Annex A > Chapter 4 - National Accountabilities and Roles > National regulatory and professional bodies > The Colleges' role and responsibility for setting and monitoring standards of care
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The Colleges' role and responsibility for setting and monitoring standards of care
235 There were differing views as to which organisation it was that laid down standards relating to the outcome of care in the period of the Inquiry's Terms of Reference. Professor Sir Kenneth Calman said that it was the medical profession as a whole, rather than the DoH or any particular Royal College:
`Q. In terms of laying down standards [relating to the outcome of care], who would do it? The Royal Colleges? The Department of Health? Would it depend on the area?
`A. It would generally be the profession, and I say that rather than the Royal Colleges, because there may be a number of areas which do not neatly fall into a particular Royal College.' [303]
236 In the specific context of supra regional services Dr Norman Halliday, the Medical Secretary of the SRSAG, by contrast, took the view that he was reliant upon the Royal Colleges for such matters, to the exclusion of a role for the SRSAG.
237 Professor Gareth Crompton (former CMO, Wales), speaking of cardiac services, said that:
`Welsh policy was heavily reliant on the best available authoritative advice, notably from ... Joint Cardiac Committee of the Royal College of Physicians of London and the Royal College of Surgeons of England.' [304]
238 Dr Roylance relied heavily on the Royal Colleges to maintain clinical standards:
`A. ... The whole purpose of a Royal College of Radiologists is to oversee standards in radiology, and they do that in a whole variety of ways. If they are not maintaining standards in radiology, I do not know what they are doing.
`Q. So you depended a lot on them?
`A. The expertise in whether the clinical work was up to standard lay within the profession and the profession was concentrated and represented and overseen by the Royal College.' [305]
`I also considered that the Royal Colleges had an overall responsibility for the maintenance of standards and that if concerns about such issues were made known to them and a solution could not be found through their own good offices, they would notify me that appropriate management action was required.' [306]
240 Dr Roylance thus indicated a belief that maintenance of clinical standards was primarily the Royal Colleges' responsibility rather than that of local management. For their part, the Royal Colleges regarded problems with local services as the responsibility of local management:
`Q. What would you conceptually regard as being the role of management in such a situation as I started off by positing, when there are some concerns being expressed about the performance or outcomes of a particular service within a hospital?
`A. Conceptually, I think if management was aware of that it would be up to management to discuss that with the clinicians concerned to try and resolve the matter, quite clearly.' [307]
241 Management faced difficulty in knowing what precisely to expect of doctors clinically, as the evidence of Sir Donald Irvine suggests:
`Q. So was it one of the problems in bringing the bad doctor to book that the non-medical management did not necessarily know what to expect of a good doctor?
`A. Yes.' [308]
242 Sir Barry Jackson told the Inquiry that part of RCSE's role in more recent years had been the preparation and dissemination of clinical guidelines for the surgical management of certain conditions. [309] However:
`... in the production of clinical guidelines, the College has no statutory power to ensure that these are followed by individual surgeons but these are again published on the assumption that they will be adopted by surgeons. The College's powers in this area and in other areas of professional regulation of consultant and other career-grade surgeons may be extended with the introduction of re-validation as a basis of continuing registration to practice, but this concept is still at an early stage of development.' [310]
243 This was echoed in respect of the RCP by its President, Professor Sir George Alberti:
`... I would also hope that we can ensure that all consultants in the country, in all specialties, continued to maintain and improve their standards, their practice and their knowledge, throughout their working career, which, in most professions, was a tacit assumption but without any obligation in the past.' [311]
244 Sir George agreed that the RCP had in the past been reactive rather than proactive:
`A. I think now we would be much more interventionist on the grounds of safety, particularly, and quality.
`Q. What you are telling me is that in those particular years, at any rate, the Royal College of Physicians would hesitate to interfere or influence the exercise of clinical freedom upon the grounds that it perceived generally that the public interest lay in an opposite direction?
`A. I think that, first of all, if we were not informed that there were problems, we would not have any ability to interfere, other than informally.
`Q. So it would be reactive rather than proactive?
`A. Correct.' [312]
245 Sir Barry Jackson told the Inquiry that:
`The College's [RCSE's] disciplinary power over members are limited. ... It cannot ... , of itself, initiate disciplinary action against individuals in relation to their standards of professional practice. The College will not remove the status of fellow or member from individual members unless they have been found guilty of serious professional misconduct by the GMC, have been convicted of a significant criminal offence or fail to pay their subscriptions to the College.' [313]
246 Professor Strunin discussed the relative roles of the GMC, Royal Colleges and trusts:
`Q. The question I was asking was the balance of responsibility or involvement between, firstly, the General Medical Council; secondly, the Hospital Trust; and, thirdly, the Royal College of Anaesthetists or other Colleges in, as it were, regulating, to use that word in its loosest sense, the competence and performance of individual practitioners?
