Who gets struck off?
BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d7842 (Published 21 December 2011) Cite this as: BMJ 2011;343:d7842
Introduction
Since its establishment in 1858, the General Medical Council (GMC) has been responsible for overseeing the professional conduct of doctors and for disciplining those whose standards are inadequate. Its remit and sanctions have changed over the years, and it is only relatively recently that clinical competence has come within its disciplinary ambit. The GMC publishes overview statistics of its procedures1 but not, so far as can be established, detailed classifications of who is suspended or erased from the list of registered medical practitioners (LRMP)—those given the current most serious penalties.
The LRMP can, however, be downloaded—for a fee—for analysis. Unfortunately, the database contains only the names of those erased or suspended, without listing the reasons for the penalty.
One study, conducted through laborious perusal of the GMC’s minutes and reports in the medical press, classified the sometimes tragic, often salacious, and occasionally scarcely credible reasons for disciplining the 584 doctors erased in the first 133 years of the GMC’s existence from 1858 to 1991, before the council’s “performance procedures” were instituted.2 It found, for instance, that the most common reason for the erasure of doctors who qualified in England was adultery with patients and that for doctors who qualified in Ireland the reason was often alcohol related. It also showed that erasure from the register would not necessarily terminate a career: 16 doctors had been erased twice, and two, three times. A contemporaneous book describes the history in sociolegal detail.3
The LRMP identifies doctors on the specialist and general practice registers and lists their sex, and the country, date, and medical school of their primary medical qualification. It identifies those who currently work (or who could)—“registered with a licence to practise”—as well as those who are erased or suspended. It is thus possible to examine the prevalence of erasure and suspension by specialty, time since qualification, and source of primary qualification.
Method
The LRMP was downloaded on 15 March 2011: it listed a total of 227 457 potentially practising doctors and those who had been erased and suspended. It was imported into IBM Statistical Package for the Social Sciences version 194 for cleansing and analysis.
The doctors on the register were classified into general practitioners (those on the GP register); hospital specialists (those on the specialist register); and trainee and other doctors (those on neither register). They were further classified by country of primary medical qualification, by sex, into UK or non-UK qualified and by the time since qualification (into three groups) as a surrogate for age.
The percentages of all the subgroups of doctors who were listed as erased or suspended were then calculated.
Results
Overall, 790 doctors (0.35%) on the LRMP were listed as erased or suspended. Of those, 111 (14.05%) were women, representing 0.09% of the women listed, and 679 (85.95%) were men, representing 0.37% of the male doctors (χ2 = 210.8, df=1, P<0.001).
Table 1⇓ shows the numbers, denominators, and percentages of GPs, hospital specialists, and trainees or others, suspended or erased, by origin of their medical degree (UK or elsewhere) and by time since graduation. Univariate differences in prevalence within primary qualification date, specialty of practitioner, and between UK and non-UK graduates are all highly significant (respectively: χ2 = 469.6, df=2, P<0.001; χ2 = 56.6, df=2, P<0.001; χ2 = 119.4, df=1, P<0.001). Multivariate analysis (stepwise regression) showed that the most important individual demographic variables in predicting current suspension or erasure are time since qualification (longer) and being a non-UK graduate.
Numbers and percentages of doctors erased or suspended from the list of registered medical practitioners, by major demographic group (list of registered medical practitioners 15 March 2011)
Doctors obtained their primary medical qualifications from 146 foreign countries, five of which provided as few as one doctor—Gabon, Mali, Rwanda, Suriname, and Togo. Forty countries, including the UK, provided 250 or more doctors on the LRMP. Table 2⇓ lists these alphabetically, with the percentage of each country’s graduates who are erased or suspended compared with the UK graduates’ baseline figure. The data are also shown in the figure⇓ in order of relative prevalence of erasure or suspension, showing the proportion of erased and suspended doctors and the 95% confidence interval surrounding this.
Prevalence of erasure and suspension of doctors qualified in countries from which more than 250 are listed in the UK List of Registered Medical Practitioners (as registered with a licence, suspended, or erased), and comparison with UK prevalence
Within the group of UK graduates, there were differences between medical schools, but these are generally not significant because of small numbers from each. Overall, the prevalence of erasure or suspension was significantly higher for people with qualifications from the non-university licensing bodies—the Scottish Triple Qualification; the English Conjoint Qualification; and the Licence in Medicine and Surgery of the Society of Apothecaries of London: 277/138 806 university graduates featured (0.199%); whereas 0.886% of the NULB-qualified were erased or suspended, 44/4924 (χ2 =101.7, df=1, P<0.001).
Discussion
Overall, these results suggest that:
Proportionately, men are four times as likely to be erased or suspended as women
Hospital specialists are being erased or suspended at around half the rate of GPs and others
Doctors in all career groups are much more likely to be erased or suspended later in life
Non-UK graduates as a group are more than twice as likely to be erased or suspended as those with UK qualifications
Among those with UK qualifications, those qualified by means of licences from the non-university licensing bodies are more than four times, likely to be erased or suspended as those with university qualifications
Some foreign countries’ doctors are substantially more likely than UK doctors to be represented in the erased or suspended group: France, Bangladesh, the Netherlands, and Austria head the list, all with five times the UK prevalence
Doctors from five countries are less likely to be in this group (Czech Republic, Greece, Hong Kong, New Zealand, and Slovakia), but the differences from the UK are not significant.
Some of these findings are unsurprising. Non-UK graduates, for example, have long been perceived as over-represented regarding the disciplinary attentions of the GMC.3 And licentiates of non-university licensing bodies have also received attention from educationalists and others as regards the robustness of their qualifications.5 6 But it might surprise some that of the top 20 countries in the figure⇓, half are in the European Union (EU). Authors of a report showing not dissimilar patterns in performance on a postgraduate medical examination speculate that the hurdle of the professional and linguistic assessments board test, not required of EU doctors, might be relevant.7
Proportion of erased or suspended doctors with country of primary medical qualification. No country’s figure is significantly lower than the UK’s by χ2 test. Slovakia and Hong Kong have no erased or suspended doctors. The statistical package does not produce an error bar in these circumstances
The GMC should be congratulated for developing an induction programme for foreign trained doctors who are starting work in the UK to help them “gain an early understanding of the ethical and professional standards they will be expected to meet, as well as familiarity with how medicine is practised in the UK.”8 In the past EU regulations have been interpreted as precluding the placing of requirements, not applied to UK doctors, on doctors coming to work in the UK and other member states. In the light of these data, hopefully the regulations will not be seen as preventing required attendance from all foreign trained doctors on these courses.⇓
Notes
Cite this as: BMJ 2011;343:d7842
Footnotes
Competing interest statement: None declared.
Provenance and peer review: Not commissioned; not externally peer reviewed.