§ 1.15 p.m.
§ Mr. Gerald Kaufman (Manchester, Ardwick)
In the debate on the Superannuation Bill today my hon. Friend the Member for Islington, East (Mr. John D. Grant) was able to go considerably wide of the Bill at the beginning of his speech. As time does not press upon me as it did in my previous Adjournment debates, I might be tempted to do the same and refer to such problems as unemployment in my constituency. But I count myself fortunate to have the opportunity to put to the House, without pressure of time, the subject I have been seeking to debate for some while. Therefore, I will confine myself to that, and be content to do so.
The subject I am raising arises out of a case which was brought to my notice by a public-spirited constituent, the Rev. Geoffrey Clark, without whose intervention a doctor might still be practising to the public danger. It is far from my mind to seek to pillory the doctor, because the case was extremely pathetic on the doctor's side, but the outcome was that two of the doctor's patients died. It is almost certain in one case and extremely likely in the other that the doctor's neglect was responsible for the deaths. From that tragic and unhappy episode arises a general case which I believe to be of considerable public importance.
The awareness of the Rev. Geoffrey Clark of the situation to which I have referred led to a complaint to the Manchester National Health Service Executive Council on 14th April last year. The complaint then proceeded to grind slowly through two different procedures until the doctor, almost one year from the date of the original complaint, was removed from the N.H.S. list by the N.H.S. Tribunal. But in the meantime the patient concerning whom the original complaint had been made had died, following the doctor's failure either to give the patient treatment or to secure treatment for the patient elsewhere.
The doctor's memory was extraordinarily shaky. Four times the doctor forgot either to make calls upon the patient's home after being asked to do so or to refer what turned out to be a very 867 serious—indeed, fatal—case to a hospital. While the complaint was going through, another patient suffering from similar negligence, the forgetfulness of the doctor who did not make calls when they had been requested, also died.
So the first patient was the subject of a complaint to the N.H.S. and the second patient died while the complaint was being processed and the doctor concerned was still being permitted to practise. From this episode two questions arise, and I have been in correspondence about both with the Under-Secretary of State.
The first question that arises is what machinery is there to prevent mishaps of this kind if no one makes a complaint? The second is: how can further mishaps be prevented while the complaint is actually being processed? When I was in correspondence with the Minister earlier this year he replied to both those points and said this:If an Executive Council consider that the continued inclusion of a doctor in their medical list would be prejudicial to the efficiency of the general medical services then they can ask the National Health Service Tribunal to direct the removal of a doctor from their medical list (and in effect from any other Council's list).This is what happened, he said, in the case of the doctor concerned.However, this is not the only procedure that an Executive Council can adopt. The terms of service also provide that: 'Where the Council, after consultation with the Local Medical Committee, are satisfied that owing to the continued absence or bodily or mental disability of a practitioner his obligations under the terms of service are not being adequately carried out, they may with the consent of the Minister make such arrangements as the Minister may approve including the appointment of a deputy for and on behalf of the practitioner, and may deduct the cost of the arrangements in part or in whole from the remuneration of the practitioner; or they may with such consent give notice to the persons on his list that the practitioner is for the time being in their opinion not in a position to carry out his obligations under the terms of service.'Those are the points which the Minister made in seeking to prove that there was machinery to remedy the situation of which I have complained. But, in fact, this machinery is totally inadequate. The machinery was far too late to stop the first death, and was in no way effective 868 in stopping the second death. This is where the suggestion which I am putting forward comes in.
My suggestion is that there should be regular health tests—and I would propose annual health tests—for doctors over 65. The doctor in this case was aged 82 and had undoubtedly, from all the evidence, become senile and no longer in command of the faculties necessary for adequate general practice. The memory had almost totally gone. Nevertheless, the doctor, as often happens with old doctors, was highly esteemed, so highly esteemed that pharmacists in the area corrected erroneous prescriptions which were brought to them from the doctor.
