Annex A > Chapter 17 - Communication Between Healthcare Professionals and Patients > Guidance from professional and related bodies > The General Medical Council

The General Medical Council

22 Sir Donald Irvine, President of the General Medical Council (GMC) from September 1995 to present, outlined the focus of the GMC's guidance in the 1980s in his written evidence to the Inquiry:

`In the early 1980s, the GMC saw its standard-setting role primarily in terms of character and conduct and hence of the standing and reputation of the profession and the doctor. As a result the guidance focused on questions of honesty, improper relationships and abuses of trust. Those issues were - and remain - important. However they virtually excluded standards of clinical practice and relationships with patients, both seen as vital today.

`Until 1995, the guidance on standards was published as part of the description of the GMC's conduct procedures.' [29]

23 Sir Donald went on:

`The guidance was the product of the culture in which medical regulation was seen as a reactive means of coping with exceptional misconduct, rather than a means of promoting good practice across the whole profession.' [30]

24 Sir Donald explained the GMC's role in the following exchange:

`Q. I was exploring with you the nature of the way in which inadequate practice might be regulated by the one branch or other of the regulatory bodies, taking as a given that the GMC is really the end of the road, the long-stop. I have it right, have I? That is essentially how the GMC sees itself?

`A. Yes, although I qualify that: within the statutory framework that I have described, we have been undergoing a considerable change of outlook ourselves which began, again, in the early 1990s, and that was effectively to see how far within the framework, the statutory framework as it was, we could be as effective as possible.

`That change of view was occasioned by our understanding that couching advice to the profession in fairly negative terms, in terms of what doctors could not or should not do, seemed to be unsatisfactory, that there had to be a better way of doing this because one effect of that policy was to leave doctors feeling that, "Well, since I am clearly not bad, none of this advice applies to me".

`This recognition was coupled also with our understanding that the culture of medicine needed to take far greater account of patients, what patients thought about doctoring, what they expected of their doctors, and there seemed to be a gap, as it were, a mismatch here between the public and its confidence in the kind of advice given and the advice that we were actually giving.

`Thirdly, it was triggered by the issues of advertising, which do not seem central to performance, but nevertheless, the examination that we made at the time and the questioning about doctors' advertising led us in, I think it was 1991, really to put as central the whole question, for instance of information to patients, to discard much of the conventional thinking which was restrictive, and it was that kind of way of thinking which then encouraged us and led us to think that we ought to address our remarks more positively and more explicitly to the whole profession about their duties and responsibilities.

`The last point - it is very fundamental to the notion of self-regulation, but that is not an end in itself, only a means to getting the best care for the patient - was to make explicit that which had always been implicit in medicine, and that there is a contract between doctor and patient and that a registered practitioner, in accepting the privileges of being registered, which includes the ability to earn one's livelihood as a doctor, enters into certain obligations to the patient, to the public, as a result.

`It is that kind of thinking, Mr Langstaff, which was a million miles away from the very restrictive interpretation that we had traditionally placed on matters earlier.

`It was in tune, lastly, with the more general move in medicine towards being explicit about good standards of practice wherever possible. The whole guidelines movement as you know was developing at that time, and I have given some background to that in Annex B to my evidence.' [31]

25 Sir Donald stated in his written evidence to the Inquiry:

`The policy began to change in the mid 1980s, as The Blue Book [32] was expanded to include new advice on standards of patient care ... This process of change culminated in the publication of "Good Medical Practice" (1995) [33] where, for the first time, the GMC defined systematically the principles of good practice expected of all doctors.' [34]

26 `Good Medical Practice' (1995) advised doctors:

`In providing care you must:

• `recognise the limits of your professional competence;
• `be willing to consult colleagues;
• `be competent when making diagnoses and when giving or arranging treatment;
• `keep clear, accurate, and contemporaneous patient records which report the relevant clinical findings, the decisions made, information given to patients and any drugs or other treatment prescribed;
• `keep colleagues well informed when sharing the care of patients ...' [35]

27 Sir Donald stated:

`Throughout the 1980s and early 1990s the Council saw a clear distinction between areas governed by law - both common law and legislation - and questions of conduct and ethics. The GMC gave no guidance on matters which it believed were covered principally by law and would be dealt with in the courts. This is still the policy, but not every subject falls neatly into one category or the other.

`This became increasingly clear in relation to consent. No advice on the issue was included in The Blue Book since consent was regarded as a complex legal issue falling outside the area in which the GMC was competent to give advice. However, neither The Blue Book nor "Good Medical Practice" attempted to provide a comprehensive guide to all matters which could raise a question of serious professional misconduct, and it therefore remained possible for the PCC [Professional Conduct Committee] to hear cases based on, or involving consent.

`During the late 1980s and 1990s the Professional Conduct Committee considered a number of such cases ... in which the PCC emphasised the importance of doctors providing information about procedures and options open to their patients, obtaining consent and respecting patients' decisions.' [36]

28 The then Secretary of the British Medical Association (BMA), Dr Ernest Armstrong, stated in his written evidence to the Inquiry:

`In 1984, the BMA published a revised edition of its ethics handbook [37] which aimed to provide guidance for doctors on a range of issues. The issue of patient consent, including consent of minors is briefly covered, with little mention of parental consent. There was a clear expectation that doctors would not proceed without valid consent but the steps entailed in seeking that consent were not explored. The equivalent publication in 1993, "Medical Ethics Today" [38] featured over 30 pages of advice on the topic of consent generally and a separate chapter on aspects of treatment of children. In the interim period between these two publications, BMA ethical guidance tried pro-actively to encourage much greater recognition of the importance of patient/parent informed consent to treatment.' [39]

29 He went on:

`The BMA's ethical publications address the type of questions which doctors routinely raise with the Association at any given time. The absence of debate about some issues does not imply that they were regarded as unimportant but indicates that doctors are likely to have felt that they were part of a professional consensus, precluding the need for questions. ... The relatively low level of emphasis given to issues of consent in the 1984 ethics handbook indicates that this was not an area viewed by doctors as ethically problematic ...

