Middlesex University Enfield
Health Science
academic year 2002/2003, semester 2

A Critical Appraisal Of The Complaint Procedures Of The
"General Medical Council" And Its German Equivalence The
"Deutsche Ärztekammer"

from: Nils Claassen
Module: Health Service Delivery, HLS 3041

Date of handing in: 27^th of May 2003
Counted words : 4375

List of contents

1. Introduction 3
2. An Introduction Of the GMC And The German Physician Chambers 4
2.1. The General Medical Council And Its Responsibility For Its Patients And Doctors 4
2.2. The German Physician Chambers And Their Responsibility For Their Patients And Doctors 5
3. Complaints Procedures Of Both Institutions 6
3.1. Complaints Procedures Of The GMC 6
3.2. Complaints Procedures Of The German Physician Chambers 7
4. Current Performance Of Both Institutions 8
4.1. Current Performance Of The GMC 8
4.2. Current Performance Of The Physician Chambers 9
5. The Importance Of Patient′s Voice 11
6. Conclusion 13

References 15

1. Introduction
At the moment the General Medical Council (GMC) has to deal with a rise in complaints cases. "The level of complaints to the GMC has risen sharply in the last few years. The number of complaints rose from 1500 in 1995 to 4470 in 2000, with only one year 1999 seeing a fall." (Kmietowicz, 2001) The German situation is corresponding to that. The Mediation Committee Of Northern Physician Chambers (Schlichtungsstelle für Arzthaftpflichtfragen der Norddeutschen Ärztekammern) received about 500 complaints in 1976 and this number grew to about 4200 complaints in 2001 according to their website http://www.schlichtungsstelle.de (2003a). So the subject seems to be worth one′s while to have a closer look on complaints and on the two bodies which have to work on it.
Most comparisons between the health systems of the different countries are done globally. This work looks at only two institutions of two different countries with almost the same tasks. It could be very interesting to see how these bodies differ from each other in dealing with the same problem: tackling complaints. Dealing with complaints is part of quality assurance and this term is well known in the health system of Great Britain for a fairly long time. But quality assurance is in relation to the health system a very virginal term in Germany but also one of the most up to date subjects at the moment. In order to learn from each other it seems to be a good idea to show how the two institutions work and to find weak points in their complaints procedures.
Therefore this work provides a short description of the GMC and of its German equivalence: the German Physician Chambers (Ärztekammern). Also their current complaints procedures will be presented. Thereafter this appraisal will point out critically the performance of both bodies in relation to current problems in tackling patient′s complaints. An answer should be given to the question why it is important to listen to the patient′s voice, especially to their complaints. Finally, this work will be summarized briefly and the outcome will be assessed critically.

2. An Introduction Of the GMC And The German Physician Chambers
Before this work can compare two different complaints procedures of two institutions in two different countries it is necessary to understand how the structures of the two institutions are and how they work. Therefore the GMC and the physician chambers will be introduced briefly.

2.1. The General Medical Council And Its Responsibility For Its Patients And Doctors
The GMC was formed as a result of the 1858 Medical Act / http://www.lhsa.lib.ed.ac.uk (2001). At the moment the full Council has 104 members: 54 doctors elected by the doctors on the register, 25 members of the public nominated by the Privy Council (not medically qualified, their role is to speak for the public) and 25 doctors appointed by educational bodies (this constellation is going to be reformed). The full Council meets three times a year and most work is done in different committees meetings throughout the year. The GMC is a charity that has the purpose to protect, promote and maintain health and safety of the community. But its main interest isn′t the protection of the medical doctors who have to be registered at the GMC. The Council is observing the doctors and it has "strong and effective legal powers designed to maintain standards the public have a right to expect of doctors." according to the GMC website http://www.gmc-uk.org (2003a). That means that the organization sees its responsibility in protecting patients not the doctors. The Council also sets standards for undergraduate, pre-registration and postgraduate medical education, and visits and inspects medical schools and teaching hospitals as mentioned on the GMC website http://www.gmc-uk.org (2003b) but it has also the power, if necessary, to strike a doctor off the register and to remove a doctor′s right to practise medicine. They take action if there are doubts rising that a doctor might not be fit to practise. Therefore they built up an own system that helps them to handle complaints, but their responsibility is not to handle every complaint because the GMC isn′t a general complaints body / http://www.gmc-uk.org (2003c). As already said the charity lays a special emphasis on the protection of patients and in addition they also declare that the rights of doctors are protected by others and not by the Council as it is emphasised on the GMC website http://www.gmc-uk.org (2003a).
But the Council also provides different guidelines for doctors like 14 principles where the duties of a doctor are described and a guidance covering general aspects of good medical practice and more specific areas. There also exists a guidance for maintaining good medical practice and local medical regulation, to help employers responsible for managing medical performance. At present the GMC is developing a revalidation system - "the requirement for doctors to demonstrate, on a regular basis, that they continue to be fit to practise." as the GMC declares on the website http://www.gmc-uk.org (2003d).
In comparison to the GMC the German equivalence "Deutsche Ärztekammer" will be described.

