Council
23 – 24 May 2000
8a
To consider
Structure, Constitution and Governance
Issue
1.
This paper follows the PAC’s discussion of the Council’s decision that there
should be a review of structure, constitution and governance.
Recommendations
2.
Council is invited:
a.
To agree that no change is not an option (paragraphs 13-16).
b.
To agree that we should develop a constitution and governance
arrangements that meet the requirements of a modern regulatory organisation
and reflect best practice (paragraph 17).
c.
To agree that we need to think radically (paragraphs 18-23).
d.
To confirm that medical regulation should continue to be professionally
led and that the majority of members should be elected medical members
(paragraph 25).
e.
To confirm that there should be significant lay participation in all
aspects of the GMC’s work (paragraph 26).
f.
To confirm that the GMC should remain independent of the NHS and
the Government, while enabling all our stakeholders to judge our performance
(paragraph 27).
g.
To agree that the review should be taken forward in four phases
(paragraphs 28-29).
Further information
3.
Antony Townsend
Finlay Scott
020 7915 3517
020 7915 3563
email: [email protected]
email: [email protected]
Background
4.
In February 2000, Council decided there should be a review of the GMC’s
structure, constitution and governance. Council invited the PAC to prepare proposals
for taking the review forward. In April 2000, the PAC discussed the review, taking
into account written contributions from a number of members. Copies of those
contributions are available from the Secretariat.
5.
The PAC recognised that the size of Council was an important issue. But it
was not the only, nor even the most important, point to be addressed. The PAC
invited the Office to prepare a paper, illustrating the issues, highlighting the strengths
and weaknesses of different models, proposing principles, and suggesting next
steps.
How did we get here?
6.
The current structure, constitution and governance are derived from the
conclusions and recommendations of the Report of the Committee of Inquiry into the
Regulation of the Medical Profession (the Merrison Report), published in April 1975.
7.
Merrison defined some basic principles of composition. The Report argued
that the GMC should be independent of the NHS and the Government; provide
professionally led regulation; give elected medical members a ‘dominant position’;
and be representative of all parts of the profession. The Report also argued that the
GMC should ensure the participation of lay people; and should provide for a
balanced approach to issues.
8.
Merrison recommended that the Council should total 90 members (now 104),
comprising 54 elected medical members (still 54); 34 medical members appointed by
educational bodies (now 25); and 10 lay members (now 25). The elected medical
majority, and the three categories of member, are laid down in the Medical Act 1983.
The statutory framework is otherwise flexible on size and composition.
9.
Merrison acknowledged that a large Council would not be suited to the
efficient and effective direction of day to day business. Merrison recommended that
there should be an Executive Committee:
‘… to see to the implementation of the policies decided on by the General
Council … and be a source of new ideas and become the leader and guide of
the General Council’ (paragraph 412).
10.
In the event, the Executive Committee was not a success and there was
widespread internal dissatisfaction. Among other things, it was thought to be too
large. In 1989, Council agreed that ‘… a President’s Advisory Committee be set up
and the functions of the Executive Committee be redistributed…’. The PAC has
grown and is now about the size of the Executive Committee when it was replaced.
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11.
The Chief Executive’s report (Council item 5) outlines the steps being taken
within the Office to continue the transition to a quality organisation, delivering service
to agreed standards. This will continue, whatever the results of the governance
review.
Discussion
12.
This paper starts with three propositions. First, that no change is not an
option. Second, that restructuring, by itself, will not provide a sufficient response.
Third, that we need to think radically, particularly on representativeness.
No change is not an option
13.
Many members, senior staff, our partners in health care issues, and
commentators, believe that our structures, constitution and governance must be
updated to provide the mechanisms needed for effective professional regulation.
14.
The problem is partly substance and partly perception. As the five year
review, Changing times, changing culture (Council item 8e), illustrates, we have
much to be proud of, for example in undergraduate medical education, standards,
and the health and performance procedures. Equally, we must acknowledge
concerns about our performance in certain areas: in particular that we have not been
able to act promptly or responsively in a fast-changing environment.
15.
Perception is also important: the confidence of patients in their doctors –
which we have stressed as central to good quality care – is damaged if our
regulatory structures are perceived to be inadequate. Structures must both look and
be convincing and effective, and should accord with acknowledged best practice.
Our structures do not pass this test.
16.
The aim should be to enable policy and operational functions to be
undertaken more speedily, more decisively and more responsively but also more
confidently, more cohesively and more accountably. There must be checks and
balances but they should not prevent swift, authoritative action in a world where
speed is often of the essence.
Recommendation: To agree that no change is not an option.
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Restructuring is not a sufficient response
17.
Efficient and effective structures are important but they are not enough. We
also need a modern constitution and effective governance arrangements. We need
clear definitions of roles and responsibilities; of authority and accountability; and of
the relationships between members and the Office. We also need mechanisms
capable of producing a formally articulated and agreed strategy supported by a
regularly reviewed strategic plan; and we need means of resolving conflicting and
changing priorities. And we need to be confident that our resources are used
effectively and efficiently in pursuit of our strategy.
Recommendation: To agree that we should develop a constitution and
governance arrangements that meet the requirements of a modern regulatory
organisation and reflect best practice.
We need to think radically
18.
Combining representativeness with efficiency and effectiveness is not a new
challenge. Merrison recorded:
‘We have had two wholly opposing views put to us about the size of the
regulating body … In our judgement these views are not so contrasted as one
might suppose, since … however one arranges the work of the GMC, both a
large component and small components will be required. … In short, the
regulating structure must achieve a balance between active involvement of
the many and efficient action by smaller groups.’ (Paragraph 386)
19.
