Mums4medics email to GMC
From Mmc
Email: Mums4Medics@aol.com
General Medical Council
Regent’s Place
350 Euston Road
London NW1 3JN
26th March 2007
Dear Sirs
Re: Professor Alan Crockard, GMC no. 0174862
I write to you as a lay person who is also the co-ordinator of Mums4Medics, an ad hoc lobby of the parents and significant others of junior doctors caught up in the current crisis in post-graduate training.
Since Mums4Medics came into being I have corresponded with many families, and with doctors both senior and junior. It will be clear from what follows that I have had detailed input from doctors in the formulation of this letter. These doctors wish to remain anonymous for the moment - given the current climate of fear and uncertainly I am sure you will understand. However, should the GMC decide that Professor Crockard has a case to answer, at least one of these doctors will come forward publicly.
It is my privilege to provide them with a voice for their detailed concerns. I would not have agreed to send this letter over my name if I was not persuaded that the arguments put forward here are worthy of the GMC’s consideration.
The current crisis in post-graduate medical training is a result of Modernising Medical Careers (MMC) and the Medical Training Application Service (MTAS). In recent days numerous senior doctors have openly spoken out against these reforms, the Secretary of State for Health has been called to Parliament to explain government policy, and 12,000 junior doctors have marched through central London. There has also been considerable coverage from both broadcast and print media.
The scale of this crisis is unprecedented and due to the complexity of the problem, I am told that a solution may be difficult to reach. Statements from both the Royal College of Physicians and the Royal College of Surgeons (England) suggest that non-emergency NHS services might have to be cancelled while attempts are made to find a solution. The public are bemused, and it seems clear that this affair may lead them to question their trust in the medical profession.
Professor Alan Crockard (GMC number 0174862) is the national director of MMC and ultimately responsible for MMC and its implementation.
I respectfully ask the GMC to examine the conduct of Professor Crockard in this matter and, if it is found wanting, to consider disciplinary action.
I understand that your usual remit relates to direct patient care, but recent high profile cases have confirmed the GMC’s wider jurisdiction. I refer to the cases of Dr Andrew Wakefield and Professor Sir Roy Meadow.
In support, I wish to draw your attention to the standards expected of a registered medical practitioner as detailed in GMC publications, principally ‘Good Medical Practice’ and ‘Management for Doctors’.
The GMC’s jurisdiction in this particular matter It seems clear that the GMC has jurisdiction over the conduct of Professor Crockard in his role as national director for MMC. Paragraph four of ‘Management for Doctors’ states:
“You remain accountable to the GMC for your decisions and actions even when a non-doctor could perform your management role”
It seems clear that the GMC expects any doctor in a managerial role to adhere to their guidance and standards. Paragraph seven of ‘Management for Doctors’ states:
“…you must make every effort to follow the guidance in this booklet, where it is your responsibility and within your power to do so …”
As national director of MMC, it would seem it was both the responsibility and within the power of Professor Crockard to follow GMC guidance.
Professor Crockard’s accountability
Paragraph seven of ‘Management for Doctors’ continues:-
“The extent to which you will be held accountable will inevitably depend on the circumstances: your position, the resources available to you and the nature of the problem will all play a part in evaluating the extent and nature of your accountability.”
The above statement appears to indicate that Professor Crockard can be held fully accountable for the MMC crisis due to his position and the resources available to him in this role.
The overall responsibility of Professor Crockard seems to be confirmed by paragraph fifty-three of ‘Management for Doctors’:
“You will still be responsible for the overall management of the tasks you have delegated.”
Professor Crockard’s awareness of his responsibilities It can be argued that Professor Crockard should have been fully aware of the extent of his responsibilities. Paragraph nineteen of ‘Management for Doctors’ states:
“You should establish clearly with your employer the scope of your role and the responsibilities it involves.”
Responsibility for the choice of selection methods therefore seems ultimately to lie with Professor Crockard also. If this argument is accepted, he would be responsible for:- • the selection and implementation of the computer based application process; • ensuring that the selection system would work within the deadlines set, and within the various logistical constraints, for example, available consultant time for shortlisting and interviewing; • delivering a process which would be accepted by the medical profession with regard to reliability of the outcomes, and successful integration of the old system into the new system.
It could also be argued that, given the optimism about MMC of its creators, it should have stood as a shining example of how medical selection and training should be run. Instead, the system has thus far been an abject and costly failure.
