§ Order for Second Reading read.
§ 4.4 pm
§ The Secretary of State for Health (Mrs. Virginia Bottomley)
I beg to move, That the Bill be now read a Second time.
This is an important Bill. Its purpose is to ensure that high-quality, professional performance is maintained by all doctors in the national health service and in private practice. It will help to ensure that patients receive the standard of caring and up-to-date professional practice that they have a right to expect.
The Government stand for first-class public services and the Bill is part of that commitment. The citizens charter and the patients charter have brought a major change in attitude and performance in the NHS, so that it is now a service centred on patients.
§ Dr. Norman A. Godman (Greenock and Port Glasgow)
I am extremely grateful to the Secretary of State. Will she confirm here and now that when she talks about all doctors, she includes in that definition hospital consultants? Most of the complaints brought to me by constituents have concerned the negligence of hospital consultants rather than general practitioners.
§ Mrs. Bottomley
I can certainly confirm that the Bill refers to all doctors. If I can make a bit more headway before the next intervention, I shall make that absolutely clear.
The Bill is part of our commitment to ensure that the national health service lives up to the highest standards expected by the public. Already, we have had dramatic improvements in the responsiveness and quality of care available. The changes that I recently announced to the systems for handling complaints, following the Wilson report, is part of that movement. Similarly, the new code on openness is a further example of how we are getting better at responding to the needs of patients and the expectations of the public.
The heart of the health service is its doctors, nurses and other clinical staff. Their dedication, professionalism and quality are rightly a source of national pride. They are respected throughout the world.
All of us in the House acknowledge the tough job that clinicians have to do. That demanding job does not get easier when the expectations of the public rise with demographic changes and, inevitably, there is always a finite budget. Only recently, the case of Child B brought into the full media glare some of the complex ethical decisions that clinicians regularly face in their normal working lives.
Doctors have been at the forefront of the culture change in the NHS. They are now rightly expected to be held accountable for the vast sums of taxpayers' money that they spend, as well as for the care that they provide. Most doctors recognise that as a valid feature of a modern health service, where it is no more acceptable knowingly to misuse its resources than it is to pursue a course of action which is clinically unsound.
672 The NHS has to be well and strongly managed. Many doctors respond positively to that by becoming involved in the management of the service, whether through GP fundholding, for example, where family doctors are able to back their clinical judgment by direct access to the budget that they control, or through the other many opportunities as medical or clinical directors of the new health authorities, as directors of public health or by offering professional advice. There are now unlimited opportunities for doctors to influence and shape the development of the health service.
Doctors are no longer the unchallenged paragons they once were in the eyes of the public. Patients are better informed, more assertive and more ready to question and complain. That certainly puts pressure on the medical profession, which is held to account in an ever more public atmosphere.
A new climate is spreading, where treatments are analysed on the basis of clinical effectiveness and outcomes. Clinical audit is well established. Our pioneering research and development strategy is spreading on a systematic basis information about the latest state of medical knowledge. Tomorrow my hon. Friend the Minister will be launching the next phase of our movement towards evidence-based medicine with the Cochrane collaboration. All those changes mean that the practice of medicine takes place ever more in the limelight and is subject to increasing scrutiny.
§ Mr. William O'Brien (Normanton)
I appreciate the opportunity to intervene on the Secretary of State and I acknowledge the report that she has given about doctors. Will she confirm or deny that she intends to introduce performance indicators for doctors and other clinicians in the health service? How will that system operate if she intends to introduce it?
§ Mrs. Bottomley
I have no such intentions; I am simply describing the atmosphere in which medical practice now takes place. It is subject to scrutiny and evaluation in a way that was inconceivable even 10 years ago and it means that all doctors are under greater pressure to keep up to date with the latest advances in medicine. As medicine becomes more complex, capable and involved, there is a pressure and an obligation on all professionals to ensure that they are protecting their patients and serving them according to the latest knowledge and understanding of care.
In general practice it is now often possible to treat and to manage diseases, such as heart disease, stomach ulcers and asthma, which once required a high degree of hospital care. Doctors, particularly in family health services, used to work in professional isolation. Today fewer general practitioners work alone because there is a much greater emphasis on team working. GPs and specialists increasingly work side by side in modern medical centres, bringing what was once thought of as hospital care closer to patients. Nurses, doctors and other professionals work together in community health teams and there is closer working between GPs and clinicians in hospitals.
That does much to improve the treatment and care of cancer sufferers, for example. Only yesterday, we unveiled our framework for the future of cancer services. That close linking and greater sharing of knowledge between GPs and clinicians in hospitals and the patients and public is a theme of that new framework. All those new developments mean an unprecedented change in the 673 way in which modern medicine is delivered. A doctor has a clear duty to keep up to date, to know what is appropriate and what is not, and to know when to seek help and advice from colleagues.
To its credit, the profession has recognised those changes and the need that comes with them to assess continually the performance of doctors. I pay tribute to the General Medical Council whose work has resulted in this Bill. The Bill stems from the profession's recognition that, no matter how qualified, dedicated or expert the majority of its members may be, the standards demonstrated by a small number of practitioners will from time to time fall below what patients have a right to expect. In those cases, proper procedures must exist that will enable action to be taken to protect patients and to raise the quality of care.
When doctors arc guilty of serious professional misconduct or when a doctor's fitness to practise is seriously impaired by ill health, the powers exist to act. Doctors who are accused of serious misconduct appear before the GMC's professional conduct committee, where the evidence is tested to the criminal standard of proof in adversarial proceedings. Doctors who are found guilty can be struck off. Similarly, the GMC has powers to suspend from the register those doctors who are too ill to perform their duties.
However, no such powers exist to deal with doctors whose performance may be seriously deficient but who, nevertheless, fall short of those extremes. The GMC receives details of a number of cases upon which it cannot take any formal action, even though it may be apparent that the underlying performance of the doctor concerned is very poor. At present, those doctors are beyond the law; they can remain on the register and the council has no power even to require them to address their shortcomings. That is bad for patients and bad for doctors.
The Bill plugs the gap. It is a Government Bill, but the House will be aware that the initiative came from the GMC. I pay a warm tribute to Sir Robert Kilpatrick, president of the GMC, who has been the primary influence behind the changes. He set up a working group to examine the problem and he single-handedly carried through consultations with a wide range of individuals and organisations both within and outside the medical profession. A period of formal consultation followed in 1992, and in November of that year Sir Robert secured the agreement of the GMC to proposals that differ little to those which appear in the present Bill. Indeed, I can say that, on being appointed as Secretary of State, three years ago, almost the first invitation that I received was to discuss with Sir Robert these proposals and how we could secure a journey to the legislative Chamber to ensure that they were enacted.
Sir Robert retires at the end of August this year. If enacted, the Bill will be a fitting tribute to his energy, determination and powers of persuasion as well as to an outstanding period as president of the GMC. In large part due to his efforts, the measures in the Bill command the wide support of the medical profession. They also enjoy cross-party support. I am grateful to the right hon. Member for Derby, South (Mrs. Beckett) for the support that she has given to the Bill in principle, and to the Liberal Democrat spokesman similarly. The hon. and learned Member for Montgomery (Mr. Carlile) sits on the 674 GMC, as does the hon. Member for Gower (Mr. Wardell) and, indeed, my hon. Friend the Member for Chislehurst (Mr. Sims), to whom I pay particular tribute, as he is the longest-standing Member of Parliament on the GMC and has been closely involved in the "fitness to practise" proceedings.
It may be of assistance to the House if I speak at this stage about the GMC in a little more detail. The GMC is the self-regulatory body of the medical profession. It consists of 102 members, 89 of whom are qualified doctors, the rest representing different professional and lay interests, including, as I have said, Members of Parliament from each of the main political parties. The House will be aware that, at present, the GMC is taking forward proposals to increase its lay membership—a further example of the need for all professions to ensure that they carry the confidence of the public in the vital work that they do.
The GMC's primary role is to maintain a register of all those who are qualified as medical practitioners. That duty provides an assurance to the public that all registered doctors are qualified to practise. The GMC must assure itself that those admitted to the register are competent. It must also ensure that those on the register remain fit to practise. As the Merrison committee put it in 1975,the maintenance of a register of the competent is fundamental to the regulation of a profession".That remains as true today as it did in 1975, or, indeed, at any time since the passing of the original Medical Act in 1858. In essence, that is the subject of today's debate. How can the GMC ensure that doctors on its register have maintained their competence in a fast-moving medical environment and continue to meet the high standards of performance set by the medical profession?
The Bill does that by making important changes to the professional regulatory powers of the GMC. New professional performance procedures will be introduced; and two new statutory committees—the assessment referral committee and the committee on professional performance—will be created to implement the new procedures. We propose to establish those new procedures in a way that is consistent with the principle that self-regulation is the most appropriate way for the medical profession to be governed and that it is the best way to maintain the high standards that the public rightly expects of its doctors, and which the great majority of doctors achieve. That principle is both long established and cherished by the profession, and it is one which the Government support.
The value of self-regulation has been further demonstrated by the fact that it was, as I have said, the GMC itself that first identified the gaps in its powers and took the initiative in asking the Government to introduce the measures that are now set out in the Bill. The professional performance procedures proposed will go a long way towards plugging the gap. They will do so in a novel way. The procedures are not there to ascertain whether the doctor is guilty of a particular instance of alleged deficiency. They do not offer individual redress for patients' complaints, although patients will receive feedback.
The Bill aims to achieve what many people say that they want when they complain: to see that something is done to stop a similar incident happening again. The purpose of the new procedures is to inquire into the underlying causes of any problems that have been 675 reported. The GMC will consider whether the matters complained of, particularly where there has been a series of complaints, show a pattern of serious deficiency in the standard of the doctor's professional performance. If that is the case, the doctor will be asked to have his performance assessed by a panel independent of the GMC, which will include two doctors of the same specialty plus one lay doctor. The panel's key role is to identify whether there are any significant weaknesses in the doctor's performance, to discuss those with the doctor and to give advice on what the doctor can do to remedy the position.
What I have described is initially a consensual process. The aim of the Bill overall is remedial. Wherever possible, we want expensively trained doctors to be put on the right track. However, it is important that the procedures work where the doctor does not consent. Therefore, much of the Bill provides for where the co-operation of the doctor is not engaged or where it breaks down for various reasons. It also provides for a doctor's registration to be suspended or for conditions to be attached to registration if that would be in the public interest and would help to protect the doctor's patients.
§ Mr. Gareth Wardell (Gower)
I support the Bill and, as the Secretary of State said, I am a member of the GMC. While a doctor is suspended and going through the procedures, will his registration on the GMC's register show that he is suspended, so that the general public can be aware of that?