2.2. The German Physician Chambers And Their Responsibility For Their Patients And Doctors
In Germany the doctors are not registered at a general institution like the British doctors at the GMC. This is related to the fact that Public Health is a matter of the different federal states and not a matter of the nation. That means that in each federal state exists a professional body of doctors - they are called: "Ärztekammern" (in the following pronounced: physician chambers). The doctors of each federal state have to be registered at one of the 17 different physician chambers where they are practising. But all the different chambers have a head organization in Germany, the "Bundesärztekammer". The Bundesärztekammer represents the occupational interests of the 363.396 doctors (count: 31/12/1999) and it is a work group of 17 different physician chambers / http://www.bundesärztekammer.de (2001a). The job of this work group is to form the opinion of the population in relation to health-political aspects. The Bundesärztekammer supports the work of its physician chambers in Germany and it has mediate statutory responsibility. It has also direct statutory responsibilities concerning quality assurance and legislation of transplantation matters.
The main tasks of each chamber in Germany are: to build up regulations for the physician chamber, create examination rules for doctors, monitoring doctors, promotion of advanced education, promotion of quality assurance, construction of ethic commissions, statements and mediation of reviewers, to support the Public Health System, to interfere when there are litigations between doctors and patients / http://www.bundesaerztekammer.de (2001b).
The main interest of the Bundesärztekammer and its physician chambers is to represent the German doctors, but they say that they also feel responsible for patients and the Bundesärztekammer describes this responsibility as being an "advocate for patient′s interests." / http://www.bundesaerztekammer.de (2001c). Generally, the Bundesärztekammer is thinking of a predefinition of general rights and duties concerning dealings between doctors and patients. They summarized these basic rights and duties in an official sample writing: "Muster-Berufsordnung" and gave it to the physician chambers. They also started different initiatives to protect and reinforce patient′s rights, e.g. the physician chambers built up reviewer commissions and mediation committees as an voluntary offer for patients. Additionally, they′ve created an IT-information system that helps to find a specialised doctor or general information about health and diseases and the physician chambers give tips how people can live healthier and they also offer assistance in drafting a patient′s last will / http://www.bundesaerztekammer.de (2001c).
In addition to this introduction of the two different institutions the complaint procedures will be explained briefly and critically reviewed after that.

3. Complaints Procedures Of Both Institutions
This part provides general information about complaints procedures of both institutions. By now, reading this part it becomes clear that there are significant differences between both of them. These information also will allow us to understand the following criticism.

3.1. Complaints Procedures Of The GMC
In the U.K. patients have different possibilities to complain about a doctor. They can choose the NHS complaints system (directly to the hospital staff or its hospital complaint manager or to a complaints manager at the local health authority or board), you can go to a Community Council in your area, you can report something to the police or you can directly go to law (civil litigation). But patients have also the possibility to complain at the GMC. The Council gives clear and detailed information about what will happen when they get a complaint from someone (patients, doctors, police, public authority etc.). The GMC provides an own complaints system and they have experienced staff that gives advice and that knows how to deal with complaints. They have also their own solicitors to help with the legal side of things. That means that the complainant doesn′t need to get his own legal advice - this help is for free, but they cannot award compensation, therefore the patient has to go to the court. If the GMC thinks that an incident is serious the situation will be assessed more detailed by one of their `screeners′. These are medically-qualified members. After that, two members (one of them is a lay member to represent the patient′s point of view) decide whether a complaint should be taken further or not / http://www.gmc-uk.org (2003e).
If the complaint is be taken further the GMC collects more information about the incident (written statements from other involved people etc.). The Council has got three legally- prescribed ways to go on in the process, described on the GMC website http://www.gmc-uk.org (2003e):
1) Conduct procedures: e.g. if a doctor has been convicted of a criminal act. The Council has to assess whether a doctor should be still allowed to continue practicing. Chosen this way the complaint and all papers will reviewed by the Preliminary Proceedings Committee (PPC). They can initiate a public hearing before the Professional Conduct Committee (PCC) and they can send a warning letter or advices to the doctor or initiate investigations in relation to the doctor′s health or they can end the process.
2) Performance procedures: to assess doctors whose general clinical performance doesn′t meet the expected standards.
3) Health Procedures: if a doctor becomes a serious danger for patients because of an illness e.g. like mental illness.
Now that the procedures of the GMC are explained briefly the german procedures should be esteemed.

