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The case for change: maintaining competence, maintaining trust

The depth of trust which underpins the relationship between the public and medical practitioners is unique. This trust assumes that medical practitioners have the necessary knowledge and skills coupled with the appropriate conduct and behaviour to provide safe and effective care in the public’s best interest. Research in Ireland and other countries has consistently shown that the public have high levels of trust in medical practitioners. The challenge for medical regulators is to establish intelligent and transparent professional accountability arrangements which maintain this trust.

Why should the Medical Council extend its professional accountability system to ensure that a medical practitioner is maintaining competence?

Maintaining trust - the case for change

In recent decades, the quantity and quality of medical knowledge has increased dramatically; gone are the days when knowledge gained through undergraduate and postgraduate training could sustain a medical practitioner through his or her professional life. Research supports the extent of this new challenge. While practice may make perfect, there is evidence to show that knowledge, skills and quality of care can decay over time. Encouragingly though, evidence also shows that interventions like continuing professional development (CPD) and clinical audit can be effective in maintaining knowledge and skills and improving the quality of patient care.

What can we learn from other sectors? Increasing recognition of the prevalence of adverse events in healthcare has seen a call for the application of systems and processes used in other high risk industries to ensure quality and safety; pilots, for example, face annual license proficiency tests.

What do the public and medical practitioners think about maintaining professional competence? Research commissioned by the UK Chief Medical Officer Sir Liam Donaldson for his report “Good Doctors, Safer Patients” found that most people thought that processes to maintain the competence of medical practitioners were already in place and also thought that regular assessment of doctors was appropriate. In the same report, Donaldson called for honesty within the medical profession regarding the problem of poor performance and noted: “most doctors know of another doctor whom, on balance, they would prefer not to treat their own family”.

Given the case for change, without systems for maintaining professional competence, is trust between the public and medical practitioners being breached?

International trends and emerging models

Many countries have established systems for regulating the maintenance of professional competence. For example, in North America, recertification by specialty boards is now mandatory; participation in professional competence programmes is a requirement for all registered medical practitioners in Australia and New Zealand; and the UK has introduced an ambitious system of licensing and revalidation based on periodic assessment. In Ireland, postgraduate training bodies have operated voluntary CPD systems for a number of years.

Internationally, the range of systems for maintaining professional competence is evidence that there is no “one-size-fits-all” solution; however, systems generally draw on one of two models. The learning model focuses on supporting and improving the competence of all doctors using techniques based on a continuous quality improvement philosophy such as life-long learning and reflective practice; while this formative approach has advantages, the main criticism is that it cannot deal effectively with poor performance. The assessment model focuses on detecting and managing poor performance through continuous monitoring or periodic evaluation of doctors; while the appeal of this summative approach is the assurance which it seeks to provide with regard to the practice of all doctors, critics question the feasibility and validity of methods.

Are there lessons to be learned from experience in other countries? Extending the system for professional accountability to include the maintenance of professional competence is challenging and most countries take an incremental approach: voluntary systems which enjoy a high degree of support transition to mandatory system; focus on assessment increases when stable and effective systems have been embedded. Choices need to be made to find a solution which fits best with the wider health system.

Medical Council leads debate for change

Since the late 1990’s, the Medical Council has been leading debate on the establishment of systems for maintaining professional competence in Ireland. This culminated in the issuance of a position statement in 2006, “Performance in Practice: Maintenance of Professional Standards”, based on consensus built by the Council with the public, medical practitioners, postgraduate training bodies, employers and a range of other interested parties.

In that position statement, the Medical Council proposed an approach to maintenance of professional competence based on three strands: continuous quality assurance through CPD and clinical audit; professional practice review through multisource feedback; and performance assessment in response to performance concerns.

The statement was an important input into the drafting of the Medical Practitioners Act 2007 and was issued against the backdrop of Judge Harding Clarke’s report on the Lourdes Hospital Inquiry, which made specific recommendation regarding maintenance of competence. The last years of health system reform in Ireland has seen an increased focus on quality and safety of care. The report of the Commission on Patient Safety and Quality Assurance, “Building a Culture of Patient Safety” has provided huge impetus for safer, better care.

A time for change has arrived.