§ Mrs. Bottomley
I understand that while the inquiry is under way, the register will show the suspension. I well understand the hon. Gentleman's concern that patients' interests should be safeguarded in that way.
§ Dr. Charles Goodson-Wickes (Wimbledon)
At the risk of sounding patronising, I wonder whether I could help my right hon. Friend. I imagine that by the time such a position was shown on the register, it would not fall within the cycle of that register's publication.
§ Mrs. Bottomley
That is true, but it is important that the information is available to those who wish to have access to the register.
§ Mr. Wardell
I am grateful to the right hon. Lady for giving way again. I am concerned that under part 3 of the procedures, the doctor could go round and round in a loop, for a period even exceeding three years. Despite what the hon. Member for Wimbledon (Dr. Goodson-Wickes) said, as I understand the procedures it is possible for a doctor to be retrained and continue to be retrained for quite a lengthy period. Would the Secretary of State be happy to put some limit on the period that a doctor can keep going round the loop?
§ Mrs. Bottomley
The hon. Gentleman makes a good point, which can be explored further in Committee when he will no doubt wish to develop his argument.
§ Dame Elaine Kellett-Bowman (Lancaster)
What about the engagement of locums? Will people be warned so that they do not inadvertently engage such doctors?
§ Mrs. Bottomley
That is something that the doctor concerned would need to discuss with his employers—either a trust or the family health services authority, 676 depending on the doctor's circumstances. Much would depend on the seriousness of the matters under consideration.
As I have said, it is important that we are prepared not only for cases where there is consent, but for those where the doctor does not consent. The Bill provides for cases where the co-operation of the doctor is not engaged or where it breaks down for various reasons. It also provides for a doctor's registration to be suspended or for conditions to be attached to the registration, if that would be in the public interest and would help to protect the doctor's patients.
I commend to the House a short paper prepared by the GMC on its proposed performance procedures. It explains step by step how the system works. A number of copies have already been placed in the Library. I shall, however, go through the course of a case where the doctor agrees to the process and then explain in more detail how the system will cope with an unco-operative doctor. I am aware that in Committee it will be possible to scrutinise that journey in even greater detail. The GMC will identify doctors whose performance is seriously deficient through information sent to it: for example, through patients' complaints, information from other doctors, or cases referred following NHS service committee hearings. Overall, the GMC expects that the number of doctors subject to assessment under the new procedures will be in the order of 100 to 150, of whom 50 to 75 might be subject to remedial training or sanction.
Anyone can bring information about a doctor's performance to the GMC's attention. The doctor may be working in the NHS or private practice. The informant will not have to be personally involved in the matter. For instance, surgeons who have to rectify the mistakes of another doctor—perhaps of cosmetic surgery—would have a duty to report those matters to the GMC.
I am pleased that the GMC has made the position clear in its Blue Book entitled "Professional Conduct and Discipline: Fitness to Practice". It says:It is any doctor's duty, where the circumstances so warrant, to inform an appropriate person or authority about a colleague whose professional conduct or fitness to practise may be called into question or whose professional performance appears to be in some way deficient.That is an important message and one that is often difficult to have fully accepted and used throughout the service, but all professionals have an obligation to be alert and vigilant about their colleagues' quality of performance.
Employing authorities and trusts will be aware of poor performance from a variety of sources. It is important that the NHS complaints and disciplinary procedures, based on the Wilson review, which we have only recently announced should be carried out properly. In addition, employers should consider whether to refer the matter to the GMC. The GMC and the employer have separate and complementary roles. Some problems will be dealt with entirely by the employer; in some cases, only the GMC will be able to act, and in a minority of cases both will need to take action.
Patients or other relatives who are concerned that other people may be suffering from the same poor treatment as they experience may wish to report it to the GMC. The information given to it will have to be well founded and 677 to give it grounds for considering that the incident is not just a one-off, but an indication of a pattern of poor performance which should be investigated further.
§ Mr. Jim Cousins (Newcastle upon Tyne, Central)
Does not the Secretary of State's remark imply that a single incident can never rank as being serious enough to challenge professional performance? Her last remark seems to imply that repetition is the centre of the argument, whereas a single incident, if it were serious enough, could be serious within the terms of the Bill.
§ Mrs. Bottomley
If the incident were serious, it might be considered as part of serious professional misconduct, but we are considering here a one-off incident that is not sufficiently serious for the existing procedures, that is of a lower order, and that therefore may be part of a continuous pattern of poor performance. The aim of the proposal is precisely to fill that gap.
Anyone who has given information to the GMC will be kept informed of the action taken at various stages of the process. They will, of course, be notified of the outcome of any hearings by the committee on professional performance.
Whatever the source of information, the GMC must take the matter seriously. The first step is to consider under which procedure the case should be considered. This relates to the point made by the hon. Member for Gower (Mr. Wardell). Should the case be considered under conduct, health or professional performance? Whatever the case may be, the matter will be considered by a screener who will be a medically qualified member of the GMC. In cases of alleged poor performance, the performance screener will be empowered to investigate the background of the case, and to consider whether a prima facie case exists of serious deficiency in the doctor's professional performance. The informant may be asked to make a sworn statement about the allegation.
The screener may wish to take advice from an expert in the same speciality as the doctor under review before deciding what action needs to be taken. The screener will either invite the doctor to undergo an assessment or conclude that no action should be taken. In that case, a lay screener is also involved in deciding that no action is required.
If further information uncovered by the screener suggested that there were health reasons underlying the doctor's poor performance, the matter could be remitted to the health screener under the health procedures. Where no formal action is proposed under the GMC's fitness to practise procedures, the doctor may be invited to comment informally on the information received. Any reply would then be sent to the informant.
Where formal action is proposed, the screener will advise the doctor of the information received by the GMC and invite the doctor to undergo an assessment. If the doctor does not agree with the screener, the matter will be considered by the assessment referral committee. That committee's role is to provide an appeal forum for the doctor who does not agree with the decision of the screener that he should undergo an assessment. It ensures that contested decisions that may affect the doctor's future are not taken by one GMC member alone.
678 Once the committee has considered written submissions from the doctor or given the opportunity of a hearing, it may either direct that the doctor undergo an assessment or decide that there is no prima facie case of seriously deficient professional performance and close the matter. If the committee confirms the screener's decision, the screener will arrange for the assessment.
If I may, I shall go into a little more detail of the assessment process. It will be carried out by an assessment panel which will consist of two medical practitioners from the same specialty as the doctor and a lay person. None of these panel members will be members of the GMC. They will be drawn from lists of specialists nominated by the professional bodies, including the royal colleges and the British Medical Association. Lay members will be nominated by non-medical bodies. The procedures to be followed by the panels will be set out in rules made by the GMC, approved by the Privy Council and laid before Parliament. The panel will also be given guidance and training on how to carry out the assessment process.
As the House would expect, the GMC has already started work on some of the details involved. In 1993 it appointed Professor Lesley Southgate, a distinguished professor of general practice, to begin developing the assessment procedures in co-operation with experts from each of the specialties. The assessment programmes will underpin the new procedures in the Bill. To give the House a flavour of what it involved, I shall describe her work in a little more detail.
Professor Southgate has pilot-tested with volunteers on several occasions her system for assessing GPs. The assessment consists of a review of a doctor's records, a written test of his or her knowledge, observing the doctor in practice, discussing performance with selected third parties, a test of clinical skills and a face-to-face interview, which includes a review of one or two of the doctor's recent cases. Those are certainly rigorous procedures which the GMC is looking to extend into the various specialties. Pilots are under way, for example, for assessing the performance of anaesthetists.
In as much as the Government's policies have encouraged those trends, I make no apology. The health service exists for its patients and to provide the latest and the most modern care. However, it is right to recognise the extra pressure that this puts on doctors. Describing how the GPs in the trial had reacted to her grilling, Professor Southgate stated:they found it stressful but a great thing once done".Perhaps that is a fair assessment of many of the changes now taking place in the national health service.
At the end of the assessment process, a report will be prepared by the chairman of the assessment panel and sent to the doctor, who will be invited to take on board its recommendations. The doctor will be asked to confirm his acceptance and compliance with the recommendations. If he does not, the matter will be referred to the committee on professional performance.
If the doctor agrees to take remedial action, a period will be allowed for the necessary training or other remedial action and for it to be put into practice before a second assessment is carried out. After this initial period of remedial action, the assessment panel will assess the doctor's progress. If the doctor's level of performance has been remedied, the case will be concluded. Where there 679 has been some progress and further action might be productive, the doctor may be allowed to undertake a further period of remedial action.
If the doctor does not appear to have benefited at all from this remedial period, there may be the opportunity to ask for the voluntary removal of his name from the register. If the doctor wishes, the matter will be referred to the committee on professional performance. Alternatively, the screener will either arrange a further assessment or refer the matter to the committee on professional performance.
It is proposed that a doctor should be allowed to go through the remedial process up to three times—this relates to the point made by the hon. Member for Newcastle upon Tyne, Central (Mr. Cousins) about how long the matter can be perpetuated—but it is not proposed that the number should be prescribed in the rules. The doctor will have the right to have the matter determined by the committee on professional performance at any time following the first assessment.
The committee on professional performance is, indeed, the committee of last resort. The General Medical Council hopes that most cases will be resolved during the consensual part of the procedures. The matters will come to the committee, however, in a number of ways: first, where the screener on receiving an assessment report considers that the doctor's performance is irremediable and the doctor has not agreed to the voluntary removal of his name from the register; and, secondly, where the doctor has not co-operated right from the start or has indeed withdrawn co-operation during the process. The doctor may, for instance, have been directed to undergo an assessment by the assessment referral committee and refused to do so.
Thirdly, the matter will come before the CPP where the doctor has undergone an assessment but is not prepared to agree to the required conditions. The doctor may refer the case to the committee. If the screener cannot get the doctor to agree to the conditions, the case must be referred to the committee. The final way is following a period of remedial action and reassessment, where there has been no significant improvement in the doctor's performance.
The procedures to be followed by the committee will be set out in rules. If the doctor has not undergone an assessment, the committee may require it. If he refuses or has failed to co-operate in some other way, the committee will be able to impose sanctions. Those include suspension or attachment of conditions to registration as appropriate. Where the committee, however, finds that the doctor's professional performance has been seriously deficient, it will be able to suspend the doctor or attach conditions on registration. For example, the doctor may be required to practise under the supervision of another doctor or refrain from performing a particular clinical procedure.
Where the committee considers it necessary for the protection of the public, it may impose immediate suspension of the doctor. The Bill will ensure that the doctor has appeal rights, which are similar to those which exist under the health procedures.
