Published: 18/08/2005, Volume II5, No. 5969 Page 16 17

Bob Sang believes the drive for a patient-led NHS is meaningless unless the public are allowed to take control of professional regulation, but the General Medical Council's Sir Graeme Catto argues that it is vital that those who work at the clinical frontline keep control


Bob Sang is an independent practitioner in mutual systems development, linking citizen engagement with learning to sustain organisational, cultural and practical innovation. He is also a director of consultancy Sang Jacobsson.

He has been a fellow of the King's Fund, strategic adviser to the Patients Association and co-facilitator of the National Primary and Care Trust Development Programme's engaging communities learning network.



Professor Sir Graeme Catto is president of the General Medical Council. He is also vice-principal at King's College London; dean of the Guy's, King's and St Thomas' Hospitals Medical and Dental School; and provice chancellor, University of London. He was knighted in 2002 for services to medicine and to medical education.

Bob Sang: In a patient-led NHS, professionally led regulation and peer review will no longer provide a justifiable and sustainable basis for the role and contribution of the General Medical Council.

It is time to move from a selfreferencing system, to shift emphasis from professionally led quality and accountability assurance to a citizen-led approach. The time is now right for a fundamental redesign of the institutions and processes of medical regulation.

First, active citizenship in health is now a top priority (key to Treasury adviser Sir Derek Wanless's call for 'full engagement').

Second, we know that a patientled NHS can work. Examples are citizens' juries deliberating on difficult medical service reconfigurations; the growing success of the expert patient programme; and social enterprises that successfully challenge inequalities. So why is this not happening in the regulatory sector?

Conventionally, there are formidable defences ranked against the move from a profession-led General Medical Council, which can be summarised as 'takes one to know one' - the belief that only highly qualified professional peers are in a position to assess the conduct and competence of colleagues.

Second, the appointed 'lay' role within existing regulatory structures is deemed already sufficient.

Structures like the National Institute for Health and Clinical Excellence's 'citizens council' and the reformed GMC council are seen already to demonstrate responsible, appropriate public accountability.

Third, it is argued that the deep technical and scientific complexity of medical developments - from curriculum planning to the day-today exercise of medical judgement and decision-making - are simply beyond the reach of most citizens.

'Doctor knows best, ' they say.

In this way the citizen role remains marginalised, with the regulation ensuring that structures do exist to accommodate 'lay' involvement, but only within predetermined boundaries. This shows how narrowly medical institutions define their own accountability and how deeply uncritical they are of their own working patterns.

The GMC, like the medical profession, cannot reform itself: the underpinning medical model provides too narrow a basis for determining the education and fitness-to-practise of doctors.

Wider social, civic, and entrepreneurial models of learning and practice can and must be synthesised with bio-medicine to support the shared production of a research, education and development agenda for the 21st century. The opportunity is here to become a role model and achieve 'full engagement' by putting the redesign of medical regulation at the heart of health reform.

Professor Sir Graeme Catto: Medical regulation is too important to be left to doctors alone. Patients and the public must be involved and meaningfully engaged.

But regulation must also engage and retain the commitment of doctors, the great majority of whom are doing a good job under difficult and demanding circumstances, as the London bombings have forcefully reminded us. Patientcentred values must be owned by the profession if they are to have meaning and force.

Like medicine itself, medical regulation must be patient centred.

As the GMC's statutory purpose makes clear, our role is to protect, promote and maintain the health and safety of the public. Delivering effective regulation is complex and requires the regulator to be independent of government, profession, patients and public.

Regulation operates at four levels: the individual doctor; within clinical teams; at the workplace; and through national bodies, notably the GMC. These need to work in connection with each other, building on and reinforcing the systems they have in place.

The GMC sets the standards that define good medical practice and supports the values which inform that practice. These cannot be imposed on the public by the profession, nor imposed on the profession by the government. They must be developed, maintained and enforced in partnership with the society in whose interests the profession is regulated. This is the essence of modern, independent, professionally led regulation in partnership with the public.

GMC commitment to a partnership with the public is demonstrated by the root-andbranch reforms we have implemented in recent years.

Lay members now number 40 per cent of the council and make up a substantial number of our associates, who quality-assure medical education and form the adjudication panels considering a doctor's fitness to practise.

We have acknowledged that we need to do more, and during 2005 we are examining what engagement mechanisms work best so that the public voice is heard across all our policy work, shaping education and standards for the profession.

We are also tracking public attitudes to our own work to ensure that those views directly contribute to our policy-making processes.

Without the public's involvement, the quality and appropriateness of medical care becomes hard to achieve. Without professional leadership, the values upon which good regulation depends lose their meaning for the doctors who are tasked with delivering patient-led services.

Bob Sang: While I do not question the sincerity of Sir Graeme's position or belittle the commitment to partnership that is central to his proposition, I do believe the position he takes is no longer tenable.

It is time to move on beyond the rhetoric of 'patient-centredness'. We should re-examine the nature of the 'partnership' for which he calls.

Further, the reform of the GMC needs to be recontextualised (ie citizen-led) as we move towards a patient-led NHS and the 'full engagement' envisaged by Wanless.

Healthcare provision and regulation are social processes that cannot remain subject to a single biomedical paradigm. The regulatory system now needs to reflect a synthesis of social and civic paradigms of health and care with the applications of biomedical science. This calls for the formation of partnerships - and partnerships are not easy. The governance and accountability of the GMC cannot be left to reforming the 'engagement mechanisms'. We will require public leadership of a robust, renegotiated partnership.

Such transformational change will inevitably lead to a fundamental redesign of medical education and medical practice - a transformation already being achieved by those doctors who are working with, and learning from, patients as fellow citizens to reform healthcare at a local level.

Institutions will continue to exist that represent the interests and professional standards of doctors.

However, the regulation of medicine is too important and must be handed on to true civic engagement and leadership; a leadership for the 21st century.

Professor Sir Graeme Catto: The GMC is a million miles from 'doctors know best' and 'it takes one to know one'. No GMC decision is taken without significant public involvement.

Fitness-to-practise panels, which replaced the professional conduct committee, are drawn from a pool of about 117 doctors and 71 lay people.

The panels are as likely to be chaired by a lay person as a doctor.

Lay involvement is not a new phenomenon. The first edition of Good Medical Practice, the GMC's flagship guidance, was produced by a working group whose lay members included, for example, Healthcare Commission chair Professor Sir Ian Kennedy.

Performance assessment teams, introduced in 1997, always have a lay assessor as one of their three members.

The case for meaningful public involvement in regulation is overwhelming. But equally I believe that doctors must feel ownership of the principles and ethics that are at the core of their professionalism.

That is why we need regulation that is professionally led and patientcentred.

The GMC is there to protect, promote and maintain the health and safety of the public. We work in the public interest; and we should be accountable to parliament, on behalf of the public.

We need to build on patient and public involvement. A range of engagement mechanisms is crucial as we recognise that 'representativeness' is a red herring and that the secret lies in getting a range of perspectives.

Participation can be involvement, consultation or partnership. We are striving to make the third a reality. If we are clear about our purpose we hope to dispel the cynicism, which often pervades such issues. l