Yet a doctor practising in this way, and without any complaint being made, had been practising to the public danger. We know what happened to two patients, but it is impossible to know what more harm was inflicted by the doctor until the practice was stopped. A routine health check of the kind I am suggesting would have prevented a situation of this kind arising, without leaving it to the uncertain chance of a complaint which might or might not come. A person who gets short weight in a shop requires a certain strength of mind to make a complaint. To make a complaint against a doctor and go through the National Health Service machinery, especially when that doctor is, on past services, popular, requires a considerable strength of mind and determination, which might not always be present, and a readiness, if necessary, to make oneself unpopular. We were fortunate in this case that in the end my constituent, the Rev. Clark, had the strength of mind to make the complaint, to follow it through in a determined way and ultimately to bring it to my attention. But we cannot rely on this happening, and until Mr. Clark did it in this sad case it did not happen.
I make it absolutely clear that the last thing I wish to do is to stop elderly doctors practising. I do not wish to hamper them, I do not wish an arbitrary date to be set from which doctors should cease to practise. It is well known that many elderly doctors with their long general practice experience are very good doctors who give good treatment; they understand their patients well psychologically; and in return their patients are 869 often very fond of them. I am in favour of doctors continuing to practise, however old they may be, with the single proviso that they should be fit to practise. But it is important that we establish their fitness to practise. Doctors do not have a retiring age and can, therefore, continue to practise indefinitely until a disaster forcibly brings to the attention of the authorities the ned to stop them practising.
We all know that senility can descend very suddenly. It can come early or late, but it comes suddenly. A doctor who has perhaps for decades been practising for the public good can suddenly turn into a public danger, as this doctor did. I suggest a regular health check from the age of 65 because that is the national insurance retirement age and, therefore, a suitable age from which to start. A regular health check could have intercepted this case—and might well have intercepted others of which we do not know—long before the case came to the attention of my constituent.
I ask the Under-Secretary of State in his reply not to turn down out of hand the request I am making to consider instituting regular health checks, perhaps once a year, on all doctors over 65. This would not, and I do not mean it to, stop elderly and aged doctors from practising, but it would protect doctors from a sudden incapacity which might not be outwardly obvious.
I am encouraged by the fact that the profession seems to have welcomed this suggestion. I understand that the issue of the General Practitioner out today which deals with the subject of this debate quotes the words of doctors who say that they would welcome it. It would, as I say, protect doctors and also protect patients. Despite what the Minister said to me in correspondence, the present machinery does not do this. The most the present machinery can do is to close the stable door after the horse has bolted, but in this situation the bolting horse can cost lives. In this case the machinery did not even stop the horse from bolting.
The executive council took the action which it was entitled to take in January this year. The Minister in his letter set out a list of actions that could have been taken in this situation. A deputy could have been appointed in fact, a 870 deputy was not appointed. The doctor's patients could have been informed that the doctor was not fit to practise. In fact, the patients were not so informed. Yet the executive council took the matter so seriously that it referred the case to the National Health Service Tribunal. Nevertheless, it neither appointed a deputy nor informed the doctor's patients that the doctor was not fit to practise.
It is farcical that what was done was simply to withhold £100 from the doctor in respect of breach of service. This inflicted no injury on the doctor—not that one wanted such an injury to be inflicted—but it did not even use the powers available to protect other patients from the incapacity of this doctor to practise. Therefore, the very next month—after the machinery which the Minister has cited to me had been brought into play and the penalty of withholding £100 had been executed on the doctor—another of the doctor's patients died in very similar circumstances to those of the previous patient.
I do not raise this subject in any way in a spirit of vindictiveness against the doctor, for whom I am very sorry, and certainly not against the executive council or anybody else. I am also not seeking to load the balance against doctors. I do not wish to create a situation in which a doctor is guilty until proved innocent. Doctors provide an exceptionally valuable public service—as I myself know, having been well treated by them recently in Westminster Hospital—and they do a vital job.
I am simply seeking to protect doctors and their patients by asking for two things. First, I ask for regular health checks for doctors who reach the age of 65. Secondly, I ask for some system of supervision of doctors against whom complaints are made. I do not ask for an onerous form of supervision since that would be intolerable, but when one has a situation in which a complaint has been made against a doctor and a patient dies as a result of lack of attention by a doctor, it leads one to think that while the slow machinery for complaint is proceeded with—and I understand that in everybody's interest it must be slow—there should be protection of the doctor's patients as well as the interests of the doctor himself.