`A. I understand the question. The reality is this. If you take the General Medical Council first, they have the ultimate sanction in that they control the register, but they have no power to go and visit anywhere, they have to wait for a complaint, and under the law that operates it has to be a serious complaint. Up to 1st July 1997 they could only look at specific cases. They can now look at patterns of performance, but, nevertheless, they are, I think, at the end of the line, because it would take a while before something comes to them. The College, again, for an individual practitioner, would have to wait for a report, although we could pick up problems in a department when we do a training visit. But, as I indicated, that is for training specifically, it is presumably training, and not to look at the clinical service per se. The Trust is the right place. That is where the work is carried out; that is where it should be done, and they have mechanisms to deal with that. They can prevent a practitioner from practising, they can suspend a practitioner, they can report him to the General Medical Council if they wish, they can go down the procedures laid down by the Department of Health for suspension, and so forth. And I would say, as the prime group who look at quality clinical practice day by day, that has to be locally within the hospital, and as far as an anaesthetic department is concerned, that is a prime responsibility of the Clinical Director.
`Q. So you are saying that the Trust represents what you might call the "front line" of quality, or scrutiny of the quality, of clinical practice?
`A. I think they have to, because there is no means of anybody externally knowing about that until there is a serious problem. We are based in London. It is unlikely we will know what is going on anywhere else in the land until somebody tells us about it, whereas that is an absolute responsibility. Now, with the clinical governance, of course, it starts with the Chief Executive, but it has always been, in my view, an absolute responsibility of the Clinical Director of the service to make sure it is properly delivered and, if there are problems, to address them.
`Q. You describe the GMC as representing what you might call the "end of the line" in terms of acting upon complaints. It is right, I think, that your statutes require you to follow the judgment of the GMC in striking off any practitioner, or removing from membership any practitioner, who has failed to meet proper professional standards. If we look at page 7 of your statement [314] where, at paragraph 5.1 you summarise the position, it follows that you do not have power, as I understand it, under your ordinances, to discipline for clinical incompetence without the prior decision of the GMC; is that right?
`Q. The corollary of that seems to be that in fact you have never actually had to exert that power; is that right?
`A. That is also correct.' [315]
247 The only formal sanction over consultants who do not follow clinical guidelines is to remove the trainer status of those who are college trainers. Sir Barry Jackson told the Inquiry:
`... we had no statutory way in which we could maintain standards at consultant level at that time, or even now we have no statutory method of doing it, other than by removing trainer status.' [316]
Sir Barry Jackson's evidence included this exchange:
`A. ... any College guideline that comes out, such as the one you have on the screen at the present moment, [317] is a recommendation by the College to its fellows and others, but it is not mandatory upon our fellows and others to follow those guidelines or those recommendations.
`Q. No, we understand from your evidence that the College may set standards, but it has very limited powers, indeed, in terms of enforcement?
`A. Sadly, that is true.' [318]
248 The Royal Colleges had no power to enforce compliance with its standards for those already in post other than the indirect one of the threat of de-recognition of training posts. [319] This does not, of course, affect surgeons who have finished training, namely consultants: `The Royal College of Surgeons of England has no formal or statutory role in identifying or enforcing retraining obligations for consultant surgeons.' [320] The greatest sanction that a Royal College can apply to an individual consultant is limited and indirect: if the consultant is a trainer or examiner for a College, the College can withdraw that recognition. [321]
249 If the Royal Colleges' powers over its members are limited, their ability to persuade their members to adopt new practices is also limited. Dr Kieran Walsh, Senior Research Fellow, University of Birmingham, indicated (at least in relation to the introduction of audit) that professionals at the grass roots were less than enthusiastic about following the lead of Royal Colleges:
`I would distinguish though, between the reaction of the professional bodies, the Royal Colleges and others and the great and the good, and the profession on the ground. I think your paper cites a study that suggested that on the ground the profession was perhaps less enamoured, less convinced, than professional bodies and organisations. That is reflected in some of the papers recruited from individual clinicians, saying "Whilst we sign up to the aims of this, we are not sure it is really going to work and deliver improvement" or whatever.' [322]
250 It is not possible for the DoH or professional bodies to implement a policy without consensus agreement, as Professor Sir Kenneth Calman agreed:
`Q. You need a very firm consensus view to carry a whole profession with a particular policy?
`A. Yes.' [323]
251 Sir Donald Irvine stated that an outstanding problem was that: `The Royal Colleges had no power to impose on individual members the professional standards they developed and were refining: they could only require an entrance examination.' [324]
252 Dr Halliday's view appears to be that the Royal Colleges assist upholding standards, but are not responsible for the upholding of those standards:
`... we are very fortunate in the way that our Royal Colleges assist us, because they are not formally part of the National Health Service. They have no responsibility for the provision of services. Their role is educational and the training of doctors. Yet despite that, they are only too happy to contribute their time, and sometimes money, to look at the things we want them to address. So I think we are very lucky in that sense.' [325]
253 Dr Halliday's description suggested that the Royal Colleges worked by exerting peer pressure on a colleague who was not adhering to the promulgated standard.