§ Mr. John Gunnell (Morley and Leeds, South)
In the hearings held by the General Medical Council at the moment, which are obviously, in general, about professional misconduct, the press are normally present. I have seen nothing in the Bill to show whether the press 680 should or should not be present or whether the decision at which the committee arrives will be made public. At this stage, is the knowledge of the procedure and the result of the hearings entirely within the remit of the GMC?
§ Mrs. Bottomley
It is the intention that such hearings should be held in private—certainly for the first two years. That is subject to review and, indeed, it is also possible, with agreement, that such matters could be heard in public. Again, the committee may wish to discuss that in more detail. The proposal that for the first two years the procedures are held in private while they are under way has considerable merit.
As the hon. Member for Morley and Leeds, South (Mr. Gunnell) will know, there are always difficulties about how freely, frankly and openly some witnesses are prepared to speak in the full glare of publicity and the press. There is often a tension between wishing matters to be fully open, but knowing that witnesses are somewhat inhibited because they know that every word that they say is likely to be read in the newspapers the following day. The proposal is a considered preliminary response to the new procedures and I am sure that it will be subject to review and careful scrutiny.
If I may turn to the Bill itself, the House will be pleased to know that it is short; it has six clauses. It will give the GMC the necessary powers to make the new procedures work where a doctor is not co-operating and the powers to impose sanctions. Much of it amends the Medical Act 1983. I have placed in the Library a revision of the relevant provisions of the 1983 Act as they would appear on consolidation of the Bill in that Act. The details of the procedures to be followed by the GMC will, as I have said, be in rules.
Clause 1 deals with the powers of the committee on professional performance, which has been described as the sanctions committee. It will be empowered to impose conditions on, or suspend, a doctor's registration. It will do so where the doctor's standard of professional performance is found to have been seriously deficient and the committee considers that sanctions should be applied to protect the public.
It is not the intention that the sanctions should be punitive. They are part of improving the service to patients. Although, in the worst cases, a doctor might be suspended indefinitely, the name will not be erased—doctors will not be struck off. That is a fine, but an importance distinction to make, as the intention of the procedures is remedial. The committee can also impose sanctions if a doctor has failed to co-operate with the assessment process.
Clause 2 covers cases in which a doctor's failings may be considered to be beyond remedial action. The doctor may be asked to consider voluntary removal from the register. Again, the doctor would not be struck off, which has disciplinary overtones. The doctor might be falling behind with the latest medical techniques, which have now become the accepted techniques. The doctor might realise that it is time to call it a day and ask to be removed from the register.
We realise that unscrupulous doctors might use the provisions of voluntary removal to frustrate active consideration of their performance. To minimise the risk of the misuse of the provision, clause 2 also provides for 681 the matter to be referred back to the relevant committee for approval, should the doctor apply at a later date for his name to be reinstated on the register.
Much of the meat of the Bill is contained in the schedule, which gives the General Medical Council the power to make rules, to set up the assessment referral committee and the committee on professional performance, and to provide for the constitution and proceedings of the two committees and the assessment panels. The rules will also give the committee on professional performance powers to impose sanctions if a doctor does not co-operate, and to give the doctor a right of appeal to the High Court where such sanctions have been made.
The assessment panel will be given powers to inspect medical records and, where entry to professional premises is likely to be denied, it will be able to apply to a magistrate for a warrant. It will be an offence for a person to obstruct the work of an assessment panel.
The House will appreciate that the procedures introduced by the Bill are somewhat complex. Its aim is simple enough, however. It is a further measure designed to improve the quality of service available to patients from the national health service, and indeed from private practice, and to ensure that they continue to enjoy the highest standards of care from our doctors. It is significant that the Bill has come from the medical profession. It is a sign of how clinicians are responding to the greater expectations made of them and recognising the legitimacy of challenges against the performance of individuals.
There was a time, perhaps, when the profession would not have been so amenable to such a proposition. We can all understand the reasons. The process of scrutiny and review is not always comfortable for doctors, even for those who have nothing to fear from its results. It is, however, an essential part of a service in which we are determined to put the needs of patients first and to maintain their confidence in the service that they receive.
What is important is that the procedures are effective, constructive and fair to staff, as well as to patients. The measures in the Bill fit well with those objectives. They are part of our commitment to a higher-quality health service of which we can all be proud.
The introduction of the Bill to Parliament gives a clear signal to doctors whose performance is not up to standard that the remedy is in their hands—it is a case of physician heal thyself. I commend the Bill to the House.
§ Mr. Nicholas Brown (Newcastle upon Tyne, East)
I congratulate the Secretary of State on coming to the Dispatch box voluntarily—I was beginning to think that she did not like coming here—and so soon after her interview with Mr. Dimbleby.
You will recall, Madam Deputy Speaker, that just before the recess, the House—not just the Opposition, but members of the Government—was demanding time to debate the crisis facing the hospital service, especially in London. I should have thought that, now that the Conservative rebels have come back to the fold, it would be safe for the Government to find time for such a debate, 682 but they tell us that there are pressures on parliamentary time. They have found a whole day to debate this Bill, however.
The principles that underpin the Bill are not controversial between the parties. The parliamentary Labour party supports the Bill, as do the minority parties, I understand. There is a consensus behind the principles that underpin it. My right hon. Friend the Member for Derby, South (Mrs. Beckett) promised it a fair wind through the House in the debate on the Queen's Speech. Indeed, in 1993, my hon. Friends the Members for Newham, South (Mr. Spearing) and for Strathkelvin and Bearsden (Mr. Galbraith), among others, tried to introduce a Bill designed to achieve the same objectives, so the Secretary of State is perhaps making too much of the courage and determination that the Government are showing by bringing this legislation before us.
The Government Whips seemed nervous about exposing the Secretary of State to debate in the House. One of the first—
§ Mrs. Virginia Bottomley
I have no idea what the hon. Gentleman is talking about. On the first day back after the recess, we had a very successful Health Question Time. All the Government spokesmen wiped the floor with the Opposition spokesmen, who were described in the press as hiding like frightened rabbits, devoid of policy. They were simply exposed for their empty cupboard by all the journalists.
§ Mrs. Bottomley
The Guardian, The Economist, the Observer and the Health Service Journal. I have never known such a slaughter of the Opposition for their lack of policy on the health front—timid, frightened and devoid of policy, Madam Deputy Speaker. I do not think that I need to say more.
§ Madam Deputy Speaker (Dame Janet Fookes)
Certainly not. That was quite a long intervention. Before we go any further, perhaps we could turn to the principles of the Bill, which is the business before us.
§ Mr. Brown
I was about to debate the principles of the Bill when I generously, in a bipartisan spirit, gave way to the Secretary of State and allowed her to mislead the House. The truth of the matter is that, when I asked the Minister of State for the estimated cost for local pay bargaining at Health Question Time, he spoke at some length in response, but never gave the House the estimates. No doubt he would describe that as professionalism on his part, but I think that the House understood what he was not telling us.
Let me return to the point that I was going to make before I so generously—but perhaps wrongly in view of your strictures, Madam Deputy Speaker—gave way. One of the first duties that I and my right hon. Friend the Member for Derby, South had when we were appointed to our new Front-Bench responsibilities was to meet representatives from the General Medical Council. They urged this Bill on the parliamentary Opposition and said that the Government had told them two things—that they could have the Bill, but that there was not enough parliamentary time for it and so they had to get the agreement of the Opposition to ensure that it received a fair wind through the House.
683 How can anyone truthfully say that, in this Parliament, there is not the parliamentary time for a Bill of this nature, Madam Deputy Speaker? We have enough parliamentary time in this Parliament to revise the entire criminal code. One could not possibly truthfully say that there is a lack of parliamentary time. No doubt the reason why we have a full day's debate on this relatively non-controversial matter is that the Government want to avoid debating more controversial matters. The Bill and its underpinning principles are supported by the parliamentary Labour party.
We are being invited to discuss what is effectively professional self-regulation. In the light of some of the decisions that we had to make last week, it is ironic that we are discussing another body's methods of self-regulation. In view of what many people think about the ethics of our profession, it is ironic that we are discussing the ethics of a profession that is held in higher esteem by the general public than ours.
The core of the Bill is self-regulation. Only the General Medical Council has a universal power to restrict a doctor's practice, or bar him or her from practice altogether. No national health authority or trust could prevent a doctor from taking up employment elsewhere, either in the health service or privately.
The General Medical Council is a statutory body. It is independent of Government and receives no public funding. It is financed by a levy on registered doctors and, interestingly, is answerable to the Privy Council, not to the Secretary of State. As the Secretary of State told us, the GMC currently has two sets of disciplinary procedures. The first deals with conduct—doctors whose behaviour suggests that they may be unfit to practise. It can deal only with single acts of serious professional misconduct, which was the point made in the intervention by my hon. Friend the Member for Newcastle, upon Tyne, Central (Mr. Cousins). The second set of disciplinary procedures deals with doctors whose health may affect their fitness to practise.
To date, unless it has been found that a doctor's fitness to practise has been seriously impaired by ill-health, or unless a doctor has been found guilty of serious professional misconduct or convicted of a criminal offence, the GMC has no power to act against an individual practitioner. That is a substantial cause of public disquiet. The profession's failure to regulate itself because it does not have the powers to do so is unfair on complainants and, of course, on those charged with the supervision of the profession.
In 1993–94, the General Medical Council received 1,626 complaints. Of those, only 195 made it beyond the preliminary screeners and only 83 cases were referred to the professional conduct committee for investigation. Clearly, that is unsatisfactory and it is right that we should consider remedial legislation.
The reason for not proceeding with complaints is often that the General Medical Council's powers are too restricted. That is the issue with which the Bill seeks to deal. The Bill will add a third set of procedures, which will provide powers to discipline doctors whose general performance over a period of time is revealed as seriously flawed. The Bill will allow the GMC to exercise discipline
in those situations where a doctor's pattern of professional performance appears to be 'seriously deficient'—in other words, so blatantly poor that patents are potentially at risk".684 Before dealing with some of the issues of detail, which we shall explore in Committee if we cannot get a response from the Minister tonight, may I raise a procedural point? The Order Paper contains a proposition to refer the Bill to a Special Standing Committee and I understand that the question can be put forthwith at the end of the debate. The idea is that, instead of the normal adversarial way of proceeding in Committee, where one side puts its inquiries and it is hoped that the Minister or Secretary of State, if she is to serve on the Committee—it would be nice to see her do so—answers the questions. The alternative procedure is to sit in a forum where specialist witnesses—presumably from the General Medical Council, the British Medical Association and patient groups—can give their informed opinions to the Committee, which, having heard their advice, can then make decisions on the issues.