MMC and GMC guidance In addition to the enormous burden on the NHS that MMC selection has thus far proved to be, various aspects of its design seem to fall foul of GMC guidance. ‘Management for Doctors’ lists requisite knowledge for such endeavours. Paragraph eighteen includes:
• use and application of information and information technology • limits of what is affordable and achievable • culture of the organisations in which you work • principles of good employment practice and effective people management
There are numerous worrying reports emerging regarding the chaos behind shortlisting. There are, I am told, proven cases of: • lost applications • variability of scoring of forms between co-markers • incorrect scores from shortlisting being submitted into MTAS • failure of anonymity • inconsistencies between horizontal/vertical shortlisting • leaking of confidential scoring criteria to applicants • applications being submitted to the wrong specialties • non-medical staff scoring forms • impossible deadlines for consultants to shortlist.
Despite the many questions and concerns raised about the shortlisting process, Professor Crockard has continued to defend its validity. Paragraph nine of ‘Management for Doctors’ lists principles for the conduct of holders of public office, which extend to doctors in managerial positions. These include:
• Integrity • Accountability • Openness • Honesty
Moreover, the final sentence from ‘Duties of a Doctor’ reads:
“You are personally accountable for your professional practice and must always be prepared to justify your decisions and actions”
I am informed that numerous legal challenges are in the process of being mounted in response to MMC selection. Preliminary reports have suggested that such legal challenges have a high chance of success. This situation has only been worsened by the frequent compromises announced in recent weeks in response to meetings of the MMC review group. It therefore seems inevitable that in the near future legal rulings will only add to the current chaos.
I am informed that this situation could have been prevented by adequate consideration of employment law when the system was designed. The managerial responsibilities of Professor Crockard are clearly stated by the GMC. Paragraph twelve of ‘Management for Doctors’ lists a number of outcomes which any doctor in any managerial position must ensure. These include:
“All decisions, working practices and the working environment are lawful, with particular regard to the law on employment…”
Such breaches of employment law can give rise to allegations of unfair discrimination. Paragraph forty-seven of ‘Management for Doctors’ relates to the fair treatment of colleagues:
“All doctors must treat their colleagues fairly. You must tackle discrimination where it arises…You should have a working knowledge of the relevant law…”
This is confirmed by paragraph forty-six of ‘Good Medical Practice’:
“You must treat your colleagues fairly and with respect. You must not bully or harass them, or unfairly discriminate against them…”
A number of stakeholders have sought to make complaints against the application processes designed by the MMC team and executed by MTAS. Due to the convoluted system, it has been difficult for affected individuals to know where to direct their complaint. Replies to complaints have, it is reported, been slow, inaccurate, unhelpful, or non-existent. Paragraph fifteen of ‘Management for Doctors’ makes the following recommendation for managers:
“You should make sure that adequate systems are in place for investigating complaints promptly, fairly and thoroughly…”
Following the highly questionable MTAS shortlisting results, a number of applicants wrote to individual deaneries to request release of data under both the Data Protection and Freedom of Information acts. Individual deaneries have replied stating that following guidance from the MMC team and the Department of Health, such information may not be released until the conclusion of the second round of applications. Many applicants believe this reply to be contrary to these acts, and have written to the information commissioner to complain. It seems possible that individual deaneries have been misinformed by the DoH/MMC team. Paragraph forty-two of ‘Management for Doctors’ states:
“provide data protection and records managers with the training and support they need to carry out their responsibilities”
It would therefore appear that this guidance might be in breach of the above GMC standards. If this policy of non-release of data originated from the MMC team, Professor Crockard must accept ultimate responsibility.
MMC and its implications for patient care Many concerns have been expressed at all levels of the profession that the Modernising Medical Careers reforms will be detrimental to patient care. A number of reasons have been given for this.
Firstly, according to figures from MMC, there are 32,000 applicants for 23,000 posts. Inevitably this will lead to 9,000 junior doctors facing unemployment in August. The NHS is overstretched; will care not suffer without these 9,000 doctors?
Secondly, under MMC proposals, doctors will be awarded their CCT following fewer years as a trainee. Combined with the mandatory reduction in working hours following the European Working Time Directive, this can only result in CCT holders with poorer knowledge, skills and experience as compared to current newly-qualified consultants. To suggest that the widespread adoption of competency based training will overcome the reduction in training hours is just that – a suggestion. Evidence to support this claim is scarce, and certainly cannot alone justify such widespread reforms to training.