3.2. Complaints Procedures Of The German Physician Chambers
In Germany patients have also different possibilities to complain about a doctor. They can also go to law (this is often related to high court and lawyer costs), they can go to an independent consulting service for patients to get useful information about: "What is the best way to do now?". They can also go to the police or to the `Medizinischer Dienst der Krankenkassen" (Medical Service Of The Health Insurance Companies): a control body of the health insurances. There are many other different consulting services which arose in the past and their origin can be found in the self-help scene (Moroff, 2003). It can be alleged that the complaints and information system for patients is still developing. Regarding the physician chambers, it is the job of the them and not of the Bundesärztekammer to tackle patient′s complaints. But e.g. the physician chamber Bremen doesn′t give detailed information about complaints procedures and about consequences for doctors as the GMC does, but they refer a lot to other websites. The physician chamber Bremen only mentions that patient′s complaints have to be handed in at the chamber and that they will ask the doctor to give them a statement. Then a complaints committee will discuss the situation and will contact the patient after that - according to the website of the physician chamber Bremen http://www.aekhb.de (2003). However, the physician chamber Bremen and all the other chambers in Germany offer free assessment- and mediation procedures. In such a case the activity of the treating physician is legally examined and a final assessment from the reviewer clarifies whether claims are justified or not. If an incident is regarded as not justified the patient has still the possibility to go law / http://www.schlichtungsstelle.de (2003b). Finally, the physician chamber Bremen mentions that it is not possible to assert a compensation claim. Therefore patients have to go to the civil court.

4. Current Performance Of Both Institutions
Now that it has become clear how the institutions are built and how their complaints procedures function, it is necessary to heave a more critical view on their work. Therefore this work looks at the different experiences of patients and other people who have been in contact with the two institutions.

4.1. Current Performance Of The GMC
Reading the different ideas and projects of the GMC the reader gets the impression that the performance of the GMC must be very good, because they are talking of the importance of the patient′s voice and they emphasise explicitly their legal power they′ve been given by the government and they also emphasise that they won′t hesitate to use their given powers to control very painstakingly the performance of doctors to protect patients. But how does the reality look like? The current complaints system is criticised for being complex, creating delays, and lacking a full range of findings and that the GMC in general is unwieldy, slow, defensive, and constrained in its powers (Dewar and Finlayson, 2001). There exist reproaches that the GMC only considers cases where there are strong possibilities to remove the doctor from the register. Wilmshurst (2002) explains that "Many allegations about doctors that the public considers serious are dismissed by the GMC at the screening stage." He instances different cases where he was in contact with the GMC and once he got an answer from the Council that makes clear that they have only an interest to take action against a doctor when his or her behaviour justifies restricting or removing his or her registration (Wilmshurst, 2002). That demonstrates that all other less serious but not unimportant incidents are not considered by them in spite of the fact that charges are proved.
Another example that backs the assumption that the GMC sometimes seems to perform illogically is the `Bristol Inquiry′. Two doctors, Mr James Wisheart and Dr John Roylance were struck of the register but the surgeon Dr Dhasmana got only the restriction not to perform heart surgery for a period of three years. "Twenty of the 29 deaths considered by the GMC were among the children operated on by Dr Dhasmana." according to a special report from BBC News http://news.bbc.co.uk (1999). In addition to that it is incomprehensible that only 53 of 150 names of affected children were considered by the GMC. Another example is a survey conducted by Health Which? from October 1999. The experiences of 264 patients were surveyed. All of them contacted the GMC about a complaint. In only six cases the Council took action against a doctor and 82% of the people explained that they were dissatisfied with the fairness of the process (Beecham, 1999).
The GMC tries to tackle these problems by changing its structure, constitution and governance. Furthermore, they want to change their procedures for dealing with allegations against doctors - this project is summarized in the consultation paper `Protecting Patients: A Summary Consultative Document′ in according to the GMC website http://www.gmc-uk.org (2003f). Their aim is to get smaller more transparent bodies acting with greater public involvement. In relation to complaints a new committee would investigate cases at an earlier stage with more flexibility to ensure that complaints are handled in the most appropriate way. They also want to introduce a new lower finding against a doctor-professional misconduct. That could empower them to investigate cases when serious misconduct is not proved (Dewar and Finlayson, 2001). But the Council doesn′t explain precisely in its paper how they want to put it into practice. Another problem is that the work of the Council includes two tasks: prosecution and judgment. There are many doubts if it is useful to ignore the fact that a separation of both functions would be more fair for all persons affected and the GMC seems to tumble concerning this point. As already mentioned the complaints system in the U.K. is not only represented by the GMC, but seemingly the Council hasn′t realised it appropriately - it is still trying to accommodate the conflicting demands of its different stakeholders: "In any reform the GMC needs to be clear about its place in a wider system and establish consensus with other players in the regulatory game about how to work together." (Dewar and Finlayson, 2001). However, comparing the GMC and the German physician chambers the performance of the chambers in relation to patient′s complaints is totally different.

