PROPOSITIONS : Call the doctor to account

On the morning of 9 January 1982, Dr Oliver Archer, a GP in the East End of London, was called to visit eight-year-old Alfie Winn. It was to be a day that has haunted the General Medical Council, the doctors' educational and disciplinary body, ever since.

Alfie had spent the night vomiting, was delirious and had a temperature of 106F. Dr Archer agreed to turn out reluctantly. When he arrived, he kicked a bowl of Alfie's vomit under the table. When the boy failed to respond to his instructions, Dr Archer declared that if Alfie "couldn't be bothered to open his mouth, he couldn't be bloody bothered to examine him". He prescribed an antibiotic and left.

Two hours later, Alfie's mother called an ambulance. Four days later, Alfie died in hospital from meningitis. His mother complained to the GMC. Dr Archer was charged with "serious professional misconduct" - the only charge the GMC can bring - for failing to examine and treat the boy adequately and for failing to refer him to hospital. At the hearing, the facts against him were found proved. But it went on to decide his actions did not amount to "serious" professional misconduct. It acquitted him.

Two years later, Dr Archer was again before the GMC. He had told a woman undergoing a miscarriage that when the foetus emerged she should wrap it in newspaper, flush it down the toilet and see him three days later. This time he was found guilty, suspended and referred to the GMC's health committee. He eventually took himself off the medical register.

Fifteen years on, Parliament will tomorrow debate the second reading of a bill aimed at giving the GMC improved powers to deal with the Dr Archers of this world. The new performance procedures are aimed both at doctors who behave intolerably to patients and at dealing with the sort of incompetence Dr Archer also displayed.

The bill is a landmark, but doubts remain about whether it will really do the job. What it does is bolt a new procedure on to the already complex system for disciplining doctors. At present there are two procedures: one for professional misconduct, based on court-style public hearings, and another for sick doctors, which is private and emphasises treatment and advice for them. The new procedure will be private; remedial rather than punitive; with powers to suspend, require retraining and, in the last analysis, prevent a doctor from practising.

The complexity of this new system, with its three interlinked procedures, has come under fire from two distinguished former lay members of the council. Jean Robinson, a vice-president of the Patients' Association, argues cases can easily involve both conduct and competence, yet will be set off down one track or the other. Margaret Stacey, professor of sociology at Warwick University, argues the GMC should recognise "that seriously incompetent practice is in fact serious professional misconduct".

No one is quite sure how many cases there will be a year. The GMC's best guess is 100 to 150, of whom perhaps 50 might face sanctions. But retraining to make doctors competent, or to change their attitude to patients, will be expensive - perhaps ?6,000 to ?22,000 a case. In the newly competitive NHS, hospitals may prefer to dispose of incompetent doctors rather than invest in their retraining.

The real difficulty lies in the word "serious": since 1858 the GMC has been able to act only over "serious" professional misconduct or, as now, when a doctor's health is "seriously" impaired or performance "seriously" deficient. When the government in the Eighties first considered legislation to allow the GMC to deal with performance, it thought about tackling the word serious. But at the recent press conference to announce the bill, Gerald Malone, the Minister of Health, was anxious to assure doctors the new procedure would not be draconian. The bill has been introduced only on condition that the Opposition will facilitate its passage and not try to alter it.

The procedure should be given its chance, and the GMC has promised a review after two years. But if it is not seen to be working well, the time will have come to tear up the Medical Acts and start again.