In principle, that procedure has much to recommend it. When I was a member of the Labour party's Treasury team, I argued that the Finance Bill could be better dealt with if some of the specialist issues were taken in such a forum rather than in Standing Committee. I do not know the Government's attitude to the procedure, but if they decide to adopt it for a Bill that is, in principle, not contentious, in a spirit of consensus and co-operation the Opposition will co-operate fully with it. I hope that, in so saying, I put a persuasive argument to the Minister of State who, I suspect, will take the Bill through its Committee stage.
We shall want to explore issues such as the Bill's structure. It has been argued that it might have been better to adopt a structure that was, essentially, put forward in the Bill introduced by my hon. Friends in 1993, which would have modified the rules for serious professional misconduct in such a way that serious under-performance would be deemed to be serious professional misconduct, rather than to introduce a third new procedure. Although there are arguments on both sides, I prefer to explore the rights and wrongs of the two different ways of proceeding with professionals than to argue it out with Ministers in an adversarial setting in Committee. The Minister will, no doubt, argue that what has been done in the Bill is right and could not possibly be done in any other way. I am not sure that that is true and I should like to listen to professional specialist opinion.
I should also like to explore with the Minister whether it is realistic to think that a doctor whose performance has been so persistently bad that he is putting patients at risk could ever be reformed by retraining. The Bill puts a great deal of emphasis on training and retraining, but there will come a time when no amount of retraining will achieve the required result and, sooner or later, someone will have to say that. I want assurance that the procedures will do so.
The assessment referral panel—the body that can require doctors to undergo assessment—will meet in private. The Secretary of State said that there were good reasons for that, and I understand them. However, it is an important principle that justice, as well as being done, must be seen to be done. Complainants will have no right to ask for a public hearing and I should like to test the arguments on whether that should be so. Obviously, I understand what the Secretary of State said, but countervailing arguments deserve to be explored.
685 The Secretary of State rightly paid tribute to the three Members of the House who serve on the GMC as lay members. I suspect that it is not widely known that serving in that capacity involves all three of them in a lot of hard work. Their contribution to public service should be commended and I endorse what the Secretary of State said.
The Bill will require an increasing lay involvement in the General Medical Council's affairs. The Patients Association, among other organisations, has properly expressed concerns about the training of lay members of the GMC assessment panels. It is important that lay members are properly trained and have experience in handling patients' complaints. The history of the involvement of the laity under the Conservative party's management of the national health service has not been untainted or unencumbered with criticism. I hope that we can achieve a laity for this function which is absolutely beyond criticism or the suggestion of being tainted with party-political partisanship. That could not be said about the laity in the rest of the national health service.
The Committee will want to explore with the Minister its concerns about the tremendous power of the initial GMC screener to sideline serious complaints, or at least to assess their importance. The screener will have an important role in either accelerating complaints through the complaints procedure or delaying consideration of them. Justice delayed is justice denied, which is precisely the issue that we are trying to remedy. So some attention to the role of the screener acting on behalf of the GMC is important.
The Secretary of State said that the Bill allows voluntary removal from the register. I wonder whether that will allow errant doctors to remove themselves from the register rather than face up to the charges brought against them. If they behave in such a way, will they then be able to request reinstatement later? I should like to explore further with the Minister precisely how voluntary removal will interact with the other proposed procedures.
The Patients Association is not alone in suggesting that a system of regular compulsory reaccreditation should be introduced as an effective means of weeding out incompetent doctors. I shall not give a view on that proposition now, but that idea is worth exploring, alongside the other provisions in the Bill. Whichever arrangements we adopt for the Committee, I hope that we will be able to do just that.
The BMA has expressed concern that, under the new system, general practitioners will have to pay for their own retraining. The Opposition want to explore the cost implications of that with the Minister. I believe that a possible inequity could be created if GPs have to pay for their own retraining while doctors who are employed by hospital trusts, or junior doctors employed by the regional department of the Department of Health—if I understand the Health Authorities Bill aright—will have their retraining paid for them.
§ Mr. Gareth Wardell
I am concerned about equivalence. To what extent does my hon. Friend agree or disagree that doctors are being considered differently in terms of their performance in comparison with the way in which other professional bodies consider the performance of their members? Does my hon. Friend agree that the Bill could be judged overgenerous and to 686 be bending over backwards to the medical profession, given the extent to which the GMC may go to protect doctors from removal from the register? That is at odds with the way in which the performance of teachers, lawyers, accountants and other professionals is dealt with. Is my hon. Friend happy that a even hand has been dealt across the professions?
§ Mr. Brown
My hon. Friend, who speaks from experience as he serves on the GMC, makes an important point. I am absolutely certain that the principle underpinning the Bill is right. We are introducing a new procedure, so only time will tell how it works in practice. I would not want to do the Bill an injustice before giving the provisions contained in it a chance to operate. I accept, however, that the Bill creates an anomaly, given the way in which one professional group is treated as opposed to another.
§ The Minister for Health (Mr. Gerald Malone)
In response to the hon. Member for Gower (Mr. Wardell), as I understand it from the GMC, it is not the purpose of the legislation to seek to remove doctors from the register. That is the sanction of final resort. I am sure that the hon. Gentleman is aware that the purpose of the Bill is to provide proper opportunities for retraining so that matters can be put right and people can be put back on the proper professional course. I am not certain whether one can make an analogy across the professions. I know from my own profession—at least when I practised it 10 years ago—that there was a continuing system of post-qualifying education. That example may serve as an analogy, but it need not be the case that the professions are on all fours with each other.
§ Mr. Brown
The Minister seems to have taken the point made by my hon. Friend the Member for Gower (Mr. Wardell) and put it back to him. I shall say something later about the anomalies that the Bill is creating between different professions inside the health service. It should be possible to obtain a commitment in principle from the Government at least about the professions inside the NHS.
§ Mr. Gunnell
The argument put by my hon. Friend the Member for Gower (Mr. Wardell), who serves on the GMC, is strengthened by our call for a general social services council and a general teaching council, which would run on the same lines as the GMC. We believe that the GMC functions well and that it would be to the benefit of other professions and the public if similar arrangements applied to teaching and social work.
§ Mr. Brown
My hon. Friend is undoubtedly right. The Bill is underpinned by the concept of professional self-regulation. The Bill places emphasis on retraining rather than immediate disciplinary sanctions. The Secretary of State and I have expressed some concern, however, about whether the emphasis on retraining, further retraining and yet more retraining might not be overgenerous to the medical profession. It would be better to wait to see how the Bill works in practice rather than fail to give it the fair wind it was promised in the Queen's Speech.
The Minister spoke about the internal arrangements governing his own profession. As I understand it, an allowance is paid for the postgraduate education of GPs. They receive £2,000 a year for undertaking 30 hours or 687 more of approved study a year. Some concern has been expressed about how that system operates in practice, and whether there are any sanctions against doctors who do not undertake that 30 hours of study. I should like to explore that in Committee, because I do not expect the Minister to offer an opinion on that on Second Reading.
The United Kingdom Central Council for Nursing, Midwifery and Health Visiting investigates cases of misconduct. The GMC, however, only investigates cases of serious professional misconduct. The Bill will allow it to consider cases of seriously poor performance. The nurses' professional body will, therefore, still have a wider remit than the GMC. As my hon. Friend the Member for Gower has said, the Bill creates an anomaly between the powers of the GMC and the powers of other health care professional registration bodies.
The GMC currently investigates cases according to the key test of serious professional misconduct—to be amended by the Bill—as do the General Optical Council and the General Dental Council. The nurses council investigates cases of misconduct, so it obviously adopts a wider criterion than that adopted by the GMC. The Council for Professions Supplementary to Medicine investigates cases according to its test of infamous conduct in a professional respect. I suspect that it is difficult to prove that and that that test is overdue for review. The osteopathic and chiropractic organisations investigate cases of unacceptable professional conduct. I understand that the Royal Pharmaceutical Society investigates cases of misconduct, but I may be wrong about that. I am, however, fairly certain about the other bodies that I have mentioned.
The practice adopted by the respective councils is anomalous, so when the Minister replies to the debate perhaps he can tell us whether it is the Government's intention to introduce legislation so that the procedures governing other health care professional registration bodies are brought into line with those now proposed for the GMC. It seems anomalous that one professional body should decide to launch an investigation according to one test, while other professional bodies that deal with related health care functions act according to a more serious test. I am sure that the Minister has given that matter extensive consideration, or at least someone has, and that the hon. Gentleman will have a response ready for the end of the debate.
Perhaps it is right to give the last word to the chairman of the BMA; after all, he represents health care professionals. In September 1993 he said:We need to retain the full confidence and trust of our patients. But we must remember that the Government can play a significant part in all this by reducing stress, raising morale, instilling realistic patient expectations, listening to the profession's concerns about the reforms and ensuring a consensus approach to the problems facing us.I endorse every word of that.
It is ironic that on a day when the BMA, representing junior doctors, wins a case in the courts concerning the stress connected with junior doctors' hours of work, we are considering legislation on professional standards. It does not sit easily for the House to expect doctors, especially junior doctors, to work very long hours and still, at the end of those long hours, perform to the highest professional standards. The fact that on the whole they do so is a great credit to the profession.
688 The ethical base of the national health service is its foundation and its enduring strength. It is its ethical base that has enabled it at least to come through, if not wholly to survive, the Government's health reform agenda. I support the Bill, but perhaps not quite in the same spirit as the Secretary of State.
§ Dame Jill Knight (Birmingham, Edgbaston)
I have read the Bill, and the papers pertaining to it, with great care, and I have several questions in my mind about the effects of the legislation. We all rely on the excellent service that we receive from the research department of the Library, and I turned with great interest to the research paper on the Bill that that Department produced.
On page 4 of the paper I saw encapsulated the reason for the Bill:
To date, unless it has been found that a doctor's fitness to practise has been seriously impaired by ill health, or unless a doctor has been found guilty of serious professional misconduct or convicted of a criminal offence, then the General Medical Council has no power to act against an individual practitioner. In particular, the GMC is not at present able to act either where a doctor's professional competence in general is shown to be inadequate, but no single act has been committed which could constitute 'serious professional misconduct', or where a single act has indeed been committed, but is not judged to constitute 'serious professional misconduct"'."So," thought I, "that is what the Bill is about, is it? I see. That is very interesting." I agreed that there was clearly a need for the Bill. However, when I turned to the Bill itself, twice in the first two paragraphs of the explanatory and financial memorandum I saw the phrase "seriously deficient". So the measure refers not to a slight problem but to practice that is seriously deficient.
As every Member of the House with any experience knows, the nub of a Bill is always in clause 1—and in the first few lines of clause 1 the term "seriously deficient" appears again. So I come to my first question: how is it to be decided whether a performance is "seriously deficient", and is not such practice covered to some extent by the GMC already? If so, does the Bill not seek to do something that will not happen?
