory bodies had to be “open, transparent and accountable and seen
to be so”. They had to give reasons for the decisions which they reached
and have clear criteria for handling cases. Complainants should be kept informed
about the progress of their cases.
“The national plan for the NHS has set out some solid principles, but the
challenge is to make it happen — to get a real voice for the public and
to change the culture of professionals away from defensiveness when regulation
is debated. It is starting to change among the leaderships, but problems remain
on the ground.”
Increased lay membership
Mr DICKSON asked how a lay majority could avoid being “captured” by
its professional body or being composed of “professional agitators”
who would wreck the processes.
Ms COVEY said that proper appointment procedures were needed along with proper
professional support for lay members on regulatory bodies.
Miss LEWIS said that she did not have a problem with more lay members, but there
was a need to retain a balance. In her opinion, professionals could be harder
on each other if the system was working well.
Mr SCOTT said that self-regulation applied to the practitioner him or herself
and at a national level. Most health care was delivered “one-on-one”
which was difficult to regulate by contract alone.
Mr ANTHONY COX (Birmingham) asked whether the Royal Pharmaceutical Society’s
dual role in representation and regulation presented problems.
Miss LEWIS replied that the Society was not a representative body in the same
way as the Royal College of Nurses or the British Medical Association. It was
not a trade union. The dual role had worked well in the past and would continue
to work if more lay members were appointed.
Ms NORMAN said that it was important to the UKCC not to be a representative
body. It was independent.
Ms COVEY felt that as the national plan was implemented such dual roles might
have to be unravelled. The public would want to see more clarity in how professionals
were regulated.