Poisoned by climate of suspicion
A year ago, Dame Janet Smith delivered a bombshell to general practice with the final report of her inquiry into Harold Shipman's murders.
Over 1,200 pages of devastating commentary, Dame Janet proposed searching scrutiny of GPs' day-to-day performance, including tougher inspection powers for primary care organisations and giving managers the power to fine poor-performing doctors.
She also delivered a coruscating attack on the GMC and demanded it overhaul its constitution and give up its adjudicating role in fitness to practise cases.
And in arguably her most important finding, Dame Janet branded the GMC's revalidation proposals unfit and demanded they be toughened.
The Government acted immediately on this recommendation, scrapping the original system, which was due to go live last April, and setting up a review headed by Chief Medical Officer Sir Liam Donaldson. His findings are due early in the new year. Early indications are he will insist revalidation be every five years, not seven as was planned.
Appraisal is also likely to be decoupled from revalidation, and GPs could instead need to provide a folder of evidence including patient satisfaction and clinical governance data and, potentially, the results of know-ledge tests.
How many of Dame Janet's other recommendations Sir Liam takes in remains to be seen.
Yet GPs say the most important change has happened already. The climate under which they work is being poisoned by suspicion. Many GPs feel they are now operating in an increasingly punitive environment and subject to 'hyper-regulation'.
The evidence appears to back them. The number of GPs suspended by PCTs tripled in the year to last March. The number of complaints referred to independent review often by PCTs has doubled in the past year.
And the number of GPs facing GMC conduct hearings has risen sharply.
Dr Jeffery Moysey, a GP in Hyde and chair of West Pennine LMC, says Dame Janet overstepped the mark and could make life far more difficult for doctors. Dr Moysey, who gave evidence to the inquiry, says GPs have grown more aware of patient safety.
There is a danger, he adds, that systems which work will be replaced by ones that are overly bureaucratic in order to fix a problem that doesn't exist.
Dr Hugh Stewart, medicolegal adviser at the Medical Defence Union, backs this view.
He says GPs already face 'multiple jeopardy' with an incident being potentially subject to PCT disciplinary action, including ending the GPs' contract, an independent review, a fitness to practise review and even a review of a GMC ruling by the Council for Healthcare Regulatory Excellence.
Dame Janet's recommendations would at the very least add a financial penalty levied by the PCT. More stringent revalidation would increase the sense of distrust in doctors.
Dr Peter Swinyard, a GP in Swindon and secretary of the Small Practices Association, says the Shipman report was a 'politically expedient hook' on which to hang 'repressive measures' against GPs.
He added that the inquiry report had not been critical of singlehanded GPs yet they seem to be targeted by the Government.
Yet it is for the GMC that Dr Swinyard reserves his most critical comments. The council, he says has failed to stand up for self-regulation. 'It's frightened of its own shadow,' he says.
'It hasn't got the guts to stand up to government and say we are trying to run professional self-regulation here.'
Finlay Scott, GMC chief executive, admits the council has been rightly criticised in the past for 'becoming too involved too early and being heavy handed'.
He says: 'We sometimes did not get the details right and it's not surprising doctors feel we were too ready to think doctors were in the wrong.'
But the GMC has changed for the better and will continue to do so next year, he adds.
The majority of GPs working in an approved environment monitored by colleagues and PCTs will see lighter touch regulation, he says.
'It cannot be in the patients' interests if doctors feel oppressed by regulation and it is our job to fully engage the confidence and commitment of the profession.'
The GMC will have a tough job convincing GPs. They see a regulatory web being built which is seemingly designed to catch them out at every turn. And that web is only going to grow in the coming year.