The hon. Member for Newham, South (Mr. Spearing) deserves great credit for consistency, in that he has worried about the problem for a long time and has introduced no fewer than six private Members' Bills on the subject. The hon. Gentleman has highlighted one instance that made him anxious—the case of a child in his constituency who had died of meningitis after his GP could not be bothered to examine him. Apparently the GMC found the facts to be proven but, amazingly to me, it felt that the charges did not amount to serious professional misconduct. If that is not serious professional misconduct, it is difficult to think what would be.
There is clearly a case to be made that we should go wider than the present powers of the GMC. No doubt we shall hear later the views of my hon. Friend the Member for Chislehurst (Mr. Sims) and of the hon. Member for Gower (Mr. Wardell); they are both members of that body. But there is certainly a case that we should go further than the GMC can go at present.
However, I am worried because the Bill confines its attention to "seriously deficient" performance, and we still have to ask whether it is considered seriously deficient if 689 a doctor feels too busy and cannot be bothered to examine a patient, who subsequently dies. My first question is: on what ground do we decide what is seriously deficient?
Would the doctor's behaviour have to result in death? Bearing in mind the case that I have described, perhaps that criterion would not be enough. Or, as some of the community health councils would have it, are there many lesser evils being perpetrated by doctors that should be dealt with at once? Not long ago, a questionnaire was sent to patients of a practice asking whether the magazines in the waiting room were up to date or whether they were dog-eared and had been used too much, and also whether the car park was sufficient for all the patients. I would not call failings in that respect seriously deficient, and I am sure that they are not what the Bill is intended to address. One sometimes needs to watch what the community health councils get up to with the money that they are allocated.
I wonder whether language inability would count as seriously deficient. A great many doctors have come to us from other countries, and there is no doubt that they serve the health service well. But patients often need to describe their condition using nuances of language that a doctor insufficiently competent in the English language cannot comprehend. Will that come under the same heading?
Page 7 of the Library research document tells us that the procedureswill not be confrontational like the conduct procedures, but will rather resemble the health procedures, in which only cases where a doctor has refused help actually go before the formal Committee.I should like to know what that means, and how cases will come before the committee.
We have heard a lot about retraining, and I understand that to mean retraining for doctors who are providing a seriously deficient service. But I am not sure whether retraining will help in the cases that some of us have in mind. Suppose, for instance, that a doctor were, as we describe it in the House, "tired and emotional". Suppose that he did not treat his patient properly because of his weariness and his emotional state—helped, perhaps, by gazing upon the wine when it was a little too red. How could one retrain someone in a case such as that?
§ Mr. Sam Galbraith (Strathkelvin and Bearsden)
It might help the hon. Lady if I said that perhaps such a case would be referred to the health committee, not the professional competence committee.
§ Dame Jill Knight
I am grateful to the hon. Gentleman, who knows, as a medical man, some of the problems that confront us here. However, I am trying to find out precisely what the Bill will do, precisely which cases it will affect and the precise way in which those cases will be handled.
When I first read the Bill, I wondered—and I hope that I may be right about this—whether, if the object of the Bill was achieved, it would avoid, or at least lessen, the ruinous and expensive business of litigation involving doctors. That is growing, without any doubt, and the implications are extremely serious. One has only to consider the United States to be aware of how very damaging it is for members of the medical profession. It is damaging because of the huge costs of medical 690 insurance. I understand from friends of mine in the medical profession that that is now beginning in earnest in Britain. Let no one here suppose that I am over-emphasising that.
I am assured that American doctors must set aside an enormous sum in insurance payments to indemnify themselves, and things are already moving in that direction in Britain. Slick lawyers in America actually follow ambulances, or comb the sensational press for horror stories of patients, who may perhaps be used to start litigation.
In addition to cost, there is an extra burden of worry for the doctor when the threat of litigation hangs over him. Does the call in the middle of the night really involve a serious condition? Mrs. Jones has phoned for no real reason on numerous occasions. Will she sue me if I do not get up, get dressed and go and see her now? How am I to know how bad her condition is?
It is in the interests of good doctors, who make up the overwhelming majority of the profession, that machinery should be in place whereby the tiny minority of bad doctors may be brought to book for wider reasons than those that are available at present. After all, doctors have an immense power over people's lives, and we should not forget that. We should recognise that what they say to their patients and the way in which they treat their patients can have a wide effect on patients' lives.
Subsection (9) of clause 1 states:While a person's registration in the register is suspended by virtue of this section he shall be treated as not being registered in the register notwithstanding that his name still appears in it.I read that two or three times, with increasing puzzlement. The name will not be removed from the register, but one will have to pretend that it is not there. How will people know that it is invisible when it is visible? That is a trick that I have not yet managed to solve.
I realise that it might be jolly expensive to remove names and replace them after a time, but surely we could have little stickers or something. Let us suppose that a doctor has been removed from the register technically, but not actually, and that he goes away and applies for a job as a locum, hundreds of miles away. When the doctors who are considering employing him consult the register and find that his name appears on it, how will they know that he is not really there, if he does not tell them?
I do not understand how that will work.
§ Mr. Gareth Wardell
I believe that the hon. Lady and I share anxieties regarding clause 1(9), because it is strange that it says:While a person's registration in the register is suspended by virtue of this section he shall be treated as not being registered in the register notwithstanding that his name still appears in it.As the hon. Lady rightly says, unless some sign is given that will be understood by anyone who has access to the register, it may be difficult to know the status of that doctor.
§ Mr. Galbraith
I understand that, when one seeks a job, one must oneself provide evidence of one's registration. It is not checked up on. That would not be 691 provided to one by the General Medical Council if one was not registered, even though one's name was on the register.
§ Dame Jill Knight
That may be the case. Nevertheless, I do not quite understand how it would work in the case of a doctor who wanted temporary employment while perhaps he was debarred from practice in his own part of the country. I am still by no means sure that that subsection quite makes sense. I want to know a little more about the way in which it will work.
I also want to know whether the patient would make the complaint. If not, who would it be? That does not appear to be mentioned. If the doctor were on a practice list, would he be barred from practising or would he receive retraining only? I am not sure about that. How long would he or she have to wait for a verdict?
I confess, I would much prefer that something were done in the Bill to speed up what I consider to be a terrible way of conducting a specific part of the disciplinary procedure, when a surgeon or doctor is accused of a serious offence. No fewer than three such cases have been brought to my knowledge, one by a constituent. He was an anaesthetist who was accused of misconduct during an operation, and he waited for three solid years for the verdict to be reached. All that time, he was paid his full salary and stayed at home, doing absolutely nothing.
I am worried about that. I have mentioned the subject in the House previously, and I regard it as a matter of immense concern, not least because of the money wasted to the health service by that type of thing.
It is also devastating for the accused person, such as the constituent whom I mentioned. Granted, he received his full pay—which he did not want to take because he said, "I am not earning this." However, the matter worried his wife so much that she subsequently became ill and died. In the end, he was found not guilty. How in heaven's name can we deny quick justice and a quick verdict in cases such as that?
I know that it must be a difficult matter for my right hon. Friend the Secretary of State, but because of the waste of money as well as the waste of a man's work and the effect on that man and his family, I should dearly have liked to read in the Bill about a speed-up of the means by which a verdict could be reached in cases of that nature.
The aim of the Bill is excellent. I understand exactly why it came into being. I am sure that it is meant to be, and will be when it has been through Committee, one more improving step for the health service.
Since I have been in the House—in fairly recent years—the patients charter has come into force. In my region, there has been an incredible reduction in waiting lists, which has served my constituents and the people of my area brilliantly. The health service that we see around us has never been so good and has never treated so many people so well, with so many complicated operations, treatments and drugs. We should be thankful for that.
However, I know that my right hon. Friend's constant anxiety is to improve, improve, improve, all the time. That is the intention behind the Bill. I know that my right hon. Friend will not mind that I asked her questions which I feel must be answered if the Bill is to achieve its aim.
§ Mr. Jim Cousins (Newcastle upon Tyne, Central)
It was that wise old Scot, Adam Smith, who said that when two or three were gathered together a conspiracy was waiting to happen. I take a more pessimistic view of the Bill and of the idea of self-regulation than my hon. Friend the Member for Newcastle upon Tyne, East (Mr. Brown). Self-regulation is nothing more than institutionalised conspiracy. That is not a specific point in relation to doctors, but a general point that we have to wrestle with in the Bill and elsewhere. Any system of rules must be capable of clear and robust implementation. The terms used to support the system of rules must be capable of being clearly understood, both by those who use the rules for their benefit and by those who apply the rules.
Rules cannot be adequately measured by the kilo or the cubic metre. The Bill lays down complex procedures. It provides a tangled framework which will create yet more conventions and practices, but it does not give us the clear definitions that the hon. Member for Birmingham, Edgbaston (Dame J. Knight) was rightly trying to establish. What is "serious"? The Bill takes us no further forward: it simply repeats the entirely inadequate terms of the existing structure of rules. It compounds the uncertainty by this time attaching the word "serious", not to misconduct, but to deficient performance. That will confuse the issue still further.
There is no focus behind the system of rules because there is no clarity on the definition of "serious". What is a serious failure of professional performance? The Bill simply does not tell us. It uses the phrase and introduces the concept into our procedures, but it provides no clarity about what it means. In that respect, it is a classic product of self-regulation. Self-regulation will always seek to multiply and mystify. When we add to the idea of serious professional misconduct the concept of a seriously deficient performance, the result is precisely that multiplication and mystification.
The Bill does not offer openness: it offers the promise of openness, which is entirely different. The seven potential stages of inquiry, assessment and counselling before the professional performance committee even meets provide further grounds for multiplication, mystification and uncertainty for everyone involved. That provides the maximum opportunity for old-boy networks—or, indeed, old-girl networks—to come into force.
Lest anyone should think that I am being unduly pessimistic, I shall quote at length—because it is powerful stuff—an article in the British Medical Journal which was written by the chief executive of the Northern and Yorkshire regional health authority. Professor Liam Donaldson, who is a distinguished doctor—
§ Mr. Malone
Before the hon. Gentleman moves on to the article, I cannot let pass without comment the assertion that phrases such as "serious deficiency" show that there is a conspiracy. Which tests in any legislation governing the law of England, Scotland or Wales are not capable of a number of interpretations? The hon. Gentleman suggests that such standards are unusual, but I suggest that they are not. There is nothing unusual in including such a test, which has to be subject to interpretation, in a Bill of this kind.
