Richard Smith: Donald Irvine—a medical leader who both failed and succeeded

richard_smith_2014On a train north I read Donald Irvine’s obituary in The BMJ, and memories flood into my mind. These memories are one of the gifts of age, preferable to T S Eliot’s gift of “the cold friction of expiring sense without enchantment.”

My main memory of Irvine is of him being savaged in the tiger pit of the BMA Council. He’d come to the meeting as president of the General Medical Council to discuss revalidation in the early 2000s. He’d been one of the main proponents and architects of revalidation after a series of scandals, foremost among them the cardiothoracic surgeons in Bristol deceiving parents about the quality of their care and the general practitioner Harold Shipman murdering many of his patients. The public and politicians were taken aback to discover that doctors after taking their final exams never again needed to demonstrate their competence, in contrast to pilots who are tested every few months.

Even the deadbeats, the backwoodsmen, and the stegosauruses of the BMA Council recognised that outright opposition to revalidation and Irvine was impossible. The public and political mood for reform was too strong. The strategy of the stegosauruses was endless delay, quibbling over every tiny detail of the process. Irvine had to be “put back in his box.” They tore into him with gusto, questioning his every statement and doubting his motivation and morals. I found it horrible to watch, like the crudest of badger baiting. Irvine didn’t go down covered in blood, but it was an experience that probably contributed to him stepping down early as president. The stegosauruses were successful with their strategy, delaying revalidation for years and emasculating the process so that only the most gormless would fail.

The savagery was inspired not only by opposition to revalidation but also by Irvine being an uppity doctor. Despite coming from a coal mining town, he had a patrician air, which the photo accompanying his obituary captured well. He was the first GP to rise to be president of the GMC, but worse he aspired to be a leader. Doctors, and certainly those who are also stegosauruses, don’t like uppity doctors who aspire to lead. For them one doctor, no matter how out of date and befuddled, is as good as any other doctor. Irvine upset many by arguing that perhaps as many as 5-10% of doctors had failings that meant they might fail revalidation.

I knew Irvine and liked him, although like many I often couldn’t follow what he was saying. I had dinner with him one evening at the GMC, misforecast the weather, and arrived underdressed and soaked through. Irvine offered me towels and removed his jacket for our dinner. We were co-conspirators. I had written a series of articles on the GMC arguing that it was a 19th century organisation unfit for the 21st that had failed to recognise that its first duty was to citizens and patients not doctors. This had not gone down well with the two previous presidents, but Irvine broadly agreed.

The first requirement of a leader is to create a vision of the future, a direction. Irvine wanted not only to see revalidation introduced but also to forge a GMC that recognised and delivered on its primary commitment to citizens and patients even if that meant upsetting doctors. His vision was to my mind the right one, and the present day GMC, although unpopular among doctors, is clear in its primary commitment to citizens and patients and has governance designed to meet that commitment.

It was on the second requirement of leadership that Irvine failed. The second requirement is to get people to want to achieve the vision. Irvine pointed in the right direction, but few followed him. He was not a “man of the people” or a “doctors’ doctor.” He was too remote and lacked the ability to spark emotion from those who might have followed him.

But did Irvine fail? As I’ve written, his vision of the GMC has arrived as has revalidation, albeit it in a diluted form. Was it historically inevitable that the GMC would change and revalidation arrive or was Irvine’s flawed leadership essential for success? Historians, if they can be bothered (which they probably can’t), can argue over this question for years, probably without reaching a conclusion. But we can agree that the BMA Council was on the wrong side of history and Irvine on the right side.

Richard Smith was the editor of The BMJ until 2004.

Competing interest: None declared.