Alison Wolf

October 20, 2006

When we describe someone as "both judge and jury", we do not mean it as a compliment. We know that monopolists are likely to be inefficient and to overcharge. Yet government departments and agencies repeatedly reach for total control, as sole providers of a service and judge and jury for their own performance. Trust us, is the message. Why should we?

This tirade was sparked by a 200-page Department of Health report on "proposals to strengthen the system to assure and improve the performance of doctors and to protect the safety of patients". This being 2006, it is also called Good Doctors, Safer Patients . Who could argue with promoting those?

The report largely discusses procedures for ensuring good clinical care from practising doctors. Then, quite suddenly, halfway through a list of 44 recommendations, it proposes to abolish the "role of the General Medical Council to set the content of the undergraduate medical curriculum" and inspect and approve medical schools. Instead, these powers would go to a new department-appointed board - not even to a supposedly independent body.

At present, medical training in the UK takes place in university-based medical schools. The Government supplies the funding and decides how many people will be trained. The Government is also, in effect, the monopoly purchaser of doctors' labour. Now it wants to get rid of any independent input into the content of undergraduate teaching or its quality and standards. It will design it, run it, pay for it and sign it off.

You might argue that the Government will want and so be bound to ensure good quality, since it is providing healthcare for its citizens. But, equally, it wants to keep costs low and to ensure high graduation rates from an expensive programme. It also has a major incentive to keep any hint of trouble or failure out of the public eye. And medicine is, of all the professions, the one where it is hardest for lay people to judge the quality of service they are receiving.

Medicine exemplifies the economists' notion of "asymmetric information", in which one party to a transaction is bound to know far less than the other, and in which markets therefore don't work very well. That is the main argument for having organised professions, which not only instil an ethic of honesty and service and decide if someone is ready to practise, but also police their fellow experts' behaviour. And the defining characteristic of professions in the Anglo-Saxon world is that they control their own training.

The organised professions tend to be the bane of a government's life, because they are not only organised but they are also often very powerful.

(I seem to remember that Baroness Thatcher, a barrister herself, particularly disliked lawyers.) They are also all too prone to raising prices and being less than enthusiastic about public disciplining of offenders. But that is an argument against giving them total power and in favour of some regulation of the professions. It is not an argument in favour of handing all power and control over the undergraduate medical curriculum to a single, in effect, unaccountable body within the DH - which is itself run and controlled by non-experts.

The people on the new board would presumably be (mostly) doctors. However, almost everyone reading this column works or has worked for a large organisation. Does anyone really believe that a doctor answerable to a politicised department will behave in the same way as one representing an independent outside organisation?

Equally seriously, how long a life do you give such a board?JThere is currently a new Postgraduate Medical and Education Training Board (which works with, rather than instead of, the Royal colleges.) Its predecessor body lasted all of nine years, which is actually a long time by current standards. Whitehall is afflicted by a complete lack of institutional memory because reorganisation and redeployment have become so endemic. Professional bodies, by contrast, endure.

I do not suppose for a moment that the GMC is perfect. More important, I have no idea if, overall, a better system for organising undergraduate medical education could be devised. But nothing in Good Doctors, Safer Patients indicates it could, or on what principles. The comments on the GMC read, generally, like a speech by a prosecuting QC, but the report conspicuously fails to discuss this part of the GMC's remit at all.

Intellectually, governments value multiple sources of power. Practically, they hate them. "Trusting professionals" is staple stuff from oppositions.

Gordon Brown's speech at the Labour Party conference was full of "devolving" and "decentralising". But by their deeds you shall know them.

Alison Wolf is Sir Roy Griffiths professor of public sector management at King's College London.

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