§ Mr. Cousins
The Minister makes a proper and fair point. To guide us as to what constitutes serious 693 professional misconduct under the existing disciplinary procedures, the General Medical Council's blue book advances several different tests. Some of them, such as not advertising doctors' services, are happily practical. That is the sort of wonderfully practical and specific measure that one always finds in such cases. The 39 articles of the Church of England contain the marvellous phrase, "Cursed be he who moves his neighbour's landmark." Among the greatest mystifications, practical matters can intervene. But the main test in the blue book is as follows:Neglect or disregard by doctors of their professional responsibilities to patients for their care and treatment".I invite the Minister to consider how that can be clearly distinguished as a test from any definition which could be given of seriously deficient professional performance. There is a problem.
Let us return to the thoughts of Professor Donaldson. I shall quote from his article extensively because it is so illuminating. One section of the article is called, "Closing Ranks". It states:Among managers I found general resentment arising from the perception that doctors are so heavily protected and that they seem to be privileged compared with other groups of staff…doctors' colleagues were often willing to report concerns confidentially and informallybutthey were extremely reluctant to go on the record. Some considered that this would amount to disloyaltyand others feared legal action. He continues:The most difficult and time consuming cases to resolve were those in which a doctor's attitude and behaviour were disruptive or highly unreasonable. So serious did this become in some of the cases I describe that clinical departments were almost brought to a standstill. The resulting poor communication, the absence of teamwork, the atmosphere of hostility, and the poor morale could not, in my view, have been other than detrimental to patient care.Those are the words of a regional chief executive, who has used the procedures available to him and been entirely unable to resolve those problems.
Professor Donaldson continues:Judgments about poor attitude and unreasonable behaviour are difficult to convert into evidence which could sustain an action for professional misconduct or incompetence.He continues in a way that is relevant to the procedures advanced in the Bill. He states:In several cases the problems remained and were little improved by the process of investigation and counselling.That is the authoritative voice of a man who has sought to examine many cases in which precisely the issues to be covered by the Bill would have been involved.
Professor Donaldson concludes:My experience of dealing with problem doctors"—that is the regional chief executive's phrase, not mine—over many years leads me to reflect that it is difficult, distasteful, time consuming, and acrimonious work. For these reasons the temptation to avert one's gaze from these problems is at times very great. Add to this the nature of the present NHS disciplinary procedures and I have no doubt that many employers do look away when they should not.He goes on to throw some doubt on whether the terms of the Bill will be adequate to deal with the problems that he recognises. His summary is that the procedures within the NHS are inadequate to deal with serious professional problems of that kind.
694 I do not want to take up the time of the House unduly, but in order to throw some light on the matter and to see, not how the rules can be laid down, but how they can be policed, I wish to share with the House one of my own experiences. I tried to discover whether a particular surgical procedure used in relation to an unpleasant sort of cancer affecting women could be carried out without the benefit of histological confirmation by biopsy. The treatment involves radical surgery and its effects are mutilating.
In my attempts to investigate the matter, it took me six months to extract a letter from the Royal College of Obstetricians and Gynaecologists. The letter states:All clearly state that"—the particular sort of cancer which I do not want to name—should be confirmed by biopsy prior to surgical treatment. Whilst the College Council have not discussed this topic, on a personal basis I would not do"—the procedure—without histological confirmation of the cancer.However, such treatment could possibly be given because the royal college has no policing mechanisms in place.
I put the same point to the Royal College of Surgeons. Sir Norman Browse, the president of the Royal College of Surgeons, replied:The view of this College and of myself personally is that no treatment should be offered a patient—especially any form of mutilating surgery—without full knowledge of the diagnosis. This implies that histological diagnosis should be obtained in all cases, whenever possible, before proceeding to surgery. I do not think there are any surgeons in the UK who would perform"—the procedure is then named—without histological confirmation of the diagnosis.Again, there is no acceptance of responsibility for policing.
I then contacted the General Medical Council to discover whether, within the terms of its disciplinary procedures, it is responsible for policing. It replied that it did not fallto the GMC to advise doctors on matters of clinical practice in specific situations. This is a function of the Royal Colleges".But the royal colleges themselves say that they are not prepared to exercise that policing function.
It is a grim and sorry state of affairs when we cannot establish whether such radical, potentially mutilating surgery can be carried out on women only when confirmed by biopsy or achieve a situation in which such a procedure can be established. That must rank—potentially, if it were proved—as a matter of serious concern.
Indeed, the matter raises serious issues of patients' rights in terms of informed consent because the NHS management executive's rules, which I wholly support and endorse, indicate that patients should have such rights. Unfortunately, the responsibility for informing patients of the procedures to be carried out on them lies with the doctors and surgeons themselves. We are going around in circles because there is no procedure in the NHS which can fulfil that requirement.
I understand that a case involving precisely that issue has been laid before the GMC, and there it has remained for many months. I accept that that is not the Minister's responsibility, but it is an important test of the concepts of serious misconduct and serious deficiencies in 695 professional performance. If we are to discover what "serious" really means, issues such as the one that I have raised should themselves be taken seriously.
I hope that the Bill will advance a new channel for clarifying those issues and I look forward to the proceedings of the Committee.
§ Mr. Malone
Before the hon. Gentleman finishes, I should make it clear that the GMC has made it public that it will look at the definition of "serious" and will set that matter out in clearer guidance.
The hon. Gentleman is making a bit much of the suggestion that we are engaged in some sort of conspiracy. When three are gathered together, it might be a conspiracy. Is the hon. Gentleman suggesting that the GMC is some sort of conspiracy? When 102 are gathered together and 54 of them are doctors appointed by the royal college and 13 are lay people nominated by the Privy Council, I suggest that that would be quite a conspiracy. I do not think that the hon. Gentleman's theory holds.
§ Mr. Cousins
I am grateful to the Minister, but I remind him of the news bulletins this morning. Adam Smith was probably rather cynical and pessimistic. Two or three might be thought to be a pessimistic view of a conspiracy, but seven or nine is clearly sufficient.
These are matters which cannot be overlooked. If the Minister is right that the bedrock concept behind the existing procedures and the new ones advanced in the Bill is the concept of "serious", a definition should be available to the House now and should form and guide part of the discussions on the Bill itself. The same request has been made by the hon. Member for Edgbaston and it goes to the heart of the matter.
I do not say that hon. Members are involved in a conspiracy, although presumably in other parts of our lives we can be, but unless the concept of "serious" is clarified for the Bill and for the existing concept of serious professional misconduct, we are no further forward in establishing the clarity, robustness and openness necessary to enable people to be clear about their rights, responsibilities and duties and for those rights, responsibilities and duties to be properly policed and enforced.
§ Mr. Roger Sims (Chislehurst)
I listened with interest to the hon. Member for Newcastle upon Tyne, Central (Mr. Cousins) who raised a number of points with which I have some sympathy. Indeed, in the past year, I have had some correspondence and discussions on minimal invasive surgery and the relationship between the General Medical Council and the royal colleges, but I am not sure how far those issues impinge on this relatively narrow Bill. No doubt we will have the opportunity to explore them on another occasion.
Before I go any further, I should declare an interest as a member of the General Medical Council. I thank my right hon. Friend the Secretary of State for her kind remarks earlier in the debate, but I must also declare an interest in the conventional House of Commons sense in that, as is recorded in the Register of Members' Interests, I receive an honorarium from the GMC in recognition of my work as a lay screener, to which I shall refer later.
I suspect that most of our constituents are pretty hazy as to exactly what the GMC is, what it does and what the difference is between the GMC and the British Medical 696 Association. As recently as last Thursday in the privileges debate, a distinguished and senior hon. Member, while floating the idea of professional self-regulation among Members of Parliament, twice referred to the BMA and its control over doctors.
Of course, the BMA is a trade union of professional people, which doctors are free to join or not as they wish. It is not comparable with the GMC, which was, as we have heard, set up by statute. If I may just correct the figures that my hon. Friend the Minister for Health inadvertently gave a few moments ago, I think that I am correct in saying that, of its 102 members, 54 are elected by their fellow doctors, 35 are appointed by the royal colleges and universities and there are 13 nominated lay members.
As we have heard, there are proposals in the pipeline to increase the lay membership. Those lay members include the hon. and learned Member for Montgomery (Mr. Carlile), who was appointed with me to the GMC in 1989. I know that he would have wished to be here today if other commitments had not precluded that. At that time, no Labour Member was appointed, but we were pleased to be joined last autumn by the hon. Member for Gower (Mr. Wardell) who has already intervened in our debate.
The key to understanding the role of the GMC is that the person who in other organisations might be described as general secretary or chief executive bears the title of registrar, for the very good reason that he is responsible for the register. It is he who keeps it, and no doctor can practise unless his name appears on that register.
The General Medical Council lays down the curriculum for medical training and monitors the work of medical schools. It satisfies itself as to the quality of medical education and it accepts on its register only men and women with the appropriate qualifications. It also has other duties. It recognises—or refuses to recognise—medical training in some places overseas and decides whether doctors trained overseas can practise in Britain with or without conditions. Those are matters outside the Bill, but I can assure my hon. Friend the Member for Birmingham, Edgbaston (Dame J. Knight) that a test known as the PLAB—Professional and Linguistic Assessment Board—test would normally ensure that doctors from overseas have a reasonable command of the English language.
The GMC not only decides the established standards that doctors must reach before practising but is responsible for maintaining those standards. It has to deal with doctors who are brought to the council's attention because it appears that they may have fallen below the standards required.
Cases normally reach the GMC through three routes. First, if a doctor is convicted before the courts, it is virtually automatic that the GMC will be notified, regardless of whether the charge is a fairly simple one of being drunk and disorderly, whether it is shoplifting or a murder. The second route is through the findings of local medical services committees. A doctor who is found not to have kept to the terms of his contract will be reported to the GMC.
It is important to understand the distinction between the relationship between a doctor and his local employing hospital or health authority and the relationship between a doctor and the General Medical Council. A doctor may have been found to have broken the terms of his contract and he will have been dealt with by a local medical 697 services committee. Ultimately, when the decision has been confirmed by the Secretary of State, that doctor may suffer a withholding of his salary—in effect, a fine—but the circumstances in which he has broken his contract may or may not be relevant to his registration with the General Medical Council.
§ Dame Jill Knight
I am most grateful to my hon. Friend, because we have a unique opportunity to acquire a great deal of information that is not always easily available to us. My hon. Friend referred to language. He may not be aware that there are quite a lot of complaints about difficulties with language. From what I have just heard, if a patient feels that a doctor has not understood him correctly, that patient cannot complain to the GMC because it has already been decided that the doctor can speak perfectly adequate English.
§ Mr. Sims
The patient could go to the local family health services authority and say he or she is not happy with the doctor and wishes to change to a doctor with whom he or she would feel more comfortable. That would be the solution in that particular case.
