Shipman hasn't ended the betrayal of patients

Anything less than rigorous checks on doctors would be a betrayal of public trust

One of the strengths of medicine is the trust patients place in their doctors. Nothing seems to shake it. Medical scandals from the Bristol children's heart surgery disaster to the crimes of Harold Shipman may have undermined our faith in medical institutions but not, it appears in those who wield the stethoscope and the scalpel.

Doctors consistently top polls of the nation's most trusted citizens. But is our trust misplaced? Anyone who got as far as chapter 26 of the fifth report of the Shipman inquiry, published last month, might begin to wonder.

The 1,300-page tome from Dame Janet Smith, the inquiry's barrister chairwoman, includes a forensic demolition of the medical regulator, the General Medical Council and its plans to introduce "revalidation", the five- yearly checks on doctors, dubbed the medical MOT.

The problem of how to deal with incompetent doctors has dogged the profession for years. The Bristol inquiry, published in 2001, exposed a "club culture" in the medical profession which covered up poor practice and led to unnecessary deaths.

That case and other scandals highlighted a remarkable fact - that from the moment they qualified to the moment they hung up their stethoscopes there were no checks on whether doctors were competent to do their jobs during careers that spanned 40 years. If you doubt whether this is a problem, read Dame Janet in chapter 26. She cites Lesley Southgate, professor of primary care at University College, London, who told the inquiry: "There are poorly performing doctors out there who are harming patients."

Professor Sir Graeme Catto, the president of the General Medical Council, said that the performance of at least 90 per cent of doctors gave no cause for concern. That meant, Dame Janet wrote, that there could be a problem of poor performance with as many as 10 per cent. Others had suggested lower figures of 5 per cent or 3 per cent, but she concluded that, whichever figure was more accurate, "I am in no doubt that the problems caused by poorly performing doctors are significant."

The report does not say how many patients are at risk, but Sir Donald Irvine, immediate past president of the GMC, pointed out that the figure of 5 per cent of "risky" doctors could, in the case of GPs, be turned around and applied to the population cared for by them.

In a recent lecture, he said: "This means several million people are put at avoidable risk without even knowing it. Looked at through patient's eyes, this is simply unacceptable. On any terms, it is morally indefensible."

Few were keen to join Dr Irvine on the moral high ground while he was president of the GMC, and he left office six months early in 2003. His mission to protect patients and make doctors more accountable had provoked fury at the British Medical Association which passed a vote of no confidence in the GMC.

His successor, the clever and charming Sir Graeme, used his fine diplomatic skills to rebuild bridges with the BMA, and together they developed a version of the five-yearly checks that satisfied all sides and was about to be implemented from April.

But they did not anticipate Dame Janet's forensic examination of their plans. She commended the original Irvine proposal but said it had been so watered down as to be useless and that to compare it to the MOT for cars was a travesty. Her most damning criticism was that the changes had been made "for reasons of expediency ... not principle" because of opposition from the profession.

Ministers were privately dismayed that years of careful negotiation with the profession had been destroyed by Dame Janet's lawyerly analysis. They were left with no option but to order a review, chaired by the Chief Medical Officer Sir Liam Donaldson, and to postpone the implementation of the new checks in April.

The episode has left the GMC looking badly bruised. An institution founded on the principle of self regulation has seen one of its main pieces of work taken over by the Government. Some might have regarded that as a resigning issue, but Sir Graeme Catto does not look like a man about to fall on his sword.

The lack of blood-letting does not bode well. It suggests a fudge is in the offing. Ministers, doctors and the GMC hope that, with a few tweaks and adjustments, a form of revalidation can be introduced that will satisfy critics such as Dame Janet and be acceptable to the profession. But past experience suggests that such a compromise is unlikely to provide the protection patients need.

Sir Donald, whom posterity may yet decide has been the hero of this story, likens the position of doctors to that of airline pilots. "I am not interested in flying with an airline that has not been subject to the proper checks. It is part of what you pay for. If they say they have not got enough pilots to carry out the checks and fly the planes, that is not good enough. In the same way, people believe today they are entitled to a good doctor - not the least good one that the profession can get away with," he said.

Patients awaiting a diagnosis, about to go under the knife, or being dosed with powerful drugs, are unlikely to disagree. Anything less than rigorous checks on doctors' performance would be a betrayal of the public's trust.