The models suggested by members and others have usefully highlighted the
tensions and the strengths and weaknesses of different approaches. For example:
a.
104 members (current): Strong on representativeness but weak on
directing day to day affairs. Potentially effective on policy determination but
individuals or sub-structures must be authorised to act or to direct action in the
interests of promptness. Can provide most but not all those needed to
discharge statutory functions; and now depends on some non-members (as
illustrated by Council’s decision to seek the use of non-members on PCC
panels). Weak on perceived effectiveness even if respective roles are clearly
differentiated, communicated and observed.
b.
50 members: Weak on representativeness unless backed by larger
representative body. Weak on directing day to day affairs unless underpinned
with good executive structures. Could provide many but not all those needed
to discharge statutory functions; and would inescapably depend on some
non-members. Risks being weak on perceived effectiveness since it could
seem an unsatisfactory compromise.
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c.
25 members: Strong on directing day to day affairs. Weak on
representativeness unless backed by a larger representative body. Could
provide some but not all those needed to discharge statutory functions; and
would inescapably depend on non-members for some of those functions.
Strong on perceived effectiveness.
20.
Representativeness is a complex concept that Merrison saw in terms of the
profession. The benefit to patients of professionally led regulation would be
jeopardised if that representative connection were lost.
21.
But we should not be trapped into thinking that this can only be secured
through representation on the governing body or that representativeness relates only
to the profession. We need to find imaginative ways of engaging all stakeholders in
making professionally led medical regulation operate demonstrably in the public
interest.
22.
This will require careful consideration of what we mean by representativeness.
For example:
a.
How does it relate to machinery for taking decisions on individual cases
within Fitness to Practise, and within Registration?
b.
How does it relate to the formulation of overall policies that must
command the confidence of the profession and the public?
c.
How does it relate to Merrison’s view that the GMC should be
representative of the whole profession?
d.
How does it relate to the public constituency, vital if the GMC is to bring
the profession and public closer together?
e.
How does it relate to the four constituent countries of the UK?
f.
How does it relate to methods of selection – election, appointment or
nomination?
23.
We cannot hope to resolve the issues by tinkering on a make and mend basis.
To do so would represent a triumph of hope over experience. The Executive
Committee was a failure; and its replacement, the PAC, has not been a success. We
have considerable experience of inventing and reinventing ad hoc mechanisms but
they have been little more than sticking plaster. We must do more than recycle old
notions. We have already signalled our readiness to embrace radical new ideas on
registration and fitness to practise. The same should be true of structural,
constitutional and governance reform.
Recommendation: To agree that we need to think radically.
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Principles
24.
It will be important to identify and agree underpinning principles. Merrison
provides a starting point, but some principles may need to be re-expressed to reflect
the different expectations and pressures we face today.
Elected majority
25.
Merrison’s general theme was that a majority of members should be doctors
elected by doctors. That must be preserved.
Recommendation: To confirm that medical regulation should continue to be
professionally led and that the majority of members should be elected medical
members.
Lay involvement
26.
The case for significant lay participation is unassailable and seems to be
universally accepted. The issue is how to achieve the balance that will retain the
strengths of professionally led regulation while acknowledging that the GMC’s
statutory functions exist to protect the public interest. There seems to be widespread
agreement that the time has come for a further increase in the proportion of lay
members who are lay people.
Recommendation: To confirm that there should be significant lay
participation in all aspects of the GMC’s work.
Independence
27.
Merrison argued that the GMC should be independent of the NHS and the
Government. The GMC, acting in partnership with others, but independent of
managerial and political considerations, is an important safeguard of the public
interest. The Government has confirmed its commitment the principle, stating that
‘professional self-regulation must remain an essential element in the delivery of
quality patient services’. But we need to find new ways to promote public
understanding of our work, and of enabling our stakeholders to judge our
performance.
Recommendation: To confirm that the GMC should remain independent of
the NHS and the Government, while enabling all our stakeholders to judge our
performance.
Next steps
28.
The Council has taken the initiative in launching this review. In taking the
issues forward, it will be essential to engage with a wide range of stakeholders,
reflecting the shared professional and public interest in ensuring efficient and
effective medical regulation. It will also be important to take advantage of
developments elsewhere, for example from the work of the Better Regulation Task
Force.
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29.
We suggest that there should be four phases:
a.
Phase 1: Work within the office, under the oversight of the PAC, with
outside support as appropriate, to identify the full range of issues and best
practice. This would include fact finding among members, based on a
professionally designed, structured questionnaire.
b.
Phase 2: A series of member workshops, based on the questionnaire
results and the review of best practice, leading to a report to Council in
November 2000 and provisional decisions on the main structural,
constitutional and governance issues.
c.
Phase 3: Consultation on those provisional decisions, with
representatives of the profession and the public, and with Government.
d.
Phase 4: Substantive decisions in May 2001, followed by detailed
discussions and negotiations on implementation including practicable
timescales.
Recommendation: To agree that the review should be taken forward in four
phases.
Resource implications
30.
Initially, the Office would undertake the further work. Outside assistance on a
review of constitutional and governance issues would cost about £1000 per day.
Members' workshops would cost about £40,000. There is no provision for this in the
budget for 2000, but we are looking at ways in which the expense can be contained
within the overall budget.
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