I said that there were three ways in which cases could come to the GMC—through a conviction, through the findings of a local medical services committee and through straightforward complaints from the public, from, patients or their relatives. Virtually all the conviction cases and medical service committee cases and many of the complaints from the public are passed on for consideration to the preliminary proceedings committee—a committee of the council consisting of nine medical members and two lay members, of whom I am one. One of the two lay members must be present for any matters or cases to be considered.
We examine a range of cases, including those that involve sex and, therefore, hit the headlines, but they are a minority. An enormous range of cases comes before us. They include irresponsible prescribing, abuse of drugs, breach of confidence, inappropriate treatment and falsifying the outcome of clinical trials. It is a long list. Each case is considered most carefully by the preliminary proceedings committee. If hon. Members sometimes see me during a late sitting in the Library with a large pile of paperwork, they will know that a PPC is pending. I can assure hon. Members that great consideration is given to each case.
When we consider a case, we can decide that it calls for no action at all. If the matter that has been raised is admitted by the doctor, we can decide that a warning or a cautionary letter in appropriate terms is appropriate, but if there is a prima facie case of serious misconduct, it is passed to the professional conduct committee, a body whose proceedings, though of a civil nature, are very much akin to the criminal courts, with similar standards of proof required.
Anyone appearing before that committee has been charged with serious professional misconduct. There have been several queries as to what exactly that means and attempts to define it. Quite a useful definition is conduct of such a nature as to call into question whether that doctor should be allowed to continue to practise without restriction. The professional conduct committee considers all the evidence and the parties involved appear before it and are examined or cross-examined. The process is 698 similar to court procedures. The committee can decide to dismiss the case, that the doctor should be admonished or that the doctor should continue to practise subject to certain conditions. It can suspend the doctor for a specified period or it can erase his name from the register altogether so that he may no longer practise.
When the preliminary proceedings committee is examining a case, it may consider that the account it has had of the events that led to that consideration brings into question the doctor's health. The doctor will then be subject to the health procedures to which reference has been made. Under those procedures, the doctor will be invited to undergo examination by other doctors who may suggest a course of treatment or certain restrictions on how he practises, the work he does, and so on. Only if he refuses those conditions or proposals will he then be subject to disciplinary procedures.
Perhaps I could interpolate in my narrative of my work on the GMC a couple of comments. First, contrary to the general perception and the view expressed a few minutes ago, my experience is that almost without exception, doctors tend to be far harder on their own profession than I and my fellow lay members would be. Quite frequently, having examined a case, I have in mind a certain course of action and find that the doctors themselves want to take a stronger line; so it is certainly not a case of doctors protecting themselves.
Secondly, the House is often anxious to protect people against double jeopardy. It is a matter about which we are necessarily concerned. Hon. Members will realise from what I have said that doctors constantly face a double jeopardy situation. A doctor may have been convicted and sentenced by the courts or he may be brought before a medical committee which may then find that he has breached the terms of his contract and his salary is withheld. However, that is not the end of the matter for that doctor. His activities must then be considered by the General Medical Council and his livelihood could be at risk.
The weakness in the procedures which I have described, and of which I have been a part for the past five or six years, lies in the fact that, at the end of the day, the GMC can deal only with single incidents of serious professional misconduct. It is virtually powerless to deal with doctors who appear to be deficient in their knowledge of medicine or in their knowledge of the correct procedures for diagnosing and treating patients. The GMC cannot deal with doctors who show a lack of sensitivity or courtesy to their patients—that does not constitute serious professional misconduct.
The Bill proposes that, when such deficiencies are revealed, there should not be formal disciplinary procedures but that steps should be taken to help to rehabilitate doctors so that, in due course, they may resume full medical practice. To that extent, the procedures proposed are akin to the health procedures which I explained briefly.
The Bill's provisions will offer an opportunity for the doctor to consider and analyse his shortcomings and to discuss and agree with fellow professionals and a lay person a course of action that he could take to remedy those deficiencies. In most cases, he would wish to take such action in his own interests and those of his patients. The question of sanctions would arise only if the doctor concerned refused to take the steps proposed.
699 I have no doubt that those powers are needed. Cases have come before the preliminary proceedings committee that do not involve serious professional misconduct but suggest that the doctor is below standard. For example, in 1993 the GMC received information from a hospital expressing concern about Dr. N's level of clinical competence. The concerns were such that the hospital decided to dismiss the doctor in question, but, in the event, he tendered his resignation and sought employment elsewhere.
The GMC requested further information about the specific incidents that had caused doubts about the doctor's competence. Although the inquiries revealed a disturbing pattern of clinical deficiencies on the part of the doctor, no specific incident was considered to amount to serious professional misconduct. Similar inquiries were made about an earlier appointment held by the doctor and about the circumstances in which he had left that post. Here, too, there was evidence of a pattern of poor performance as well as evidence that the doctor lacked insight into his deficiencies. Again, however, there was no specific evidence of behaviour by the doctor which amounted to serious professional misconduct, so the GMC was unable to intervene.
In another case, the council received details in March 1993 of a medical service committee report involving Dr. S, who was a general practitioner. He had made a diagnosis over the telephone and he did not visit the patient at home. The patient's condition subsequently deteriorated and he was admitted to hospital where he underwent an operation for an ulcer. The medical services committee considered that the doctor had not placed himself in a position to diagnose the patient's condition properly and to treat him appropriately.
The case was then passed to the GMC because it raised questions as to whether the doctor had been guilty of serious professional misconduct. On the basis of the evidence before it—the GMC bases its decisions only on such evidence—it was decided that it would be sufficient to send the doctor a letter of warning and advice regarding the standard of medical care which patients are entitled to expect.
§ Mr. Cousins
The hon. Gentleman's example brings us to the heart of the matter: why was it not decided that serious professional misconduct had occurred in that instance? If the case was serious enough to warrant sending a warning letter, why was it not sufficiently serious to be regarded as professional misconduct?
§ Mr. Sims
I do not have all the details of the case before me, but I have explained that serious professional misconduct involves the question of whether a doctor should continue to practise. In that case it was felt that, although he had fallen short of the standards that could be reasonably expected, the question of suspending him or removing him from the register did not arise.
§ Mr. Cousins
I do not wish to pursue the hon. Gentleman on this point, and I am grateful to him for giving way a second time. Does he not see that that means that the evaluation of the case was determined not according to the nature of events but by the severity of the sanction? That is precisely the kind of institutionalised self-regulation that is so dangerous in such matters.
§ Mr. Sims
I do not accept that view. The case was considered carefully in the way that I have suggested and 700 that was the decision reached in that case. But the narrative continues, because shortly after that incident there was another medical service inquiry about the doctor's surgery hours and his provision of services to patients. In that instance, it was found that he had not complied with his contractual responsibilities but that was not serious professional misconduct.
Shortly after that, the family health services authority wrote to the council expressing general concern about the standards of service provided by the doctor. It referred to the disorganised running of his practice and it mentioned his bad record keeping. The FHSA expressed particular concern about those matters because the doctor had persistently resisted the authority's attempts to improve his performance and to rectify his deficiencies.
The difficulty for the council is that its disciplinary procedures are designed to deal principally with specific allegations that a doctor has behaved towards patients in a manner that may amount to serious professional misconduct. Therefore, it was not able to pursue the case. I accept that, if it had taken a different course in the first instance, things may have been different. However, the doctor's pattern of performance certainly justified intervention by the GMC, but it did not have the power to do so.
§ Mr. David Congdon (Croydon, North-East)
I think that I understand my hon. Friend's point about the new powers in the legislation and how they will enable the council to investigate a doctor's pattern of performance and behaviour. I wonder whether he can help me on another point. When a single act is committed which falls short of serious professional misconduct but which nevertheless deserves some form of sanction, will the new powers in the Bill enable it to be investigated?
§ Mr. Malone
Let me clarify the matter. If one specific incident showed a deficiency—it would be unlikely to be isolated, as it is more likely to be part of a pattern—it would be possible in certain circumstances for it to come within the procedures that are proposed in the Bill.
§ Mr. Sims
I am obliged to my hon. Friend.
I shall quote one further case, as it is a graphic example. Two years ago, a surgeon in Yorkshire made errors in his surgical practice that were so extensive that the complaints about him were subject to inquiry by the regional health authority. In its report, that RHA categorised faults, and described a minor fault as being an error whichalthough falling foul of the Bolam test is readily understandable, in the context of a busy surgical practice, and which is unlikely to be repeated.It went on to describe an intermediate fault as being an errorof serious proportions, which warrants disciplinary action, or appropriate retraining but which is not sufficient to call into question the fitness of the surgeon to continue in surgical practice, in that appropriate retraining is likely to eliminate the risk of repetition.It referred to a major fault as being an errorof such substantial proportions as to cast doubt upon the fitness of the surgeon to continue in surgical practice.701 In that particular inquiry, the report found intermediate fault in the case of five patients and minor fault in four, but in none of the nine did it find major fault. The case was reported to the GMC, but it was unable to act because, in the light of that classification and the report following a detailed inquiry, there was no single incident of serious professional misconduct. Quite clearly, that surgeon should not have continued to operate. In fact, he retained his position after giving an undertaking to his employers to undergo retraining and to work for a time under supervision. But he could have chosen to leave and go elsewhere—if not practising in the NHS, then privately, without any hindrance whatever. The GMC would have been helpless. He seems to me to be a perfect candidate for the performance review procedures that we are discussing.
Not all the complaints that come to the GMC go before the preliminary proceedings committee. Indeed, if they did, we would be overwhelmed. There is, as we have heard, a screening procedure. A medical screener—one of the doctor members of the council—considers each complaint and whether action should be called for, or whether the complaint should go forward to the preliminary proceedings committee for consideration, or he can decide that it calls for no action. Until a few years ago, a letter in those terms was then sent out.
The president of the GMC, to whom my right hon. Friend the Secretary of State quite rightly paid tribute for the energetic and dedicated manner in which he has led the GMC for a number of years, felt that, if people were to receive a letter telling them that the GMC was taking no action over their complaint, that decision should be not only taken by a medical member but endorsed by a lay member. He asked me, therefore, whether I would accept the office of lay screener, with the task of looking at all the cases on which the council said that it was taking no action. That I did, and I looked at some 40 cases a month. Indeed, after a year or two, the president, realising the burden, appointed a second lay screener. Hon. Members who have noticed the size of their postbags in the past few years may not be surprised to hear that, although there are two of us, I still deal with some 40 cases a month.