Thirdly, the MMC proposals do not allow for trainees to gain a broad experience as a junior before selecting a specialty. Many believe this is one of the great strengths of the current system. MMC training will equip doctors with a narrower field of experience as well as less experience. It will also force doctors to commit to a specialty early, thus possibly increasing the numbers of doctors in specialties for which they hold little enthusiasm. These factors are all arguably detrimental to patient care.
Many believe an erosion of standards is the inevitable consequence of MMC. Such an outcome would be against a number of standards set by the GMC.
Paragraph ten of ‘Management for Doctors’:
“All doctors have an obligation therefore to work with both medical and non-medical managers in a productive way for the benefit of patients and the public.”
Paragraph twelve lists a number of outcomes which any doctor in any managerial position must ensure. These include:
“Systems are in place to enable high quality medical services to be provided”
“Care is provided and supervised only by staff who have the appropriate skills (including communication skills), experience, training and qualifications”
“Significant risks to patients, staff and the health of the wider community are identified, assessed and addressed to minimise risk…”
‘Duties of a Doctor’ makes the following requirement under the heading ‘Provide a good standard of practice and care’:
“Work with colleagues in the ways that best serves patients' interests”
If these arguments are accepted, it seems possible that Professor Crockard may have acted in breach of these various GMC standards.
Professor Crockard’s interaction with colleagues There have been worrying reports that the culture of the MMC team has been one of spin, denial, silence, and deception. This has only served to increase the anger felt by the profession, and add to the worries felt by applicants to this system. Whatever the truth of these reports, Professor Crockard must, once again, take ultimate responsibility for the effects of his team’s perceived behaviour. Paragraph seventeen of ‘Management for Doctors’ expresses the need for managers to:
• communicate clearly • manage resources and plan work to achieve maximum benefits… • make sound decisions in difficult situations • consider and act upon constructive feedback from colleagues
Sadly, Professor Crockard seems not to have listened to constructive feedback from colleagues. The British Medical Association has long been calling for changes to the MMC proposals, but these have fallen on deaf ears. The team responsible for MMC appears to many to have been making light of the crisis. The BMA’s Junior Doctors Committee has now withdrawn from the Review Body as has the Chair of the Consultants Committee. The medical profession generally now finds itself in a difficult position.
Such an approach to the real concerns of colleagues is not consistent with the standards expected by the GMC. ‘Duties of a Doctor’ lists the principles any medical practitioner must follow in their work. Under the heading ‘Be honest and open and act with integrity’ are the following statements:
“Never discriminate unfairly against patients or colleagues”
“Never abuse…the public's trust in the profession”
It appears possible that Professor Crockard has failed to meet these standards in his role as national director of MMC.
The effects of MMC/MTAS It is difficult not to draw the conclusion that the chaos the medical profession now finds itself in is a direct result of the poor planning, implementation, and overall management of the MMC team. As its national director, Professor Crockard must accept ultimate responsibility. The GMC publication ‘Management for Doctors’ details the requirement for appraisal of those doctors in managerial positions (paragraphs thirty-two and thirty-three):
“You should also take part in annual appraisal and revalidation, both of which should involve someone who knows about management looking at your performance as a manager”
“You should review your own performance as a manager and take part in regular audit and reviews”
The GMC may wish to examine whether Professor Crockard participated in such appraisal and review processes.
Moreover, paragraph thirty of ‘Management for Doctors’ clearly states:
“As a manager, you must work within the limits of your competence”
Given the scale of the disaster, it is difficult not to conclude that Professor Crockard may have been working beyond the limits of his competence. Indeed, the British Medical Association’s Junior Doctors Committee recently called for Professor Crockard to resign. I am told that surveys conducted by both RemedyUK and Professor Brown (Addenbrooke’s Hospital) have demonstrated that most responding doctors agreed with this demand.
In conclusion, I would respectfully suggest that there is sufficient evidence to consider an investigation into the conduct of Professor Crockard in relation to his role as national director of MMC. In company with my many correspondents both within and outside the profession, I am concerned that his actions may have seriously damaged the good reputation of the profession, and eroded the trust that the public have in doctors.
I look forward to your early reply.
Yours faithfully
Lindsay Cooke
