Annex A > Chapter 4 - National Accountabilities and Roles > Summary of respective roles of bodies concerned with standards and their implementation
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Summary of respective roles of bodies concerned with standards and their implementation
290 This section attempts to summarise the shared and divided responsibilities for setting and implementing standards borne by the various bodies described above.
291 A distinction has to be made between general and specialist standards and between setting and implementing standards once set.
292 Dr Graham Winyard said that prior to the publication in 1989 of `Working for Patients':
`General standards were set by the GMC and the Medical Royal Colleges, through general and specialist examinations, the inspection of training posts and involvement in consultant appointment committees. However the prime responsibility for a doctor's ongoing standard of professional practice lay with that individual and was seen very much as a matter for him or her. General peer pressure was undoubtedly important in maintaining overall standards but could prove much less effective when an individual was, for whatever reason, resistant to criticism.' [359]
293 Of the period of concern to the Inquiry, Sir Donald Irvine and Professor Liam Donaldson, CMO for England and Wales, referred to Black's `Quality Assurance of Medical Care', which comments:
`In the 1990s, developing standards of good care is increasingly likely to fall to national expert groups such as the medical Royal Colleges, partly because they are most likely to have the resources necessary to assemble the scientific, clinical and medical ethical expertise needed to construct guidelines which are competent and widely acceptable, and partly because of the sheer complexity, time and expense involved in achieving such guidelines. The implementation of standards, on the other hand, may be a more local matter in the form of protocols which can be attained within specified but manageable deadlines by practitioners operating under widely differing circumstances.' [360]
294 In practice, responsibility for setting general and specific standards was divided, as was their implementation.
295 The GMC advised and advises on generic professional standards. It did not and does not set clinical standards for particular specialties (such as paediatric cardiac surgery). [361] Such specific standards were and are set primarily by the Royal Colleges. The GMC's view was that:
`The Royal Colleges and specialist associations were primarily responsible for detailed, condition-specific clinical standards ... The GMC offered no specific advice on audit during the 1980s and early 1990s.' [362]
This view was mirrored by that of the RCSE, which had published guidance on child surgery but `... has not published any guidance specifically referring to the competence or conduct of paediatric cardiac surgeons'. [363]
296 Furthermore, the GMC only enforced or implemented the standards it established. It has no jurisdiction to enforce the specialist standards laid down by the Royal Colleges.
297 The DoH meanwhile looks to the Royal Colleges and the GMC together to maintain standards. Dr Halliday told the Inquiry:
`The Secretary of State is not responsible for the way medicine is practised. He has no duty to Parliament for that. The responsibility of how clinical medicine is practised is a matter for the General Medical Council. The Secretary of State is obviously concerned about the way that service is provided and he looks to the Colleges and to the GMC to ensure that that is the situation.' [364]
298 The crux of the split between setting standards and implementing them is that the bodies that set specialist standards (the Royal College) have no direct power to enforce them, and the body (GMC) charged with enforcing general standards is unable to enforce specialist standards, not least because they cannot assess compliance with them. Leading Counsel to the Inquiry asked Sir Donald Irvine:
`So far as standards then were concerned during 1984 to 1995, standards of good practice, we have heard from the evidence given to us by the Royal Colleges that they would promulgate the standards in their own particular specialisms. Much of the evidence that we have heard suggests that there was a vacuum when it came to the enforcement of those standards. Is that how you would have seen the years 1984 to 1995, or not?
`A. The enforcement by the Royal Colleges, do you mean?
`A. In general terms, yes.' [365]
299 Sir Donald was subsequently asked:
`Q. So in terms of standards throughout the period we are looking at, the Royal Colleges would set the standards of performance generally speaking for doctors and their specialties, would they?
`A. Yes. They would indicate in their various ways what standards would be expected for their individual specialties.
`Q. But there was no sanction from the GMC for a failure to meet those performance standards until 1997, I think?
`Q. 1997, was it? The change was brought in in 1995, but that was the first year for "seriously deficient professional performance"?
`Q. So the only sanction for the failure to meet a Royal College standard would either be up to the Royal Colleges themselves or to the local employer?
`A. Yes.' [366]
300 The evidence of the GMC was that it set professional, but not clinical, standards; that it adopted but did not enforce clinical standards, and that it expected employers (with the assistance of the Royal Colleges) to enforce those clinical standards.
301 The evidence of the Royal Colleges was that they lacked any means to enforce clinical standards, and relied upon the GMC to ensure professionalism.
302 The evidence of the DoH was that it relied on both the Royal Colleges and the GMC to set standards and to enforce them, but declined any direct responsibility itself for doing so. Responsibility for clinical treatment was that of the individual clinician (or, at least, consultant). The role of the DoH was, in part, to set the framework within which standards might be set and implemented, but its focus was split until 1995 as between management and policy, and its emphasis was on financial rather than clinical performance.
303 The individual doctor was required to satisfy the GMC of basic medical competence, and the Royal Colleges of specialist competence, but only at the outset of a career, as a one-off qualification.
304 This last point has been addressed by Continuing Medical Education (CME)/Continuing Professional Development (CPD), to the evidence on which we now turn.
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Footnotes
[359] WIT 0331 0002 Dr Winyard
[360] Cited by Irvine D and Donaldson L. `Quality and Standards in Health Care'. `Proceedings of the Royal Society of Edinburgh' (1993); 101 B:
1-30 at p. 16 (WIT 0051 0045). The full Black 1990 reference is: Black N. 1990. `Quality assurance of medical care'. `Journal of Public Health Medicine', 12, 97-104 (cited at WIT 0051 0055)
[361] WIT 0062 0026 Mr Scott
[362] WIT 0051 0009 Sir Donald Irvine
[363] WIT 0048 0013 Sir Barry Jackson. However, `In 1995 the SAC in Cardiothoracic Surgery approved a programme for advanced training for those wishing to specialise in paediatric cardiac surgery ...' (WIT 0048 0011). The document is:`Suggested Paediatric Cardiac Surgical Training Programmes' (WIT 0048 0018). `Training for Paediatric Cardiac Surgery' (J Stark's document presented to the SAC 1995) (WIT 0048 0016) and `Training Curriculum in Paediatric Cardiothoracic Surgery' (WIT 0048 0021) are `... the specific curriculum document for training in paediatric cardiac surgery that is used at Birmingham and Great Ormond Street to follow through the training of individuals on the rotation between these [two] hospitals' (WIT 0048 0011)