`By 1993, it is very clear from the BMA's published advice that professional guidance was already moving distinctly in a rights-based direction.' [40]

30 As regards the discussion of risks associated with surgery, Dr Armstrong stated:

`The 1984 BMA advice typified much thinking at the beginning of the period in that the guidance contained next to no detail and left a great deal to clinical discretion. It was generally assumed that doctors would come to their own decisions in each case about the manner in which consent was sought and the degree of information provided. The core statement in the extract from the 1984 handbook is that "the onus is always on the doctor carrying out the procedure to see that an adequate explanation is given" [emphasis added]. [41] No indication is given in the guidance, however, about what would constitute adequacy or by whose standard (doctor's or patient's) adequacy should be judged, although it would normally be assumed that the medical standard would be the benchmark. There is a brief paragraph on the importance of clear communication and avoidance of misunderstanding but the necessity of discussing risks associated with treatment is entirely absent.' [42]

31 Dr Armstrong went on:

`... the 1984 guidance makes clear that doctors should answer questions unambiguously but again leaves open how much information doctors should volunteer if no question is posed.' [43]

32 He stated that:

`The graver the decision and the riskier the procedure, the greater the need for well informed consent to be provided.' [44]

33 He added:

`The BMA expects doctors to base their recommendations for treatment on the most reliable evidence available about benefit and there is a clear expectation in the BMA's 1993 advice that doctors should not conceal any piece of information materially relevant to the patient's decision.' [45]

34 Dr Armstrong stated that the idea that a surgeon had an obligation to refer to specific factors such as outcome data `was not an issue for discussion in 1984'. [46]

`A not uncommon argument during the period (although not one endorsed by the BMA) was that doctors had moral obligations to promote hope of recovery. In the 1993 version of its advice, the BMA noted that a past concern of doctors had been to avoid worrying patients and that historically this had led to a reluctance to tell them the full implications of an illness or the different options for treatment. While the Association assumed that this approach was increasingly being seen as outdated by 1993, it noted a continuing reluctance on the part of some doctors to discuss uncertainties in medicine. It is very likely that this idea about the duty for beneficence was interpreted by some members of the profession as a justification for not discussing risk, despite the ever-increasing emphasis placed by courts and by professional guidance on informed consent. In addition at the beginning of the period in question [1984], it is possible that some doctors were discouraged from drawing comparisons with outcomes from other colleagues or other facilities because of a perception that this could potentially undermine patient confidence or risk improper disparagement of colleagues.' [47]

35 The BMA's `Handbook of Medical Ethics' (1984), referred to by Dr Armstrong, stated that:

`Consent is only valid when freely given by a patient who understands the nature and consequences of what is proposed.

`Assumed consent or consent obtained by undue influence is valueless ... It is particularly important that consent should be free of any form of pressure or coercion ... No influence should be exerted through any special relationship between a doctor and the person whose consent is sought.

`Doctors offer advice but it is the patient who decides whether or not to accept the advice. The necessary degree of understanding of what is proposed depends on the patient's education and intelligence and the seriousness and urgency of the condition being investigated or treated. The onus is always on the doctor carrying out the procedure to see that an adequate explanation is given.' [48]

36 The 1993 BMA guidance `Medical Ethics Today: Its Practice and Philosophy' gave the prerequisites for valid consent under the heading `Consent to examination and treatment':

`In order for the consent of any person to be valid it must be based on competence, information and voluntariness. In our view, this can be broken down into several fundamental points:

`a) the ability to understand that there is a choice and that choices have consequences;

`b) a willingness to make a choice (including the choice that someone else choose the treatment);

`c) an understanding of the nature and purpose of the proposed procedure;

`d) an understanding of the proposed procedure's risks and side effects;

`e) an understanding of the alternatives to the proposed procedure and the risks attached to them, and the consequences of no treatment;

`f) freedom from pressure.' [49]

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Footnotes

[29] WIT 0051 0007 Sir Donald Irvine

[30] WIT 0051 0008 Sir Donald Irvine

[31] T48 p.31-3 Sir Donald Irvine

[32] `General Medical Council's Professional Conduct and Discipline: Fitness to Practise' (published by the GMC)

[33] WIT 0051 0122 - 0132 ; `Good Medical Practice', GMC 1995

[34] WIT 0051 0008 Sir Donald Irvine

[35] WIT 0051 0124; `Good Medical Practice', GMC 1995

[36] WIT 0051 0076 Sir Donald Irvine

[37] WIT 0037 0143; `The Handbook of Medical Ethics', BMA 1984

[38] WIT 0037 0149; `Medical Ethics Today: Its Practice and Philosophy', BMA 1993

[39] WIT 0037 0018 Dr Armstrong

[40] WIT 0037 0019 Dr Armstrong

[41] WIT 0037 0144; `The Handbook of Medical Ethics', BMA 1984

[42] WIT 0037 0020 Dr Armstrong

[43] WIT 0037 0021 Dr Armstrong

[44] WIT 0037 0021 Dr Armstrong

[45] WIT 0037 0021 Dr Armstrong

[46] WIT 0037 0021 Dr Armstrong

[47] WIT 0037 0021 - 0022 Dr Armstrong

[48] WIT 0037 0144; `The Handbook of Medical Ethics', BMA 1984

[49] WIT 0037 0158; `Medical Ethics Today: Its Practice and Philosophy', BMA 1993