The president's introduction

This three-part article aims to examine, from a lay person's perspective, the Malta Medical Council Report 2005 and to suggest a way forward on the Council's purpose, goals and functions.

In his introduction to the report, the president, Judge Victor Caruana-Colombo, comments: "In compiling this report the Council takes the opportunity to appraise its own conduct and activities to guide doctors and dentists, and to better serve the public."

Appraising one's own conduct is a laudable exercise in itself but not good enough. What the Council lacks is the use of a range of tools to help it to measure its success more effectively. For instance: 1) feedback from users of its services; 2) An audit and quality assurance exercise; 3) a tracking survey to measure its views about regulatory priorities against those of the public and the profession, and 4) Parliament to scrutinise the Council's annual report.

My professional experience tells me that unless an independent body exists to appraise our conduct and activities, we are all guilty of some degree of self-deception and a pre-disposition to rationalise our weaknesses and justify our failures. Too many of us, in fact, believe we are better than we are, and refuse to face the fact that we lack proper direction and commitment; we tend to procrastinate and often shirk our more burdensome responsibilities.

I assume the Council has to date deemed it inappropriate to engage an independent body to scrutinise its structure and functions; if so, one would expect the Council to introduce its own system of appraisal/ assessment for all doctors in public and private practice, independently of the annual audit of doctors and services that is reported to take place in the National Health Service.

Incidentally, it would help if the secretary-general of the Medical Association of Malta were to spell out more clearly to the public the nature of the audit system he refers to in his letter titled "In favour of proper medical audit" and whether this audit follows an up to date Fitness to Practice model (The Times, May 4).  

The Council and the media

The President chides the losing parties who turn to the media when they feel an injustice has been done to them. As he puts it: "It is not uncommon for losing parties to lambast decisions of a court of law as being bad or unfair, and not unexpectedly this also happens with decisions of the Medical Council. However, what is not expected is for such parties to draw editors, commentators and reporters of the press, held to be of good standing, into misinforming their readers. Some of the contributions published in the local press over the last year made denigratory comments about specific decisions of the Medical Council, and expressly invited, even challenged it, to respond. The Council however refuses to enter the arena of the media in order to substantiate its rulings, particularly those made in the exercise of its quasi-judicial function."

When an acquaintance of mine first read these comments, her first reaction was that the Council hates publicity and is very touchy about its decisions being commented upon; in fact, as she put it: "It is quite telling that it has not said that the articles which appeared in the media were incorrect or libellous in any way".

The Council seems to have a visceral aversion to publicity. It has no Press Office and no Website of its own. It has a tendency to view public complaints in a negative light instead of looking at them as a precious source of public feedback, allowing it to see itself from a fresh perspective and enabling innovative and patient-centred improvements.

As Sir Liam Donaldson, the Chief Medical Officer for England, puts it: "Assessments made by patients following their experiences, whether positive or negative, offer information that may have a bearing on the performance of both health systems and individual practitioners" (Good doctors, safer patients - Report 2006)

The Council has a great deal to learn from some of its counterparts abroad, particularly from the UK General Medical Council, which is internationally recognised as the leader in medical regulation.

The president must be familiar with the GMC's policy regarding its involvement with the media. It releases notices to the media in advance of hearings that are to be held in public. The media are permitted to attend the public meetings. Those that are not held in public are the ones that relate to a doctor's health. Any determinations from these hearings are also made public and are available on the GMC's Website.

Notice of the Council's hearings is put on the notice board of its offices at 181, Melita Street, Valletta, for the information of the public, at least eight days before. Hearings are public unless the proceedings are considered to be offensive to modesty, or in other exceptional circumstances, in which the case the hearing is held behind closed doors.

The Council offices are on the top floor of an ancient house with no lift. If the Council truly wants its hearings to be accessible to the public, there is no better way than its building being relocated to a more decent place that would give better access to the public, particularly to the elderly and persons with disability. Additionally, it should inform the media well in advance of its hearings that are to be held in public.

Furthermore, any determinations of these hearings should be made public and be available on the Department of Health's Website which it currently adopts. It would help if the Council were to clarify in plain language to the public what it considers to be "offensive to modesty or exceptional circumstances".

Rightly, the president is not at all satisfied with the delay in hearings. According to him: "One major reason for this is the numerous witnesses being brought forward by the parties concerned, who in most instances are not restrained from so doing to ensure a fair and equitable hearing".