871 The Minister in his letter to me said:I have no reason for thinking that, in general, the safeguards I have mentioned are not proving effective.In general, they may not prove ineffective, but the fact is that in particular they did prove ineffective. A patient died; and one cannot know whether in other cases they are proving ineffective.
I ask the Minister not to give a "Yes" or "No" now, but to say he will go from the House today and carefully consider the case I have put to him and write to me, letting me know how he proposes to deal with the situation, which I am sure he takes quite as seriously as I do. I ask this because in the end the lives of patients are more important than any other consideration.
§ 1.35 p.m.
§ The Under-Secretary of State for Health and Social Security (Mr. Michael Alison)
It is important, at a time when we are considering the broader question of the reorganisation of the National Health Service, not to lose sight of the sort of problems that bear on the man in the street. This is why I am grateful to the hon. Member for Manchester, Ardwick (Mr. Kaufman) for raising this topic today. He dealt with the matter with some delicacy in the light of the tragic personal aspects of the case, with its unavoidable public repercussions. Perhaps he would convey to his constituent, the Rev. Mr. Clark, the appreciation of us all for the public spirited and delicate way in which he has intervened in this matter.
The hon. Member will agree that the problem is not an unmanageable one in point of size. Perhaps I can put the matter in perspective by saying that there are approaching 50,000 doctors employed in the National Health Service, more than half of whom are employed in the hospital service.
Under the terms and conditions of service of hospital medical and dental staff a hospital doctor's regular contract comes to an end when he reaches age 65. Where service needs prompt it, a hospital authority might occasionally extend a contract for one-year periods or less until the doctor concerned reached age 70; there is no provision for employment of hospital doctors after that 872 age. Any doctor rendering services in a hospital must continue to satisfy his employer that he is fit to do so, and any employer not so satisfied may require the doctor concerned to submit to a medical examination.
Only a relative handful of doctors over 65 are in fact employed in the hospital service. Of the 20,000 or so general practitioners under contract to the National Health Service only approximately 1,400—or about 7 per cent.—were on the last date for which figures are available, 1st October last year, aged 65 or over. Of these 1,400 the majority are, I am quite sure, capable and conscientious, as I am sure the hon. Gentleman would agree. I have no doubt that they give good service to their patients, by whom they are held in high regard, and that such doctors would be the first to recognise any impairment of their ability to provide treatment for their patients and the first to accept the consequences of such a recognition, however unwelcome.
Having said this to set the scale of the problem in perspective, I ought to add that I fully recognise the force of what the hon. Member said about the efficiency of a doctor being quite literally a matter of life and death in some circumstances. What I hope to show in what I shall now go on to say is that outlets exist for any problem situations to come to notice and that they can be dealt with urgently if necessary. Where the problem is not so urgent the statutory procedure for dealing with complaints against practitioners is likely to be involved. This is admittedly time-consuming and I will say more about this aspect when I talk about the procedure.
Let me turn then first to what I suppose one might call "consumer" practice where patients are dissatisfied with the effectiveness of their doctor. Every patient is free at any time to change his doctor, without having to explain either to his doctor or to anyone else why he wishes to do so.
The procedure for making a change is described on the medical card issued to each patient; but essentially it is very simple. The patient, after having given notice to the local executive council, chooses the doctor by whom he would prefer to be treated, goes to him, and asks to be accepted by him as his 873 National Health Service patient. If the doctor agrees, the patient informs the executive council, who make the necessary arrangements. If a patient has difficulty in finding another doctor he can go to the executive council and ask to be assigned to the medical list of one of the doctors in his neighbourhood.
The point about this, in the context of the hon. Gentleman's concern, is not only the obvious point of a patient's right to change his doctor, but the fact that an executive council would soon become aware of a doctor who was at all regularly giving rise to concern.
The second main point is that the terms of service of general practitioners provide that executive councils may themselves take action against a doctor who for any reason is failing to provide a satisfactory service. Where the council are satisfied that because of a doctor's continued absence or bodily or mental disability his obligations under his terms of service are not being adequately carried out, they may make arrangements for carrying on the practice.
