Making judgements about ourselves and others is a universal human phenomenon repeated daily in social intercourse, examination halls, or courts of law. It is the desire to do this in an objective, repeatable, reliable and constructive manner that underpins the principle of professional self-regulation. However, this principle has been challenged by evidence of error in healthcare worldwide, and in the UK by several high-profile individual failures which have exposed flaws in regulatory systems. The subsequent public enquiries and their reports have stimulated modifications to training and assessment including regular appraisal and continuing professional development to ensure competence, introduction of a national system for reviewing doctors in difficulty, and several reviews of the concept of professionalism. In short, we will only retain the high level of public trust currently accorded to the medical profession if we combine effective assessment of competence with continued monitoring of performance. Assessment is thus an essential part of ensuring safe and effective patient care.

So much is obvious. But are we not doing this already? The medical profession has from earliest times made a commitment to place the interests of the patient before those of the practitioner and to maintain the highest standards of practice through examination and peer review. The problem is that this commitment may not be shared by all members of the profession. The absence of explicit standards and transparency makes assessment of performance difficult and therefore limits accountability.