Doctors used to bury their mistakes. But, increasingly, the ghosts are haunting the profession. After a series of high-profile scandals, from the Bristol babies heart deaths to struck off gynaecologist Rodney Ledward, people are no longer prepared to assume that the doctor was right - they want proof.
The General Medical Council, criticised for failing to do enough to stop dangerous doctors, wants to show it is putting its house in order.
Last week president Sir Donald Irvine launched revalidation, its plans for regular checks on doctors' competence. All 190,000 people on the GMC register will get a copy of the proposals and the council is keen to hear from 'all interested parties' via its website and a series of meetings 'throughout the UK'.
Sir Donald describes revalidation as 'a much more effective mechanism for detecting poor performance before patients are harmed' that would allow doctors to demonstrate their excellence.
Is this enough to restore public confidence in the GMC and in the profession? Are consultants, GPs and juniors convinced this is the way forward?
Not necessarily, according to Dr Brian Ayers, medical director of one of the country's largest trusts, Guy's and St Thomas's.
'It could double our workload if we have to go and look at someone else's records every five years, 'he points out. Dr Ayers already has to check 400 consultants' appraisals every year. Under the GMC's draft plans, it is likely that medical and clinical directors will be involved in revalidating other doctors as well.
The guidance calls for a three person team to assess doctors every five years and recommend either revalidation or referral to the GMC.
Two of the team will be doctors, the third a lay person. One of the team will be 'a registered doctor who has personal knowledge of the doctor's practice' - likely to be a medical or clinical director of the trust where the doctor works.The other medic will be someone who does not know the doctor but works in the same specialty.
Candidates for revalidation will have to keep a folder, detailing their practice, their regular appraisals and how they keep their skills up to date.
They will also have to describe any 'critical incidents'.
Dr Ayers would like to add an 'objective test' of skills, such as asking an anaesthetist to intubate a dummy or live volunteer. 'To what extent can an appraisal be trusted between 'buddy' doctors?'he asks.
Doctors have warned that the system could cost serious money.
Suffolk GP Dr Brian Goss told the British Medical Association's GPs conference earlier this month, it could even be as much as£2,000 per doctor per year.But GMC lay member Sue Leggate denies it, claiming that 'managers will be worried about resources'. Ms Leggate, part of the steering group behind revalidation, points out that as chair of Epping Forest primary care trust, 'I would be horrified if we were taking resources and time away from patients - it is not about that.'
Revalidation itself will involve the three-person team assessing the folder. The GMC believes this system, building on the regular appraisals to be brought in under chief medical officer Professor Liam Donaldson's 'Supporting Doctors, Protecting Patients' programme , w ill avoid duplication. Dr Ayers hopes that will be the case: 'If we have to have revalidation to satisfy the politicians and the public that doctors are up to scratch, then building on annual appraisals is the only way of doing it without an incredibly complicated centralised system.'
Ms Leggate says: 'For most doctors it is information that they collect now.'
The assessment team will decide whether the doctor can be revalidated, or asked to take action to remedy any shortcomings, or should be referred to the GMC's fitness-to-practice procedures. The medical register will show whether or not a doctor is revalidated, but there is no proposal to allow the public to see detailed results of the assessment. Ms Leggate says there will be no detailed feedback to the employing trust, either: 'The information will have been generated through the trust in the first place and assessed by them through the chief medical officer's proposed scheme.'
It should be relatively straightforward to put this in place in hospitals. But the big question is how will it work in primary care, where GPs run their own empires?
Alastair Henderson, policy manager for the NHS Confederation, welcomes revalidation in principle, but warns:
'The health service is responsible for the services GPs provide. It is important that NHS organisations have an input into the assessment groups for GPs.' PCGs or PCTs could take on this role, he says.
London GP Dr Sam Everington believes revalidation 'is probably not enough' to deal with the 'crisis in confidence' afflicting the profession. It should be much tougher : 'None of this is about trying to get doctors off the register, ' he says.
'The people who think revalidation has gone too far don't understand the depths of the crisis.'
Sir Donald Irvine will speak at the HSJ /York University symposium on health to be held in York on 19 July, with Catherine Elcoat, deputy head of the NHS clinical governance support team. The topic will be 'A View from Here: Governance'. Free admission.
Details on 01423-507771.
See features, pages 26-29, 30-31.
Revalidation: the timetable Consultation ends 25 September Finished proposals due out May 2001 Roll out to all specialties 2001 www.gmc-uk.org/revalidation