Before they take action under this provision, councils are required to consult the local medical committee and also to obtain the approval of the Secretary of State. But these checks and safeguards do not prevent councils from operating the procedure. During the last five years the procedure has been invoked 19 times, mostly because the doctor had developed some form of illness but occasionally for other reasons. Clearly this is the right procedure where there is evidently an urgent situation—in other words, a doctor is so impaired either physically or mentally that he or she is more likely than not, if faced with an emergency, to do damage by act or omission. It is very unlikely that occasions will not arise when patients have some cognisance or awareness of a limitation such as the hon. Gentleman described—the sudden onset of senility.
I have indicated that the procedure is used fairly rarely, but its existence no doubt facilitates more informal action by the executive council, the local medical committee, or by partners and colleagues, where through sickness or age or for any other reasons a doctor's capacity to practise effectively has become impaired. From time to time I become aware of individual cases of this nature, where as a result of such informal persuasion doctors resign 874 or retire or engage assistance or reduce their medical lists, or limit their clinical responsibilities in some way. In the nature of things, the cases that occur are disposed of without being brought to the attention of my Department formally. But we hear about them.
In short, I hope the hon. Gentleman will accept that where doctors over, or for that matter under, 65 are not giving a satisfactory service there are mechanisms operating which can and do reduce or eliminate the problem—if need be, urgently.
§ Mr. Kaufman
This is all very well, and I accept what the hon. Gentleman says. But will he turn his attention to the specific example which I mentioned in which an executive council had a case brought to its attention which it regarded as extremely serious—so serious that it referred it to the National Health Service Tribunal? It did not employ the mechanism available but simply fined the doctor a relatively small sum. How can we be sure that the safeguards are operating adequately?
§ Mr. Alison
I hope that I shall cover that point when I deal more particularly with the case which the hon. Gentleman has brought to our notice today and in earlier correspondence.
I should like to turn to the statutory procedure dealing with complaints against general practitioners and for taking the drastic step of removing their names from the medical lists of executive councils. It might be helpful, therefore, if I were briefly to explain these procedures. Family doctors are independent contractors who are under contract with local executive councils. Under their contracts they are required to comply with the terms of service set out in the National Health Service (General Medical and Pharmaceutical Services) Regulations. For example, a medical practitioner is required to render to his patient all proper and necessary treatment; to visit and treat a patient whose condition, in the opinion of the doctor, so requires; and to take all necessary steps to enable a patient to receive treatment from the hospital and specialist services where the patient's condition requires such treatment and the patient agrees to receive it.
875 If a patient considers that his doctor has failed to comply with the terms of service, the patient or, as appropriate, his representative can complain to the executive council. The handling of complaints is governed by procedure laid down in the National Health Service (Service Committees and Tribunal) Regulations. The complaint is first considered by the chairman—a lay member—of the medical service committee of the executive council. There are some detailed points of procedure at this stage leading up to consideration of the complaint by the full committee which has the power to decide whether there shall be an oral hearing.
Apart from the chairman, there are three other lay members and three professional members on this committee. After any hearing that is necessary, the committee reports the relevant facts from the evidence placed before it and the inferences it has drawn on whether there is a breach of the terms of service. It reports its findings to the executive council and recommends what action should be taken. The executive council makes a decision on the complaint and sends copies of the service committee's report, together with a statement of its decision, to the parties concerned and to my right hon. Friend the Secretary of State.
There is a right of appeal to the Secretary of State against the council's decision. In the more serious cases, executive councils may consider that the evidence revealed by a service committee case is such that it should make representations to the National Health Service Tribunal that the continued inclusion of a doctor's name in the council's medical list would be prejudicial to the efficiency of the general medical services.
This disciplinary procedure is a quasi-judicial one. It provides a framework for the investigation of legitimate complaints by patients but at the same time gives practitioners some degree of protection against frivolous or unjustified complaints. By the very nature of their work doctors, as a profession, are perhaps peculiarly exposed and vulnerable to unreasonable complaints.
The procedure provides for certain processes to be gone through and because of its formal nature it is difficult to cut corners. An executive council can take 876 the serious step of making representations to the National Health Service Tribunal only when it has sufficient evidence to suggest that it would be in the public interest to prevent a practitioner from continuing to provide services. In Tribunal cases certain steps have to be followed to safeguard the interests of practitioners as well as those of patients and it inevitably takes some time to marshal evidence and have a case considered by the Tribunal. However, those administering these procedures endeavour to ensure that cases are dealt with as quickly as is consistent with the administration of justice, which, alas, sometimes grinds relatively slowly.
