It remains a concern that there are no objective checks on doctors' competence once they have passed the milestone of completing their postgraduate training, writes John Hillery
The announcement of random performance assessments for doctors is a further move by the medical profession in Ireland to bring its regulation into the 21st century. Over the next year, 1,000 doctors chosen at random will be asked to co-operate with an assessment of their practice.
Already a large number of doctors are voluntarily allowing an assessment of their continuing educational activities. Now a more intensive review of everyday practice will allow doctors to demonstrate that they are performing in line with international standards.
We do not currently have legal powers to enforce co-operation with these procedures or name those who do not comply. I would like to see such powers in a new Medical Practitioners Act. In the meantime, I believe that every doctor will understand the benefits to them and their patients of having their activities examined and declared to be of high standard.
Indeed, the process we have outlined is an accepted part of medical practice in many countries.
The planned assessments will involve the completion of questionnaires by a doctor's medical and non-medical colleagues and patients. Once the results are accumulated, a report will go to a committee of the Medical Council. This performance committee will have medical and non-medical members.
I will be asking that the chair of this committee be designated to a non-doctor. The committee will make recommendations based on the report. It may request additional information in some cases. International experience suggests that in most cases, the doctor's practice will be satisfactory.
The results for between 3 and 5 per cent will indicate the need for them to take steps to improve areas of their practice. In some cases this may include time out of practice and retraining. If the reports give cause for serious concern, a review of the doctor's practice involving visits and observation by trained assessors (doctors and non- doctors) will be necessary.
In extreme cases, the Fitness to Practise procedures may have to be used. The aim is to recognise good practice, initiate interventions to remediate doctors who may be developing problems and, where indicated, remove dangerous doctors from practice. It is important that the public is aware that current Fitness to Practise procedures will operate alongside the new competence procedures and continue to deal with complaints of serious misconduct.
Medical self-regulation in Ireland was confirmed by the passing of the Medical Practitioner's Act in 1978.
Self-regulation was granted because of the specialist nature of the issues involved. It was also acknowledged in the Dáil debates on the Bill that the profession did set high standards and would deal robustly with those who fell below these standards. The high standards of the majority of Irish doctors are acknowledged both at home and abroad. However, it remains a concern that there are no objective checks on their competence once they have passed the milestone of completing their postgraduate training.
The practice of medicine has changed greatly since 1978, the Medical Practitioner's Act has not. It is now archaic. It promotes, indeed insists on, secrecy. It empowers the profession to react to poor practice, but does not allow the Medical Council to intervene early to prevent poor practice.
Even the reactions that are allowed are of an extreme nature, bound by a legal straitjacket and incapable of dealing with subtle, low-level signs that may indicate that a doctor is practising in a fashion that will lead to severe problems in the future.
Currently, each complaint to the Medical Council from whatever source is investigated as thoroughly as this system allows. A committee composed of doctors and non- doctors reviews the complaint and the doctor's response to it. Extra information is sought and weighed in making the decisions.
The number of cases that go to inquiry is constrained by the need to produce prima facie evidence that a doctor has a case to answer. A formal inquiry has all the benefits and disadvantages of a court trial.
The highest standard of proof is required ("beyond a reasonable doubt"). Witnesses are exposed to adversarial cross-examination by lawyers acting for the doctor.
Having discussed this with both doctors and complainants, I know it is a highly stressful experience. If the doctor is found guilty of misconduct, they have a right of appeal to the High Court. The complainants and the prosecution have no such right if the case goes against them. This does not seem reasonable. Observers use the resultant statistics to claim that the process does not work.
I acknowledge that there are limitations in the current system that work to the disadvantage of good medical practice and the public interest. However, this is due to the deficiencies of the current Act rather than to any resistance from the profession.
My predecessors have campaigned for changes in the Act to include more flexible processes to facilitate the management of a variety of complaints and the inclusion of more non-doctors on council.
The Minister for Health has promised such powers in a new Act.
She and the department acknowledge the need for flexible legislation that will evolve with changes in medical practice and patients needs. There are obvious complexities that must be dealt with. There are resource issues for both the State and the profession.
To ensure a high level of patient safety, a strong system of clinical governance must be developed in the health services in tandem with the regulatory processes for doctors.
The development of the new Act cannot be rushed. In the meantime, doctors must acknowledge that the demonstration of adherence to high standards is a professional responsibility.
Recent high-profile cases have caused concern for the public and the profession. The commitment of doctors to their professional and ethical responsibility to maintain their own competence and deal with problem colleagues has been called into question. In the 21st century, it is not sufficient for us to say we are performing as the public expect - we must demonstrate that we do.
The processes being introduced by the Medical Council will show that the profession insists on high standards and can be trusted to maintain them.
• Dr John Hillery is president of the Medical Council