The General Medical Council is under attack but, Seamus Ward reports, its rearguard action is well underway

Sir Donald Irvine is fighting to save the reputation of the medical profession - and he knows he will only win if doctors are prepared to be more open about their performance at work.

The General Medical Council, of which he is president, has borne the brunt of criticism following the series of scandals which has hit the profession: its failure to deal swiftly with disgraced doctors from Harold Shipman to Rodney Ledward and Richard Neale.

However, Sir Dona ld still believes the body can play a key role in protecting patients. Legislation approved by Parliament earlier this month will allow the embattled organisation to suspend doctors under investigation and inform hospitals if they are looking into a doctor's practice.

And at an HSJ/York University symposium on clinical governance last week, he insisted the solution to the profession's woes was regular revalidation, overseen by the GMC.

'How can we say the basic qualification I acquired in 1958 has any meaning at all in describing my fitness to practise?' he asked. 'The fact that things work so well is testament to the fact that doctors take keeping up to date seriously but I would like the profession to demonstrate this directly.'

David Black, medical director of Queen Mary's Hospital in Sidcup, asked whether anything could be done to change the attitudes of doctors who don't see the importance of communicating with patients.

'The evidence is that some can change and some cannot, ' Sir Donald said.'It seems to depend on whether they can understand their behaviour.

'But some have to be confronted with their behaviour in a way we are not used to. Some, perhaps, will have to find something else to do.'

Over the years clinical competence had been taken for granted and the profession had failed to improve attitudes to patients.

'When I was a medical student more attention was paid to attitude because often that was all doctors had to offer patients. But with the rise of scientific medicine somehow or other this has been lost.'

Doctors were not opposed to clinical governance but saw it as yet one more item in their growing workload: 'There is a real morale problem which the government as well as the service has to handle.

That has something to do with making sure there is time to get these things done. A lot can be done by changing the organisation with rational delegation - particularly in quality assurance by bringing in other people with the skills to make this happen. You don't need a medical qualification to do some of the work that underpins quality. On the contrary, it could be a handicap, 'he added.

Delegates were concerned about how clinical governance would work in practice and asked how trusts could collect patients' views, particularly those from ethnic minority groups. Andrew Cash, chief executive of Northern General Hospital trust in Sheffield, said this was extremely difficult.

'We need to have a system where patients' experience is built into the appraisal system for clinicians.

'It is complicated and if you are not careful you will get the articulate lower middle-class view. But the national plan does give us a good opportunity to embrace the public.'

Mr Cash said trust between clinicians and patients had to be rebuilt and the public would ask why it had taken so long for revalidation to come to the fore. He added: 'It is difficult to work out which organisation is monitoring who. I think I heard someone say that there are 27 different monitoring bodies, and as a chief executive that is quite difficult to come to grips with.'

Sir Donald acknowledged that the regulatory bodies' isolation from each other had been criticised. A lot of effort was going into bridging these gaps. 'At the minute it is difficult for people to see because not quite all the pieces are on the table yet, but when they are the test will be to get them to fit together so each bit does its task in harmony with the others.'

Rescue remedies Catherine Elcoat, deputy head of the NHS clinical governance support team, told the symposium that clinical governance had to be based on five 'foundation stones'.

Systems awareness: learning from errors and near misses.

'An individual may have made a mistake but a series of systems failures may have enabled the situation to occur.'

Teamwork: 'There is evidence that a patient with a carcinoma of the lung will be cared for by 19 different clinical professionals.'

Communication: 'I don't think I have come across any health service commissioner report that hasn't highlighted communication as a contributory factor to people being dissatisfied with the care they received.'

Ownership: 'If you don't involve the whole clinical team you will not get the same result.'

Leadership: 'We have got to convince staff that this time it's for real.'