15 November 2022: Melville - A

Professor Colin Melville is the top guy in the General Medical Council for education and standards. He’s been there since 2017. He started out by expressing “our sincere acknowledgement of the things that have happened to folk”. He also mentioned, “our part as the GMC in wishing to learn and how we take that forward”. Not quite an apology.

The witness gave a brief overview of his career in medicine. His role now at the GMC covers the two matters of education and standards. He made reference to the publication “Good Medical Practice” which is being revised currently. The timing is unfortunate since it is due to be published in quarter two of next year. Too bad they don’t think of holding that back until after the Inquiry reports.

Prof Melville then reviewed the process through which the GMC “as the regulator” is involved in the training of undergraduates and postgraduates across the UK. The GMC does not set the curriculum, but it does set the “outcomes” to be achieved through the medical schools. He was once the head of a medical school himself. Overall, he was fine about the split roles in the process, because to do it another way would make it “messy in a different direction”. He feels the bodies involved work together well. It takes five or six years for a medical student to go through their courses. Changes to education are done between the various bodies inviokved, and they attend their respective meetings.

Counsel asked about Duty of Candour, and it is something the GMC produces guidelines on and is part of the outcomes. The witness was asked about how it is being taught. He said it is more a matter of how it plays out in real life. He does see a change as a result of the Duty of Candour initiative. Anyone can use the Duty, and it is something a new medical student has to be made aware of under good medical practice. Reference was made to “Outcomes for Graduates”, specifically the section on ethical and professional principles. Counsel quoted relevant sub-headings related to the Inquiry topics such as consent, informing patients so they can make informed choices, Duty of Candour, and others. Clearly, new doctors should be doing all the things listed, (or not doing certain things). These are at the heart of what the infected blood community are living with. This witness is describing the situation now. How far back were these types of expectations to “first, do not harm” in place? Surely it was not some time after the clinicians involved in the Contaminated Blood Scandal did their harms?

The “fitness to practice” protocols contain the standards for doctors across all the specialisms. There are specific “Domains” which seek to embed good professional and ethical behaviour throughout the entire learning and practicing life of a doctor. The approach of the GMC seems to be well received by the teaching schools. Prof Melville stressed that the bullet points which were displayed are not comprehensive lists but rather they are illustrative examples of what applies under the headings. The bullet points had the usual stuff such as honesty and integrity, but include “demonstrating emotional resilience”, and “demonstrating situational awareness” too. That’s interesting.

There are real cases involving the treatment (or mistreatment) of patients which are used in lectures as illustrative of the topics being covered, but also of how practice has changed over time. It would make a lot of sense for the example of infected blood to be a major case study (and warning) on how bad things can get. It would go some way to providing a lasting legacy of lessons being learned arising from the lives and deaths of the infected and affected. The Chair picked up an anomaly of definition related to Duty of Candour, and the witness was grateful for that and said he would pick the matter up. He said that the Duty of Candour did not just apply “when things go wrong”, but it applies, “full stop”.

Various sections of documents included the topic of consent. The witness noted how more recently the guidance had changed from the doctor simply informing the patient of what they were going to do, to one of having a conversation with the patient to make a decision together. It became obvious that the machinations which many might have thought had taken place years ago about doctors fully involving patients in their healthcare are actually not so long in place; and in some instances they are still being debated and implemented. A new assessment is being introduced in 2024-25 to further embed these expected behaviours and standards over how doctors act professionally and interpersonally. UK medical education is highly regarded internationally, he said. He also said assessments in exam situations cannot cover everything about being a doctor, so it is a sample of items being tested at that point.

After qualifying, there are still ways for bodies such as the GMC to promote and ensure high standards, apparently. There had historically been a publication listing all the things doctors could do that would get them struck off (the “Blue Book”), but that negative approach was seen as unhelpful. The “Good Medical Practice” document concentrates on the positive of how things should be. It is full of “you should” and “you must” statements. “You must” is used for an overriding duty or principle. “You should” is used to explain how a doctor can meet the overriding duty. In cases where a tribunal is considering the fitness to practice of a doctor, the Good Medical Practice document is used. The example was given for when a doctor “must” be open and honest, and to do that a doctor “should” put matters right, provide an apology, and provide an explanation. Clarification was given that these standards apply to all doctors registered to practice by the GMC, even if they are working overseas. Of course, there will be standards in the other country, too. There are mostly common elements across the schools and colleges, and the four nations, but for Scotland, for example, there are additional matters under Duty of Candour.

“The fact that we now have appraisals for all doctors …”, said the witness in response to a question. This sure rang alarm bells. So, he is admitting that prior to this fairly new thing of appraisals, doctors were left to their own devices. “The Reflective Practitioner” is a new publication to support doctor appraisal. But Social Work has had a book with the same title for decades. They are not at the cutting edge in this regard. The witness admitted how the move to appraisals has not been welcomed by all doctors – there’s a surprise – why would they want to be held accountable and have someone check their homework? The usual excuse is that they are too busy. Showing his expertise in employment matters, the Chair intervened to seek clarity on how appraisals works for the upper end of doctors, such as consultants. The normal condition of an appraiser having to be in a more senior role than the appraisee, does not fully apply. Prof Melville said continuous professional development (CPD) is facilitated through the appraisal process. So, how was it done before that since it had just came into place?

The next topic was related to human factors such as implicit and explicit bias. The witness began answering by talking about two glider pilots entering a part of airspace they were not comfortable being in. They both thought the other would say something so neither did. They crashed. This was not the first time Prof Melville went off on a figurative fictional meander. Looks like you can take the pedagogical doctor out of the medical school environment, but you can’t take the medical school thinking out of the doctor. The example was given of bias against women. The witness agreed that there are still aspects of bias to be worked on by the medical profession.

Counsel asked about the GMC and its capacity to change entrenched attitudes. The witness agreed that it can take time to make changes. The questioning moved to the matter raised recently by Prof Roberts in relation to Tranexamic Acid. He saw the GMC having a role in such opportunities for improving outcomes for patients but it did not have the main role in relation to making progress. Similarly, the Dame June Raine issue with the Yellow Card Scheme not being fully embedded in clinical practice was raised. He recognised the issue but was unsure of the effectiveness if there should be a legal duty to use the system, in part because he was not sure how that would be monitored.