The Registrar's report

In this part I shall focus on the current composition of the Medical Council, its function of hearing complaints and inquiries, and its decision regarding concurrent practice of more than one profession.

The Council is composed of 13 members, five appointed by the Prime Minister, one appointed by the University of Malta, five elected from among registered medical practitioners and another two elected from among registered dental practitioners. All Council members hold their appointment or office until March 2007.

Although elected medical members make up an overall majority of the Council, in keeping with the principle of professionally-led regulation, there has been no increase in the proportion of the Council's lay members, in keeping with the principle that professionally-led regulation is in partnership with the public. Low lay representation will continue to be a thorn in the flesh for the Council in terms of its credibility unless the government intervenes to increase its lay membership or, better still, to create an independent commission for the appointment of lay members.

It is unlikely there will be an increase in lay membership by March 2007 or that an independent commission, as is desirable, will appoint the lay members of the Council according to specific criteria and principles. An independent appointment commission would provide a level of transparency and credibility, not possible in the present system.

Regrettably, both Government and Opposition express no interest in a reform of the Council. The Health Minister, Dr Louis Deguara, continues to disregard media and public opinion about a reform of the Council, while Dr Michael Farrugia, the Shadow Minister, is totally oblivious to public perception of the pathetic state the Council finds itself in. For instance, no reference was made to a reform of the Council in the Labour Party's Health Document presented at the Labour General Conference on July 20.

Complaints and inquiries

The Council has various committees to hear and collect evidence in inquiries and "to submit a reasoned report based on such evidence to the Council for its consideration and judgment". The president sits on all these committees. I have serious reservations about the exercise of the Council's quasi-judicial system and I find it highly disturbing that one organisation should set the rules, investigate cases and pass judgment on those cases.

It is right for the Council to be responsible for all decisions taken by a committee but none of its members, including the president, should sit on any of these investigative committees. Sir Liam Donaldson states in his report to which I referred in the first part (Good doctors, safer patients, 2006): "As the complexity of both medicine and the system in which it is delivered increases, the General Medical Council cannot reasonably be expected to fulfil the roles of complaint recipient, processor, investigator, prosecutor, judge and jury".

The Malta Medical Council received 11 complaints against medical practitioners in 2005. Nine of these were dismissed upon receipt of a satisfactory statement from the medical practitioner concerned. Although the respective parties were given the Council's reasoned decision for its ruling, none of them, to my knowledge, was given access to the medical practitioner's statement and, worse still, an opportunity to orally rebut it. The Council must have viewed these complaints as 'frivolous', a word which defies definition.

An underlying reluctance by the Council to engage openly and in a humane fashion with complainants allows feelings of injustice and poor treatment to fester. As Sir Liam Donaldson puts it: "To engage in a dialogue with a complainant may have been felt to disadvantage the objectivity (and indeed the outcome) of any subsequent formal procedures. Such an aversion to active conflict resolution does not advantage any party."

One of the main problems that emerge from the foregoing scenario is the lack of an up-to-date and commonly understood working definition of being "guilty of professional or ethical misconduct in any respect" (Article 32 of the Health Care Professions Act, 2003). This undoubtedly leads to a lack of clarity among the Council's members on the criteria, standards and threshold to be applied in reaching a judgment on cases at the different stages of the complaints procedures. It is imperative that the Council starts to work without delay on what constitutes good medical practice - this would be a pivotal reference point, setting out what doctors in public and private practice are required to do and patients are entitled to expect.

The public would expect the Council to take measures and apply a remedy to a patient's complaint against a medical practitioner who fails to give an appointment to a patient before an operation in a private hospital and who shows no respect for a patient's privacy at his/her hospital bed; who fails to explain the likely effects of the operation to the patient and imparts no information to the patient about his/her post-operative care plan; who, at the post-operative stage, fails to refer him/her to a specialist for a resultant disorder and declines to pass on a copy of his medical notes upon a patient's request. Given the foregoing scenario, the Council would still be totally satisfied with the explanation provided by the medical practitioner and dismiss the patient's sworn affidavit.

