Spot the incompetent doctor

On the morning of 9 January 1982, Dr Oliver Archer, a GP in the East End of London, was called to visit eight-year-old Alfie Winn. It was the start of a long journey, whose culmination may finally be marked today, more than 13 years later, with the announcement by Stephen Dorrell, Secretary of State for Health, that doctors are to face a contractual obligation to report colleagues whose work they believe to be incompetent.

Dr Archer was called because Alfie had spent the night vomiting. He was delirious and had a temperature of 106F. The GP had agreed to turn out only after an acrimonious conversation with Alfie's mother on the phone. When he arrived, he kicked a bowl of Alfie's vomit under the table. When the boy failed to respond to his instructions, Dr Archer declared that if Alfie couldn't be bothered to open his mouth, he couldn't be "bloody bothered" to examine him. He prescribed an antibiotic and left.

Two hours later, Alfie's mother called an ambulance. Four days later, Alfie died in hospital from meningitis. His mother complained to the General Medical Council, the doctors' educational and disciplinary body. Dr Archer was charged with "serious professional misconduct".

At the hearing, the facts against Dr Archer were found proved. But the GMC went on to decide that his actions did not amount to serious professional misconduct. He was acquitted.

Two years later, Dr Archer was again before the GMC. He had told a woman undergoing a miscarriage that when the foetus finally emerged she should wrap it in newspaper, flush it down the toilet and come to see him in three days' time. This time he was suspended and referred to the GMC's health committee. He eventually took himself off the medical register.

The case of Dr Archer, and the GMC's initial failure to act, caused understandable outrage and no little soul searching within the GMC's own ranks. The council began a long hunt to find a new procedure that would allow it to deal with incompetent doctors.

Since Dr Archer, there has been a depressing litany of them. Their numbers may be tiny compared with the 50,000-plus doctors now practising. But their effects can be traumatic and even lethal.

Two years ago, Dr Carol Starkie, a consultant pathologist at Selly Oak Hospital, Birmingham, took early retirement on health grounds after 300 tissue samples taken to establish whether patients had bone and other cancers had to be re-examined after surgeons and others became suspicious of her diagnoses. Some cancers had been missed. At least two children without cancer had been subjected to unnecessary chemotherapy. And, as the inquiry widened to cover close to 2,000 samples, it became clear that colleagues had first voiced worries about Dr Starkie's behaviour and judgement in 1985, and that four years later complaints that she was providing a "second-rate" service were well known locally.

Then in July this year, Dr Samuel Kiberu, a consultant histopathologist, was suspended after misdiagnosing hundreds of cancer patients while working at eight different hospitals over five years as a locum. Most errors were minor, but 89 were serious enough for patients to be recalled. A month ago Nicholas Siddle, a consultant gynaecologist at University College Hospital, found himself struck off after leaving seven women in pain and distress from internal injuries after he had performed keyhole surgery without proper training.

It was the case of Dr Starkie that finally forced the Government into acting, setting up the working party whose recommendations are published today.

Mr Dorrell's new requirement is in fact just the latest plank in a programme of action to ensure that as far as possible such cases do not happen again - and that when they do, they are tackled early.

This autumn, an amendment to the GMC's powers will become law. It embodies a procedure aimed, in the GMC's words, "at doctors who are incompetently doing their best", allowing the council to tackle not just individual incidents, but a pattern of poor performance by a doctor.

Alongside this measure, a separate Private Member's Bill, sponsored by the Labour MP John Austin-Walker, has just become law. This allows the tribunals that hear cases against GPs, dentists and pharmacists to suspend them pending the outcome of inquiries and appeals. It also allows the tribunals for the first time to disqualify doctors from working as locums or assistants.

Admittedly, the council has been painfully slow in addressing the problem of incompetence. And criticisms remain of the new procedure it has adopted - not least its Byzantine complexity, its reliance on private rather than public hearings, and its retention of the legal definition that performance must be "seriously" deficient before it will act. But at least the GMC has acted, and it has promised to review the procedure after two years.

No one knows how many doctors will be caught by the new procedure. The GMC estimates 100 to 150 a year, of whom 50 may face sanctions. And doctors have raised legitimate worries about whether NHS trusts will pay for the retraining that the GMC may say a doctor needs. While it may be cheaper for a particular NHS trust simply to sack an incompetent doctor, that may not be in the public interest, given the pounds 250,000 investment that each doctor's training represents.

Despite such concerns, doctors are already clearly moving Mr Dorrell's way. A year ago, the GMC stunned the profession by finding guilty of serious professional misconduct Dr Sean Dunn, the chairman of the anaesthetic division at the East Yorkshire NHS Trust. He had failed to report or act over Dr Behrooz Irani, a locum anaesthetist, despite several warnings from operating theatre assistants that Dr Irani was not just unsafe but downright dangerous. Among other misdemeanours, and before he was struck off, Dr Irani had switched off the alarms on anaesthetic equipment and left one patient in a permanent vegetative state after fouling up the anaesthetic.

As a GMC spokesman said at the time, the finding against Dr Dunn "is intended to send the clearest possible signal to doctors that they must take action if they believe colleagues' professional performance to be deficient".

NHS trusts, too, have begun inserting into doctors' contracts a duty to report when they believe colleagues' performance is below par.

This presents, as Dr Mac Armstrong, secretary of the British Medical Association, observed yesterday, a neat paradox. While trusts are imposing on all their staff, doctors included, contracts which prevent "whistleblowing" to the outside world about problems within the NHS, they are demanding "whistleblowing" on their own staff internally, in the interests of good patient care.

It also presents a new and welcome moment in the development of the medical profession. A profession is nothing if it is not self-regulating. But too often self-regulation has come to look to outsiders like self-protection - a process in which practitioners will not tell on colleagues because they are all members of the same club and "there but for the grace of God" go they. The GMC is recognising that in the 1990s, that attitude will not do. Mr Dorrell is reinforcing the message. It is to be hoped that the doctors accept it, not just with good grace but with pride.