If the Medical Council's Discussion Paper on Competence Assurance Structures 1998 is adopted, a huge shake-up of the medical profession in this State is on the cards. The paper, which proposes the introduction of quality assurance structures, is currently under discussion by the medical fraternity.

Under the Medical Practitioners Act (1978), the council is responsible for protecting the public interest in dealings with members of the medical profession. The council is responsible for maintaining registers, regulating the quality and standard of undergraduate and postgraduate education, holding disciplinary procedures and publishing ethical guidelines.

"The Act," notes the council, "offers no specific advice on maintaining the continuing competence of doctors." However, "the international trend by many licensing authorities is towards the pro-active assurance of competence by doctors. Such a strategy envisages the use of educational and audit procedures to offer the public a continuing assurance that, once training is completed, doctors continue to maintain their skills."

According to the council, "it is no longer acceptable for bad doctors to be identified and sanctioned. Our responsibility as a self-regulating profession must be to do our utmost to ensure that patients do not come to harm in the first place. Recent experience by the General Medical Council in Britain of professional misconduct in Bristol has raised disturbing questions about the extent to which the profession monitors its activities."

In its discussion paper, the council outlines a competence assurance scheme which assesses doctors over five-year periods and requires them to achieve a total of 250 points during this time. Under the scheme, 60 per cent of points are awarded for continuing medical education or continuing professional development. This requires the establishment of specific education and validation structures.

A further one-fifth of points are to be awarded through peer review of competence. "This," says the discussion paper, "will probably occur on the basis of small groups of peers undertaking practice visits, review of protocols and case review. Valid protocols and procedures . . . must be developed."

The final 20 per cent of points, the council suggests, are to be awarded for performance review. "Some systematic audit of practice with effective peer comparison would be included in this section," the document states. "The audit must be practical and associated with a strategy to effect change if appropriate."

If the scheme is adopted, every doctor on the Specialist Register will be required to get 250 points over five years to be eligible for entry to the register for a further five years. "The inevitable implication of the scheme," says the council, "is that every doctor working in independent practice would be required to enter his or her name in the Specialist Register. All other doctors (in training or with limited registration) would then become subject to specific supervision during the defined period of their limited registration."