Before I leave the question of the steps that can be taken in effect to stop a doctor from practising, I should mention that it is open to the Secretary of State to pass facts which have come to his attention to the General Medical Council for consideration by it of disciplinary proceedings.
It is at this stage that I should say a little about the particular case with which the hon. Member was concerned and which he specified in some detail. The complaints made against this doctor were made early in 1970 and the service committee of the local executive council heard them in July of that year. The executive council endorsed its committee's recommendation and sent the cases to my Department in August. The Secretary of State considered that the cases were serious enough to justify a substantial withholding of remuneration, and after completion of the appropriate processes under the Service Committee Regulations a withholding of £100 was directed in January, 1971.
The executive council also made representations to the National Health Service Tribunal which sat in February, 1971. As a result of the Tribunal's decision, the doctor's name was removed from executive council lists at the end of March of this year. I accept that it took a long time for this to occur, but about this I would say two things. The first is that this doctor very rarely answered any letters, so that the statutory procedures tended to be slowed down on this account. But I can think of no other case in which this extraordinary unwillingness to communicate by correspondence or by any other means has 877 arisen; it is virtually unique. The second is a point I have already touched on generally. The National Health Service Tribunal is in effect depriving a person of his livelihood—at least so far as the Health Service is concerned—and the need for speed in the interests of patients has to be balanced against the fact that it would be wrong to take such a step without giving the practitioner every chance to put his or her side of the case.
Before I come to the hon. Gentleman's main suggestion, perhaps I could just say about his subsidiary point—that immediately a doctor has been the subject of a complaint there should be a sort of audit of his work—that I do not think it would be practicable. Even supposing it was right to divert scarce medical manpower to this sort of function, I do not think it would be fair to ask general practitioners to submit to checks when, as I have said, a complaint may be trivial or even malicious. And if someone were charged with deciding whether the degree of seriousness of the complaint justified checks, then that person would in effect be prejudging to a large extent the result of the statutory procedure for considering the complaint.
I turn to the particular suggestion which the hon. Gentleman put forward, namely, that there should be an annual medical check of general practitioners over the age of 65. However, first I reassure the hon. Gentleman that, always being anxious to listen carefully to any points made by hon. Members, I shall ponder and weigh carefully what he said. In turning down the main burden of his argument, I do not completely rule out any reaction to what he said, he having taken great pains to elaborate and expound his thesis.
The first point to make is that, although a medical check would no doubt pick up actual physical impairment, it is hard to see how such a check could settle the acid question whether the practitioner has sufficient energy and competence to conduct his practice. 878 The question is surely one which might depend on the size of the practice and its location. Running a practice which depended on covering large rural areas, normally snow-covered in winter, is clearly a great deal more physically onerous than running one in, say, a suburban area. The job of coming to conclusions of this kind would be invidious.
This leads me to my second point, that, because it would be an invidious task, I doubt whether many doctors would be prepared to undertake such a medical examination of their colleagues. In effect, it would mean taking their future employment prospects into their hands in an informal and unofficial way.
I have tried to deal as carefully as possible with the hon. Gentleman's points. I can well appreciate the local concern about the complaints made against the doctor which led to the hon. Gentleman's interest in the matter. I hope that I have shown that remedies exist for the general problems with which he is concerned. The particular statutory procedure for complaints against practitoners is, as I have said, slow; but, as I have also said, we must not forget the interests of the patients and, equally, the vital aspect that the doctor's livelihood may be at risk.
I think that I can fairly say that both my right hon. Friend and I are open to any suggestions regarding better management of the National Health Service, but we doubt whether the hon. Gentleman's imaginative suggestions would be practicable and, indeed, fully effective in the circumstances with which we are concerned.
I am sure that the hon. Gentleman appreciates the difficulties. I certainly undertake to consider carefully the details of what he said. I also undertake to write to him again on this subject. However, I am bound to conclude that, on first hearing his further exposition of these points, I cannot see that health checks for doctors over 65 would fully avoid the hazards which have arisen in this case.