254 Sir Alan Langlands confirmed that the Royal Colleges had provided assistance to SRSAG:
`Both groups [SRSAG and NSCAG] have regularly sought advice from the Medical Royal Colleges and other professional bodies on such matters as the services to be designated and the best units to provide these services.' [326]
Relationship between the Royal Colleges and the GMC
255 Sir Donald stated that an outstanding problem was that:
`Co-ordination between the various professional bodies with regulating functions was limited and accountability often unclear.' [327]
256 A principal change of philosophy in the GMC's policies during the period 1984-1995, he said, was that of `regarding poor or unsafe clinical performance as within the GMC's scope rather than as the sole responsibility of others'. [328] This did not, however, imply that the GMC would review Royal Colleges' training reports. The reason for declining to do so is given in the following exchange:
`Q. Did the GMC have any function in reviewing the reports by Royal Colleges for the purposes of their accreditation of their specialist training?
`A. No, it is not empowered to do so under the Act.' [329]
257 It should be noted that a College such as the Royal College of Paediatrics and Child Health (RCPCH) now takes a firm line on the enforcement of standards. Professor Baum, Former President, RCPCH, said it would `hold our College Fellows responsible, if knowingly they were not alerting us to a failing in standards'. [330] However, reference may be made to the tables of comparisons for the limited extent to which any disciplinary power has been exercised by the College (or, indeed, any of the Colleges).
258 The primary approach is thus working with a colleague to remedy a problem . If this is not possible, RCPCH's sanction is to report the clinician to the GMC:
`... if it was outwith that kind of corrective programme, then we would openly say "This is a matter we must refer to the General Medical Council".' [331]
Proposed reforms of the Colleges
259 The Royal Colleges would wish to have similar powers to maintain the standards of performance of consultant as they currently have for doctors in training:
`... I would wish very much indeed that the Medical Royal Colleges could be given statutory powers to maintain standards at consultant level, just as they now have statutory powers of maintaining standards for trainees in ensuring that any consultant appointed is appropriately qualified and trained and competent to carry out the responsibility of a consultant. That statutory responsibility has only been given to them in the last two years through the medium of the specialist training authority and the College's participation in the specialist training authority. I would like to see that extended to consultant level, and I think that that would strengthen medicine throughout this country enormously. And I hope very much it happens.' [332]
260 Similarly, Professor Sir George Alberti told the Inquiry:
`... it is evident that continuing lifelong education is essential for all consultants, and that this should be assessed at regular intervals'. [333]
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Footnotes
[303] T66 p.17 Professor Sir Kenneth Calman
[304] WIT 0070 0001 Professor Crompton
[306] WIT 0108 0020 Dr Roylance
[307] T28 p.129-30 Sir Barry Jackson
[308] T48 p.83 Sir Donald Irvine
[309] WIT 0048 0004 - 0005 Sir Barry Jackson
[310] WIT 0048 0005 Sir Barry Jackson
[311] T9 p.3 Professor Sir George Alberti
[312] T9 p.41-2 Professor Sir George Alberti
[313] WIT 0048 0003 Sir Barry Jackson
[314] WIT 0065 0007 Professor Strunin
[315] T14 p.13-15 Professor Strunin
[316] T28 p.141 Sir Barry Jackson
[317] RCSE 0001 0009; `How Doctors Explain Risks To Patients'
[318] T28 p.120-1 Sir Barry Jackson
[319] Although Sir Donald Irvine and Professor Liam Donaldson state: `In Britain, the accreditation of training schemes for doctors in hospital, general practice or public health medicine has led to the setting of standards and their enforcement by the Royal Colleges.' Irvine D, Donaldson L. `Quality and Standards in Health Care'. `Proceedings of the Royal Society of Edinburgh' (1993); 101 B: 1-30 at p. 22; WIT 0051 0051 Sir Donald Irvine
[320] WIT 0048 0012 - 0013 Sir Barry Jackson
[321] WIT 0048 0013 Sir Barry Jackson: `Since 1996 the Colleges have been implementing a structured system of continuing medical education in which all practising surgeons were expected to participate as a professional obligation. The Senate has more recently expressed the view that it is mandatory for all practising surgeons to participate but the only sanction the Colleges currently have against individuals who fail to participate would be to withdraw recognition as a trainer or examiner for the College. It should be recognised that not all surgeons are necessarily trainers or examiners'
[323] T66 p.35 Professor Sir Kenneth Calman
[324] WIT 0051 0006 Sir Donald Irvine
[326] WIT 0335 0020 Sir Alan Langlands
[327] WIT 0051 0006 Sir Alan Langlands
[328] WIT 0051 0007 Sir Donald Irvine
[329] T48 p.110 Sir Donald Irvine