The medical profession-who governs?
By Niall Hunter-Editor
'Who governs the medical profession?' is set to be a major debating point in the coming months as Health Minister Mary Harney starts to steer through proposed and long overdue new legislation aimed at tightening up the regulation of doctors in Ireland.
The proposed legislation provides for increased lay membership of the doctors' regulatory body, the Medical Council, which doctors claim will amount to a de-facto lay majority on the Council.
Primarily, however, doctors' representative groups are concerned about what they feel would be excessive Ministerial control over the Council. The Council, since its inception in the late 1970s, has had as its function the protection of patients; a function, which is, says it has carried out efficiently within the confines of cumbersome and restrictive legislation. However, to date it has remained independent of the State.
Under existing legislation, the only State involvement in the Council is the right of the Minister to nominate four members to the 25-member Council. This is set to change.
The Minister'ís proposals also encompass changes in how the Council deals with professional misconduct by doctors, including the establishment of a new preliminary proceedings committee to filter out less serious complaints and a lay majority on professional conduct committee, which deals with serious complaints. In addition, a health committee is to be established which would help doctors who have addiction problems.
Crucially, the legislation, when it is introduced, will put on a statutory and compulsory basis monitoring procedures for doctors.
New legislation on the regulation of doctors has been sought for many years, not only by politicians and consumer groups who are seeking greater transparency and accountability, but also by the profession itself, which has pointed to the fact that the current laws are outdated and too cumbersome.
Under the heads of bill for the legislation, which is currently going through a consultative process, the number of members elected by the medical profession would be reduced from 10 to seven and the number of members nominated by medical training bodies would be reduced from eight to five. The new Council will continue to have 25 members, but doctors or their organisations will nominate only 12.
The remaining 13 could theoretically include medical members,thereby possibly giving a medical majority, but it is proposed that there should be seven members who are non-medical, and this could include people from advocacy groups and health consumers.
The Irish Hospital Consultants Association says that while it welcomes increased lay representation, the new proposals will lead to a de-facto lay majority on the Council, something it says does not exist in the regulatory groups in other EU countries.
It points out that the GMC, which regulates doctors in the UK, has 40% lay membership and this is the highest lay membership in Europe among medical regulatory bodies.
The IHCA says it is concerned that while doctors and other groups can nominate members to the Council, appointment of members would de facto be in the hands of the Minister, who under the new law would have the power to 'hire and fire' members of the Council and would be able to direct the Council to follow a particular policy, on pain, presumably, of dismissal if it failed to comply.
The consultants' group says this would fly in the face of the traditional clinical independence of doctors and their right to advocate on behalf of patients, and could lead to the medical profession becoming simply 'an arm of the state.'
The IHCA is broadly in agreement with new provisions in the legislative proposals on how doctors would be investigated by the Council and subject to disciplinary procedures.
It is concerned, however, that these procedures, in addition to maintenance of professional standards proceedings of the Council, may be made available to the public under FOI.
It fears this could lead to reports on trivial complaints being blown out of all proportion by the media, or that it could encourage lawyers to undertake 'fishing expeditions' for potential litigation. This it is argued, would lead to a climate of fear that would be injurious to good medical practice and in the long run, affect patient care.
Doctors also, not surprisingly perhaps, do not want disciplinary hearings of the Council to be held in public, which is provided for in the legislative proposals, and is currently the case with General Medical Council (GMC) hearings in the UK.
Under Mary Harney's proposals, these hearings would be held in public unless either party requests a private hearing and the disciplinary committee is satisfied that this is appropriate.
So is the medical profession over-reacting and merely defending its oft-quoted 'vested' interests?
This would imply that the profession has something to hide. Doctors would argue that if this were the case, the Medical Council would have far more than 300 complaints per year to deal with.
This it would point out, is out of a total of around 9,000 doctors in practice in Ireland and many millions of doctor-patient consultations each year. Doctors would argue that that while there is a need for regulatory improvement, the perception that there is a vast amount of negligence out there is unfounded, with the Neary case being the exception rather than the rule.
Mary Harney, in defending her new legislative moves, has stressed that any new regulatory systems must be seen to be transparent.
The Department's feeling is that while overall, the standard of medical practice in Ireland is good, the fact that there is no compulsory monitoring, peer review or quality assurance is a major deficit which could in theory lead to more Dr Neary scenarios.
The emphasis in the legislative proposals too, is on the public, in other words patients, as we all usually are at one time or another, having a greater say in how doctors are regulated.
Even non-medical interest groups, however, may be concerned if there was a move towards greater state control of medical regulation, which could subject it to unwanted political interference.
Launching her proposals recently, Mary Harney said the medical profession should not police itself, by itself.
The Minister's proposals have so far come under criticism from different groups for going too far in regulating doctor and not going far enough, so she would probably argue that the proposals have steered a middle ground which have sought to balance the need for better regulation with the need to continue meaningful medical expert input into the workings of the Council and the regulatory process.
It should also be remembered that a crucial part of the new legislation will be provisions for making it compulsory for doctors to keep up to date with medical developments and to comply with monitoring procedures.
Whatever the medical groups may say about proposed Ministerial controls on the Council being more stringent than in other countries, the lack of a compulsory competence assurance system in Ireland is a cause for concern, as such systems do exist in other countries.
Under the current system the public has no formal guarantee that most or all doctors are keeping up-to-date or are competent, although many update their skills and education on a voluntary basis. The Medical Council, in its current role, can merely 'fire-fight' when serious cases of poor performance come to light, rather than being able to stop poor performance happening in the first place.
Medical Council President Dr John Hillery has pointed out that most members of the public believe, when asked, that doctors are compulsorily assessed regularly, when this is not the case.
New competence assurance provisions, he says, will put in place something the public thinks is there and should already be there.
The debate over medical regulation is set to continue in the coming months in preparation for the planned introduction of new legislation early in the new year.
The sooner a regulatory system where physicians are brought to buck on medical malpractices, negligence and downright unethical practices the better. There is no system in this country for physicians who have made decisions that were not in the best interest of their patients to be questioned and reprimanded, this is essential when one considers that medical physicians take people's lives in their hands.
The drug companies govern because they provide the research funding. The patient does not seem to be well represented here.
Here we go again with the usual bladder of concern from the Doctors interest groups on concern for the patient and the hardy annual of the patient doctor relationship. Have they learned nothing from the Neary and other debacles. Doctors you serve us the patients - get that into your arrogant skulls. Minister - stick with your proposals.
I thought the health service was run from the Four Courts? They dictate that our health service is run along expensive, wasteful, defensive lines. No? It seems obvious to me that many of the stupid practices now in vogue are caused by a terror of litigation?