Two inquiries concluded, 13 pending

Only two inquiries were conducted in 2005 and another 13 were still pending by the end of the year. The final decision of the Council in the two inquiries determined were as follows: one doctor was found to have exceeded "the limits of correctness" in his professional attitude towards a patient, and was cautioned; the second "was found guilty of having designated himself the title of 'professor' when he had no such University appointment, of having announced that the services provided in his private clinic were of superior quality to those of other clinics, and of having offered discounts on some services provided in his private clinic - he was fined Lm500".

The public may rightly express its own legitimate concerns about the apparent leniency of these two rulings. The assumption is that the Council either applied the principle of proportionality, weighing the interests of the public with those of the practitioner and considered any mitigation in relation to the seriousness of the behaviour in question and that the offence was at the lower end of the spectrum of misconduct.

Medical practitioners whose conduct, competence or performance falls below an acceptable standard are an inevitable feature of any medical workforce. While one-off mistakes need to be thoroughly investigated and any harm put right, they are unlikely in themselves to indicate an impaired fitness to practice that calls for erasure from the register or a temporary suspension of his/her licence. A hefty fine or a caution with an order for the medical practitioner to undergo therapy or a period of training will do. This line of reasoning is more likely to be in tune with public sentiment.

It is reported that 13 inquiries were still pending by the end of 2005. It does not seem to occur to the Council that unreasonable delay in the determination of cases is likely to have deleterious psychological effects on patients and their dependants, and indeed, on the defendant medical practitioner. In addition, undue delay, particularly in allegations of sexual abuse and serious neglect by doctors, poses a significant risk to the public. This regrettable state of affairs should not be allowed to continue and certainly does not command public confidence. Blaming litigating parties for delay is certainly not the answer.

Concurrent practice of more than one profession

The Registrar reports that the Council "decided that under no circumstances would it permit a medical practitioner or dental surgeon to practise his/her profession concurrently with another health care profession". No reasons were given by the Council for this draconian measure.

On July 17 I put the following question to the Press Office of the UK General Medical Council: "Does the GMC permit a medical practitioner to practise his/her profession concurrently with another health care profession... assuming of course that the medical practitioner is qualified as an alternative health care practitioner...?" The GMC's response was an unqualified "Yes".

The majority of medical practitioners that I know of are disinterested in alternative approaches to treatment. Others fear legal action and medical consequences of not giving the "community standard" of treatment or even allowing their patients to do so. There are a few who are discreet and yet open-minded enough in adopting a holistic approach. I hope that, when presented with convincing, factual information, the mainstream medical profession in Malta will one day come to realise the great benefits that complementary alternative medicine provides in connection with a number of chronic diseases such as cancer, arthritis and others.

I also hope that medical practitioners will tell patients about all the various alternatives to surgery, radiation and chemotherapy - I see this practice as the patient's right to informed consent. The Council should take a more sensible and humane approach to patients. The time will come when pressure from the public and members of the medical profession will lead the Council to alter its decision and to adopt a policy in line with that adopted by the UK GMC and other countries

Germany is the world leader in non-conventional cancer treatment, and there are dozens of cancer-oriented hospitals as well as outpatient facilities, most of them situated in attractive spa towns. German CAM doctors tend to be very well trained and, on the whole, better integrated into the nation's medical establishment. They are free to use many innovative treatments that are unknown or unavailable in other parts of the world. They more easily integrate conventional and non-conventional treatments.

Increasing numbers of medical colleges in the United States have begun offering courses in alternative medicine. For example, the University of Arizona College of Medicine offers a programme in Integrative Medicine under the leadership of Dr Andrew Weil which trains physicians in various branches of alternative medicine.

Why is our Council so afraid of and deficient in innovative ideas? The Council owes an explanation to the public for its decision. It is my understanding that its decision was not taken in the exercise of its quasi-judicial function; hence, the Council Registrar can shed light on this matter in the media. Moreover, it would be interesting to learn what advocates of complementary alternative medicine have to say about the Council's decision.

(To be concluded)