I proposed a motion, seconded by Dr. Matthew Sadlier, at the IMO AGM in April last year (2016). The motion, that the IMO should call on the government to fund the Medical Council entirely from its own resources, passed unanimously. In proposing the motion, I said the following: “We believe a significant anomaly, effectively hidden in plain sight, has arisen in the funding of medical regulation over several years now.
It was a Forensic Medicine lecture in Earlsfort Terrace by the late Professor Hickey that first alerted my classmates and me to the fact that, once qualified, we were obliged to pay an annual retention fee to the Medical Council, the regulatory body of our profession. He explained this obligation derived from the privileged position medicine occupied in society as a self-regulating profession.
This privilege had been granted because the state had determined that society’s interests were best served by self-regulation, because it was doctors themselves who were considered best placed to maintain standards, adjudicate on doctors’ performance and to sanction doctors appropriately if required. As part of this balanced social contract between society and our profession, within the model of self-regulation, doctors were required and undertook to fund medical regulation themselves. Therefore, when I qualified, doctors themselves constituted the majority of the membership of the Medical Council. However lay members constituted a minority of Medical Council members, in order to ensure representation for wider society. Despite this minority lay membership, this model was still regarded and referred to as self-regulation. In keeping with that, doctors through their annual retention fees funded the Medical Council in its entirety. I do not believe that anyone beyond our profession considered that inappropriate. My impression is that even within our profession few had a contrary opinion. There were some who did however, as this Medical Council newsletter from 1997 makes clear (I held up the newsletter). I will read from it: ‘Retention Fees: some letters received from doctors on the retention fee indicate some misunderstanding of the background and need for the current retention fee. Self-regulation has been the hallmark of the profession since 1858 and in this country since 1927 and a consequence is funding of the council by the profession… (There follows an explanation of the good uses to which the fee is put, before it concludes)…Self-regulation by the profession in other countries, e.g. Australia, South Africa, United Kingdom is jealously guarded and as here, funded by the practising doctors.’
I have read nothing elsewhere that undermines that position. However, a decade after this newsletter, the Medical Practitioners’ Act 2007 swept away self-regulation in this state, leading the way internationally in certain respects. The Minister for Health at the time argued when introducing this legislation that self-regulation was no longer appropriate for a modern, democratic and mature state, populated by a by now highly educated citizenry. Her view was very widely shared in society and self-regulation ended with enactment of the Act. Despite this, our profession continues to fund the statutory regulatory body.
And while this continues to be the case, not only will an injustice be done to doctors, but the important work of the Medical Council will be impeded and undermined. Because, in addition to the necessary tension that will always exist between a regulator and its trade or profession, there will be a perpetual unnecessary tension between the Medical Council and doctors regarding the level of the retention fee, the use to which the fee is put, concerning late fee payments, etc. Therefore, in the same way we as a profession funded the Medical Council in its entirety during the era of self-regulation, discharging our obligation fully, that duty has now transferred to the state in this current era of external regulation. The state, in keeping with its aims to be modern, democratic and mature, must now discharge its obligation fully. The retention fee for doctors must be abolished immediately. In its place, the state must appropriately fund the Medical Council from its own resources.”
In conversation since then with colleagues, I have been struck by the level of agreement with this position. As well as agreeing that in principle the state should fund medical regulation, they express dismay at such issues as the lack of accountability for spending decisions by the council to the doctors levied to fund it and the possibility that the fee will rise greater than wages indefinitely. However, in conversation with some colleagues and professionals outside the profession, there has been a concern that doctors, because of their on average better off income, would be unpopular with fellow citizens for insisting the state fully meet its obligations. However, even if that is the case and I am not at all sure that it is, it should not stop the state from conducting itself in a principled manner. If some in wider society conclude there is a case for a specific levy on registered medical doctors, there exist accessible democratic mechanisms, which have appropriate checks and balances, to attempt to legislate for that view. However, I believe many of our fellow citizens will support the ‘democratisation’ of the regulatory body’s funding.
In conclusion, while the end of the era of self-regulation rescinded the previous long-standing balanced social contract between society and our profession, another balanced social contract in fact now exists in its place. Under that new balanced social contract, within the model of external regulation, the obligation to fund medical regulation has fully transferred to the state. While we are aware that professional regulation confers some benefit to the medical profession, it also confers substantial obligation. Society gains professionals who undertake a long education and apprenticeship and then work within a particularly strict ethical framework and culture. For confirmation of that, one need only examine surveys of public opinion of various trades and professions, which consistently indicate that doctors remain exceptionally trusted. Our profession now needs to galvanise itself to end this anomaly immediately. I urge you to discuss this issue with your colleagues and to make contact with your representative bodies.
Dr. Kevin Kilbride, Consultant Psychiatrist, HSE Dublin North City MHS