The president fails to offer a formula for a better streamlining and speeding up of hearings. Certainly, this function is no longer a problem for the GMC's Fitness to Practice Panels. It would help if the Council were to turn to its UK counterpart for assistance regarding its long-standing and intractable problem.

Targets

The president proposes a few specific targets for the Council to achieve. He acknowledges that the professional and ethical code of conduct of medical/dental practitioners in Malta is out of date and still governed by the 1971 regulations; according to the president these must be updated in keeping with current thought and practice worldwide. He also acknowledges that medical registers need updating in line with EU regulations. The issue of revalidation of medical/dental practitioners needs exploring.

Code of conduct. The president singles out only one item for review in terms of the updating of the professional and ethical code of conduct - the advertising and canvassing by medical/dental practitioners. A General Notice for the Guidance of Practitioners has already been published by the Council. The notice gives a detailed and comprehensive view of what it considers contrary to the public interest and discreditable to the profession for a medical practitioner "to advertise or canvass, directly or indirectly, for the purpose of obtaining patients and promoting his own professional advantage".

Regrettably, the president not not comment on the likely mechanism the Council intends to adopt for the updating of the code of conduct. For instance, will the Council adopt a piecemeal or a comprehensive approach to its updating? Will the Council invite suggestions from patient groups and organisations representing medical, charitable and other professional interests? Links will also have to be clarified with other key areas such as fitness to practice, revalidation and education.

The registers. The president acknowledges that the existing medical registers require updating in line with EU directives and the Health Care Professions Act, 2003. He hopes that the registers will be available online as soon as they are completed. No deadline is given for their completion and for the nature of information they would convey.

The public has been anxiously awaiting the publication of these registers given the Council's reason for the delay in the publication of its Annual Report 2004: "It was not possible to have the Registers of the Medical Council printed in 2004 as the Council could not function in the period from November 2003 to the middle of April 2004."

An accessible and up-to-date Medical Register (or Registers) is an absolute necessity for the benefit of patients, doctors and employers. Registration is more than a bureaucratic process; its information has a crucial role to play in enabling patients and employers of medical practitioners to be sure that those who provide medical care are safe, up-to-date and fit to practice.

Revalidation. Revalidation is a system whereby medical practitioners would have their fitness to practice reviewed regularly and their licence to practice renewed if they satisfied the requirements of the review. The point of revalidation is to increase public confidence that all licensed medical practitioners are up to date and fit to practice.

According to the UK GMC, the arguments for revalidation are threefold:

"First, if a doctor's licence to practice is to be meaningful it must be based on more than the possession of qualifications obtained some years before. The licence should be justified by evidence that the doctor is up to date and fit to practice; and the evidence should be based on performance in the roles undertaken.

Second, revalidation will help to raise standards by requiring doctors to demonstrate that they have reflected on their practice, and taken action if necessary, using evidence gathered from their practice through audit and in other ways.

Third, revalidation will make an important contribution to patient safety by securing confirmation that doctors are up to date and fit to practise; by identifying for further review doctors who fail to secure local certification; by providing a backstop where local systems do not exist, or exist but are inadequate; and through robust quality assurance". (General Medical Council's Annual Review 2004/05, p. 5).

It is imperative for the Council to find the right mechanism for revalidation. This exercise will require extensive consultation with the medical and dental professions as well as the public. Additionally, an exercise of this nature would entail a significant workload for the Council. I am not at all convinced that the Council is equipped to achieve this goal satisfactorily in the medium term.

Financial statement

The public and the medical/dental profession would expect to find in the report the Council's audited annual financial statement. This has not been the case. The Council is an autonomous body and, as such, should be independent for its finances on the government or other institutional source. It levies fees from its registered medical practitioners and dental surgeons for initial registration and yearly retention fees thereafter.

I find it rather strange, given the Council's autonomy, that the Minister of Health can make funds available to the Council: "The Registrar of a Council or of special Accreditation Committee shall, under the direction of the relevant Council or Committee, be responsible for the administration of such funds which the Minister may make available to the Council or Committee as the case may be for its purposes, and for such fees as may be collected by it."(HCPA 2003 - Miscellaneous Provisions, Part 1, Section 45).

The time is ripe for the Council to publish an audited financial statement that fulfils the information need of its members and the public.

To be continued