4.2. Current Performance Of The Physician Chambers
First of all, it should be mentioned that it was difficult and hardly possible to find any literature in relation to criticism about the physician chambers, about the Bundesärztekammer or about the general complaints system in Germany. This fact might be the result of the fact that the German health system hasn′t understood yet how important it is to have a good complaints management. Complaints are still seen as factor of disturbance. They are more suppressed than promoted (Kranich, Vitt and Berger, 2002b). Furthermore, there exists no exhaustive complaints management in Germany like in the U.K. where patients know the Community Health Councils. They can be found all over the country - 250 offices nationwide. But in Germany there are only innumerable different consulting services but no real independent, integrative and overall help for patients. And what about the chambers? They take a passive role and there has never been a need for any change. However, that doesn′t mean that they are performing well in what they are doing.
As already mentioned, the different chambers in Germany offer free assessment- and mediation procedures. That are drop-in centres - they work in eight offices in Germany and each of them represents one or more federal states. The city state Bremen for example is united with the states Lower Saxony, Mecklenburg-Western Pomerania, Berlin, Brandenburg, Saxony-Anhalt, Thuringia, Hamburg and Schleswig-Holstein in the Mediation Committee Of Northern Physician Chambers (Schlichtungsstelle für Arzthaftpflichtfragen der Norddeutschen Ärztekammern). Their office is in the town Hannover / http://www.schlichtungsstelle.de (2003c). But these mediation committees give only advices. They try to assess the situation by hearing doctors, patients and a representative of the doctor′s liability insurance and then try to explain all participants what could be done. If the charges are proved and the doctor or the insurance is advised to take the responsibility that doesn′t mean that they have to do that. In such a case the patient has only one possibility left: going to law, but without support from anybody - except the solicitor whom he has to pay on his own.
The next point is that the participation in the investigation is voluntarily. If the doctor doesn′t agree to cooperate, the mediation committee has no further possibilities to proceed the investigation and the patient is on his own according to the website of the mediation committees http://www.schlichtungsstelle.de (2003b).
Another point is the given information about the duration of the procedure. The average duration takes about thirteen month and there are heavy fluctuations. As already mentioned the GMC is also criticised concerning the time they need to get in contact with complainants and the time they need to make decisions.
A further point is the question how independent the physician chambers are. The chambers pay the free mediation committee service according to the website of the Bundesärztekammer http://www.bundesaerztekammer.de (2003). So what can the patient expect from them? The GMC has got the same problem. They say that they want to protect patients but they have also to represent their doctors. It is almost impossible to believe that both, the GMC and the physician chambers are able to handle patient′s complaints with impartiality.
One interesting fact is that the physician chambers don′t tell anything about `removing a doctor from the register′ or about any sanctions against them. There are no information given about those procedures and they also don′t explain who has the power to do that. But it is obviously that they have got the power because it is one of their sovereign tasks to monitor and control the performance of their doctors as mentioned on the website of the `Deutsches Ärztenetz′ http://www.arzt.de (2003). However, their total complaints system is based on mediation and not on prosecution and judgment like the GMC′s.
The description above reinforces the impression that patient′s complaints in general are not tackled appropriately and that it is rather difficult than easy for patients to go on in the process, especially if his or her complaint couldn′t be solved by the mediation committee. But this is more a general problem in Germany than only a problem that is caused by physician chambers.

