The second edition of 'Maintaining Good Medical Practice' toughens up previous guidelines and spells out what is expected for doctors in terms of self-regulation and their duty to ensure they keep up-to-date with new technology.

The three main new elements are:

• that doctors must take part in clinical audits and must respond to them "constructively".
• that the importance of patients' need to know when things go wrong is recognised. "Truth is the best thing," said Sir Cyril Chantler, chairman of the GMC standards committee, at a fringe session at the NHS Confederation's 50th anniversary conference.
• that members of medical teams have a role to play in ensuring that their peers delive quality care.

Sir Cyril said: "For the first time we are making it clear that these are the standards against which doctors can be judged by their peers if there is a problem with their medical practice."

Criticism

The GMC - doctors' regulatory body - was criticised by Health Secretary Frank Dobson following its hearing into the case of three doctors in Bristol who were found responsible for the deaths of 29 babies following heart operations.

Sir Cyril said the public's declining confidence in the medical profession could be partly explained by the fact that medicine had become more complicated and people had increased expectations of what the health service could deliver.

Exocets

NHS managers in the audience said one of the main weak points in self-regulation was local remedies.

Bristol surgeon James Wisheart has a merit award, despite being struck off

When patients first make a complaint, doctors try to deal with this on a local level. Only more serious complaints get passed onto the GMC or the health service ombudsman.

The managers said the remedies either had no teeth or were too threatening, causing the medical profession to close ranks.

One manager likened the threat of being charged with serious professional misconduct - the maximum penalty available to the GMC - to an Exocet missile.

He said there needed to be a middle option available to punish doctors who failed to meet agreed standards.

First step

Rabbi Julia Neuberger, chief executive of the King's Fund, said the new GMC guidance was only a first step to improving standards. The next was to develop stronger local regulations, but she added that this was not the GMC's job.

She agreed that local problems were often dealt with by "buying off" patients who complained to avoid a legal case and bad publicity.

"These guidelines give a framework that the NHS can run with. They are much tougher than before," she said.

Carrot and stick

Sir Cyril said a carrot and stick approach might work. He thought merit awards, given to a majority of hospital consultants, should be set at different levels, with doctors who showed real excellence getting higher awards.

Rabbi Neuberger said patients should have a voice in deciding on excellence.

"Service users should have a view on awards. Exocets are not very efficient and can be threatening which is not very helpful," she said, adding that there should be alternatives to cash awards for rewarding good doctors.