In excerpts from the upcoming issue of Commentary magazine, Sir Terence Stephenson, chair of the General Medical Council (GMC), is interviewed by former editor-in-chief Professor Humphrey Hodgson about relations with the medical profession, the Bawa-Garba case, and the NHS' shortage of doctors.
Humphrey Hodgson: Relations between the profession and the GMC are at the lowest they’ve ever been. Is that down to the paranoia of the profession, or do you think the GMC should have approached the case of Dr Hadiza Bawa-Garba differently?
Terence Stephenson: The relationship is at a low ebb. Did I think that was going to happen when I started in my role? No, because one of the reasons I stood as chair is that I thought the GMC needed to improve its relationship with the profession, and I think there’s a lot of evidence that we have done that over the past 3 years, until this case erupted.
We have reduced the number of investigations of doctors, and reduced the fees for doctors (especially trainees), for the first time in a long time. We have commissioned an independent review by Professor Louis Appleby, a leading UK’s leading mental health expert, to look at vulnerable doctors and accepted all of his recommendations. These are all things we were doing to show that the best way to protect the public is to look after doctors, but of course this case has set that back hugely. It would be naïve to think otherwise.
HH: One thing that distressed the profession was the GMC’s decision to appeal against the Medical Practitioners Tribunal Service (MPTS). That was at your discretion; it wasn’t mandatory.
TS: If you take external advice from the QC, and they say the tribunal has erred in law, and if you then don’t appeal, you’re setting a precedent. In that sense you have no choice, because the regulator can’t be above the law. You seek the legal advice – and you can take it or not take it – but I think most people take the advice of QCs, especially if you’re a regulator.
The GMC has only had a right of appeal since 2015, and it was granted by parliament. It had been requested by the Health Select Committee several times that the GMC have a right of appeal. So doctors can appeal against the MPTS if they feel they’ve got it wrong, and the GMC can appeal against the MPTS if they feel they’ve got it wrong, and all I can say is that [at the time of the interview] the fact that the High Court upheld the appeal suggests that our QC’s interpretation of the law was correct.
To give an analogy, I’m sure you’ve been trained in automatic external defibrillators. You put the panels on someone, and it says to ‘shock now’. You have a choice; you don’t have to do what it says, but on the whole all of us who are trained to use defibrillators are probably going to take the advice the machine is giving us unless we’ve got a very good reason not to. Similarly, if you take advice from someone who’s an expert in the law, in this case a QC, and they think the tribunal erred in law, of course it’s up to you whether you follow that advice. You could sit on your hands and do nothing.
You seek the legal advice – and you can take it or not take it – but I think most people take the advice of QCs, especially if you’re a regulator.
But the reason it would be difficult to let this precedent run is that in the British justice system you’re tried by 12 peers and the evidence is held orally and cross-examined. A tribunal of three people sitting in Manchester – one lawyer, one doctor, one layperson – cannot trump a criminal trial. They cannot go back over the evidence and unpick it. They didn’t hear the original evidence, they didn’t hear the cross-examination, didn’t see the people in court, didn’t see their demeanour, and that’s why I think the High Court quite clearly said a tribunal cannot go behind a jury trial.
That’s the point of law – it’s about the relationship between a civil tribunal and a criminal jury trial. Of course Dr Bawa-Garba is seeking leave to appeal from the Supreme Court and if she’s successful and her appeal is upheld, we’ll go along with that. We’re completely bound by the law of the land, and we’ll change our view.
[Ed: Shortly after this interview, Dr Bawa- Garba won the right to appeal]
HH: You’ve used the National Training Survey to highlight the issue of doctor numbers. Professor Jane Dacre, president of the RCP, recently said we should double the number of doctors. What do you think?
TS: When I spoke at the Oxford Union [in January] I was quite clear; I said the facts speak for themselves. The Organisation for Economic Co-operation and Development data shows the UK has got the 4th lowest number of doctors, the 4th fewest number of beds and the second highest bed occupancy rates, at 95%. You don’t need to be a doctor or a health economist to recognise there is an extraordinary stress on the system. There’s not enough doctors not enough beds, and the beds are full. I will echo what I said earlier, and what your college has been saying stridently for some years: it’s an under-resourced, underfunded, under-doctored health service, and it’s in big trouble.
We welcome the RCP pushing for the 25% increase in the number of medical students in England, [but] that will take 10–15 years to make an impact on general practice or hospital consultant numbers, so we need a quicker fix than that. We also welcome the funding settlement that’s been talked about. Since 1948, the NHS has had a year-on-year increase of 4% in funding in real terms. Since the austerity crisis of 2008 there’s been a at settlement, or maybe 1%. Put all that together and you’ve got a perfect storm.
It’s no wonder that morale is low, and that doctors feel that they are stitching together a creaking health service. I’ve been working in the NHS continuously for 35 years this year and it’s as bad as I’ve seen it. I don’t know what the number is, and I wouldn’t presume to know, but we need more doctors and we need them sooner than the 25% increase in medical students will play through.
You don’t need to be a doctor or a health economist to recognise there is an extraordinary stress on the system.
HH: How loud do you think the GMC’s voice is in the Department of Health’s ear – or the secretary of state’s ear?
TS: The GMC reports to parliament, not the secretary of state, and has done since 1858. The Health Select Committee used to ask for regular hearings. In my very first year we did one but it hasn’t asked since, but that’s the route through which we report to parliament.
The secretary of state is a busy chap and has a lot on his in-tray and has to take Cabinet with him. I’m sure we’re one voice that he listens to but he has his other advisers, and keeps his own counsel.
I think it would be wrong to personalise it. He’s a member of a democratically elected government who can choose to put more or less percentage of GDP into healthcare.
The full version of this interview will be featured in June's Commentary magazine.