5. The Importance Of Patient′s Voice
It is obviously that both institutions in both countries have many problems to look after their patients in relation to complaint procedures - Germany more than the U.K.. Why should the institutions listen more carefully to their patients and their complaints. Therefore, we first should have a look on two graphs:

Mediation Committee Of Northern Physician Chambers, number of complaint application forms since November 1976 until 2001, in consideration of the additional federal states of Germany since 1990, http://www.schlichtungsstelle.de (2003a).

(Kmietowicz, 2001)

It can be determined that in both graphs is an ascending tendency in complaints. This fact might result from a changing health awareness on behalf of the population. The population as consumer behaves more critical, the general state of knowledge is higher and people know better than in the past what is good or bad for them (Hölling, 2002). Especially, people with chronic diseases know that. They are experts of their own illness.
The producing industry knows for a fairly long time how important customer′s opinions are. They consider customer′s complaints as impulse and occasion to change and improve their products. That also happens increasingly in the sector: provision of services (Kranich, Vitt Berger and Pritzkuleit, 2002a). The health sector also could use patient′s opinions to assess and improve the quality of medical and nursing services. Furthermore, if health policy would be oriented towards the real needs of patients it would also cause a big cost-saving (Berger, 2003).
Moreover, if complaints would be evaluated systematically then it would be easier to detect grave and undesirable developments in health systems. If the number of complaints rises in a special area that might be an evidence for a weak point in the system or in the institution (Kranich et al., 2002a).
There are many more reasons which back the assumption that it would be a good idea to listen more carefully to patients and their complaints but unfortunately that cannot be delivered in this short appraisal.

6. Conclusion
In general it is quite interesting to see how much the GMC and the physician chambers differ from each other. They even distinguish between their responsibility. The GMC says that they want to protect patients and that the interests of doctors are protected by others, but the german physician chambers and their head organisation the Bundesärztekammer explain that in the first place they act on behalf of doctors.
The two institutions also differ in the general structure. The GMC is more centralised and includes all doctors of the U.K. The physician chambers act independent from each other and get only general advices from their head organisation, the Bundesärztekammer. Even the personnel structure is different. The GMC also employs lay members. There are lay members in the Council, in the different committees and a lay person is asked for his opinion during the process of assessing a patient′s complaint. The German physician chambers don′t have lay members. There are lay members in their reviewer commissions and mediation committees but they don′t have lay members in the chambers themselves.
The next interesting point that should be criticised is the way how the GMC presents its given powers. In relation to `removing a doctor from the register′ the GMC almost presents its powers as if it wants to advertise with that. The physician chambers behave more reserved concerning this point.
The Council is also criticised for the selection of cases. Most cases were dismissed in the past and only those were recognised where the Council saw a possibility to remove a doctor from the register. This fact backs the assumption that the Council don′t have a real interest in protecting patients but in monitoring its doctors and in removing them if necessary. All other less serious but important cases are dismissed at the first investigation stage. The survey Health Which that is mentioned on page eight backs this statement.
One point that must be mentioned implicitly at the end of this work is the amalgamation of different tasks. The GMC mingles the protection of patient′s interests with the representation of and its responsibility for doctors. That means that the GMC isn′t independent at all, even if it wants to be. The German physician chambers have got the same problem because of their relation to the mediation committees. The second point is the amalgamation of prosecution and judgment. The GMC should be clear about what it wants. An amalgamation of two interest groups and to be charged with too many tasks, potentially contains the risk not to perform well (different interests because of different interest groups: patients and doctors) and also the risk to be criticised for not acting fair, because normally two important powers like prosecution and judgment should be executed separately. This point can′t be criticised regarding the physician chambers because their main interest is mediation and not prosecution or judgement - however, that doesn′t mean that they are performing better than the GMC does.
On the contrary, generally, the impression is that the German health system is sampling at the moment. In relation to the complaints system it is nearly the same problem. This assumption is backed by the fact that Germany has innumerable different and independent consulting services. But most of them don′t exchange any information - that makes it almost impossible to collect data, to apply statistics and we can deduce therefore that the quality of complaints procedures won′t improve if we are not able to tackle those problems. The GMC only seems to have some difficulties in performing and in finding its definitive role in the system but in Germany there even doesn′t exist a body that helps patients to carry a complaint from the beginning to the end with all the support they need. The German health system is changing and it should have a look over the nation frontiers to learn from other countries like the Netherlands, Sweden or the United Kingdom.

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