Of course, some of the complaints are trivial and, inevitably, some of the letters are from people who—perhaps one could kindly refer to them as such—are eccentric. There are matters that the GMC cannot deal with. People write in to complain that their doctor has knocked them off the list. He is perfectly entitled to do that, just as—as I explained earlier to my hon. Friend the Member for Edgbaston—one can knock oneself off the doctor's list. People write in to complain that the man next door is throwing rubbish over the fence. They say, "He's a doctor. I want you to do something about it." I am afraid that that is outside the GMC's purview, as are arguments between patients and doctors about fees for private medicine.
But some of the cases that I have seen on which the GMC cannot act—I have to agree that it cannot act—leave me uneasy, and they are about doctors who are not up to the standard that patients should reasonably expect. Misdiagnosis is one area. It is easy to misdiagnose symptoms. Doctors are human. They can make mistakes. Medicine is not an exact science. Various symptoms can be interpreted in a number of different ways. Misdiagnosis 702 is not serious professional misconduct. But if one finds several similar cases of misdiagnosis on the part of the same doctor, perhaps that suggests that he has fallen behind with keeping up to date with medical knowledge, and that the GMC should be able to act. I have to agree to a letter saying, "We are sorry, but the GMC cannot act."
I see complaints about a doctor's attitude. The classic one, sometimes quoted by the president of the GMC, is of the patient who walked into the doctor's surgery, to find him bending over his desk, writing, completely ignoring the patient. As she got nearer, she realised that he was writing out invitations to a drinks party, or whatever. After an interval, without looking up, he said, "Yes." That is not really quite the way in which one expects to be received by a doctor.
I recently saw a complaint from a 20-year-old girl who, with her mother, went to consult her doctor. He sent the mother out of the room, with no explanation, and asked the daughter to undress. He stood watching while she did so. His subsequent treatment of her, the way in which he sought to find out what was the matter, asked questions, touched her in various parts of her anatomy, was generally insensitive. Far from being reassured, that young lady left the surgery in distress. That is clearly not a case of serious professional misconduct. Restricting the way in which that doctor can practise may not be the answer. In fact he may be a rather good doctor, medically, but he needs to be pulled up about his attitude to patients.
We are talking about doctors who have fallen foul of the GMC. Let us be quite clear that most doctors, be they GPs or hospital doctors, are competent, conscientious and caring. But there are some who are simply incompetent. There is a particular problem with locums, who work for a short time, either in general practice or a hospital. Before very long, their shortcomings begin to come to light. By that time, nobody can do anything about it—the locum may be nearing the end of his stay, he may have already moved on or he may been rumbled and resigned. Neither the family health services authority nor the hospital, whichever employed the locum, can take any action because it is no longer that doctor's employer. Often, the hospital or doctor's practice is glad to see the back of that locum and so will do nothing about the problem. However, sometimes the GMC receives an account of the series of incidents that have caused concern about the locum. However, as no one incident could be described as serious professional misconduct, the GMC can do nothing.
I hope that I have clearly shown that in such cases the GMC should be able to act. It needs the powers in the Bill to do the job that Parliament and the nation expect it to do. I hope that the Bill will make rapid passage through both Houses.
Before I resume my seat, I want to refer to the motion on the Order Paper that the Bill be committed to a Special Standing Committee. I have always been an advocate of Special Standing Committees. Indeed, I have sat on one or two of the relatively few such Committees that there have been. I do not think that the procedure is used enough. Hon. Members will be aware that it is a cross between a Standing Committee and a Select Committee. As the hon. Member for Newcastle upon Tyne, East (Mr. Brown) said, it provides an opportunity for people affected by a Bill or with views on it to express those views directly to the Committee, without the need to find 703 a sympathetic Member of Parliament to do so on their behalf. It is also useful when there has been little opportunity for consultation before a Bill is published.
However, none of that applies in this case. The proposals were first published two years ago and very wide consultation has taken place. At the back of the original proposals are two pages listing all the organisations and individuals that have been consulted. The president of the GMC spent a great deal of time meeting a wide range of organisations and individuals, seeking views that he then took into account in the formulation of the Bill, which has wide support. Therefore, I have to say that whatever the merits of the Special Standing Committee procedure, it is not appropriate or necessary for this Bill. Indeed, it would simply delay our proceedings. I urge support of the Bill, but ask the House to reject the committal motion.
§ Mrs. Diana Maddock (Christchurch)
Few subjects are capable of stirring up such anger and emotion as complaints against doctors. Those whom we tend to regard as saintly while all is going well are too easily cast in the role of devil when treatment begins to go wrong. Of course, most doctors are well trained, careful and competent. To sustain that high standard can be very difficult, which is why we need a comprehensive and thorough system of complaint investigation—to ensure not only that those who fall below acceptable standards can be identified, but that they are brought to account, retrained where appropriate and disciplined where necessary.
The GMC is an historic body, but despite its long history it is often misunderstood. Examples of that have been cited this afternoon. It is not a trade union for doctors, although some of our correspondents seem to think that it is. It does not even deal with breaches of contract by doctors; that is the role of doctors' employers. Its statutory and historic role is to deal with the registration of doctors. That means that it has a duty to register doctors who have reached the requisite level of qualification. It also has the duty to affect a doctor's registration by attaching conditions to it or by the ultimate sanction of erasure from the register if the protection of the public so requires.
During recent years the GMC has changed a great deal. We have already heard that under the leadership of its current president, Sir Robert Kilpatrick, it has modernised itself and is moving towards simplification of some of its registration procedures. It is determined to increase the proportion of lay membership to ensure that the non-medic has a full role in its deliberations. I believe that the measures that we are discussing today would not be before us had it not been for the energetic efforts of many of those lay members, including the hon. Members for Chislehurst (Mr. Sims) and for Gower (Mr. Wardell) and my hon. and learned Friend the Member for Montgomery (Mr. Carlile). My hon. and learned Friend very much regrets that he is unavoidably unable to be present for today's debate. He strongly supports the Bill, as do I and my other colleagues. I believe that increasing lay membership is of great importance for the future credibility of the GMC.
Until now, apart from special procedures to deal with sick doctors, which have already been mentioned, the GMC has been able to affect the registration only of 704 doctors found guilty of serious professional misconduct, something that we have discussed at length today. Despite the apparent relaxation of the standard of proof permitted by the Privy Council as a result of the McAllister case, the standard of proof remains high and the quality of misconduct amounting to "serious" is unsatisfactorily limited.
Many cases of sheer bad doctoring have slipped through the net. There is a clear need to provide a procedure to deal with the doctor who is sloppy, who is rude, who is persistently inefficient or who is the source of constant complaint from patients, without any particular incident that could be described as serious misconduct. Unfortunately, some doctors are an accident waiting to happen. The procedures introduced by the Bill will enable the GMC to deal with such circumstances. I believe that the intention is not to introduce a new punitive procedure; the emphasis will be on advice and retraining, although the ultimate sanction of erasure will be available for those whose deficiency of performance cannot, in the end, be remedied.
The cost of remedial training has been estimated at £530,000, according to the Bill's financial memorandum. That may be an underestimate, especially if the introduction of the new procedures brings forward a flurry of cases. I hope that the Minister will confirm that should the cost be greater, public interest demands that it should be met in full, save in so far as it is reasonable for the cost to be met by the doctor himself.
The Bill represents a step forward in the consumer's interests and I hope that the House will support it.
§ Mr. Anthony Coombs (Wyre Forest)
Like a number of hon. Members who have spoken, particularly the hon. Member for Newcastle upon Tyne, Central (Mr. Cousins), I support the principle of the Bill, which can only be good for patients and for the reputation of doctors. At the same time, however, I have some reservations about how exactly it will work out in practice, and about whether the definitions of seriously deficient performance will allow the public's aroused expectation—I am sure that it will be aroused as a result of Bill—to be met in practice.
A danger exists in the Bill. The public will feel that, in relation to a range of performance, if they are not satisfied on a local basis, they will be able to report their doctors to the General Medical Council. When they find that it is not prepared to entertain such complaints, I am concerned that they will be disappointed and that, therefore, we will not have taken any steps forward in improving credibility in or the quality of the medical profession's care for patients.
In the medical service, not just in Britain, but in the rest of the western and industrialised world, the power of the consumer is far greater than it used to be, through both the patients charter and league performance tables, which have been suggested by hon. Members on both sides of the House at various times. The population's deference for doctors has fallen. Previously, doctor always used to be right; now doctor is someone whose judgment can often be questioned. Given that sociological or even emotional change in attitudes to the medical profession in the past few years, it is inevitable that people will demand not only higher standards from doctors, but more specific accountability from them.
705 The hon. Member for Newcastle upon Tyne, Central quoted Adam Smith in putting forward his ideas about a committee.
§ Mr. Coombs
Very good. I shall quote an article in The Sunday Telegraph which appeared at the end of last year by Dr. James Le Fanu. He quoted Robert Louis Stevenson talking about some of the virtues that people expected from doctors, apart from professional competence. They included generosity, discretion, tact, heraclean—whatever that is—cheerfulness and courage, which, the article states, brings
air and cheer into the sick room and often enough, though not as often as he wishes, brings healing.Dr. Le Fanu went on to talk about the seven sins of medicine as described by the late and distinguished Sir Richard Asher. They are obscurity, cruelty—both physical and mental—bad manners, over-specialisation, love of the rare, common stupidity and sloth.
I do not know whether many of those points would come within the definition of seriously deficient performance as set out in the Bill, but I am sure that a significant number of members of the public will expect that they will be able to report any of their doctors who do not exhibit those virtues and who consistently or otherwise exhibit some of the deadly sins to the GMC, and that, as a result of this new consumer-friendly Bill, which we all so avidly welcome today, those doctors should be able to be brought to account. That is dangerous. The public's perception and that of the GMC, which, as our excellent brief from the Library states, anticipates only about 100 to 150 cases per year, may be considerably out of kilter in relation to the credibility problems that I have described.
I have a particular interest in the matter, as, I am sure, every hon. Member does. It so happened that Dr. Carol Starkie, who is quoted as being one of the doctors who could be assisted by the new procedures involving the committee on professional performance, was a constituent of mine—certainly her parents were, and she grew up in my constituency. Hon. Members may recall that, a couple of years ago, she was a consultant based at the Royal Orthopaedic hospital in Selly Oak, Birmingham, and that she was found to have misdiagnosed no less than 42 potentially cancerous tissue samples.
That aroused enormous public concern, including, obviously, among the people directly affected and their families. Five years ago, a family in my constituency—I have not asked whether I may quote them today, although they have been upfront in their complaints—lost a son aged 18 as a result of what they believed to be the professional incompetence of a locum and a local general practitioner. The boy was diagnosed as having a temperature for about four days. It gradually went up from 102 to 104 to 105 deg F. On the Thursday evening, a doctor insisted that he merely had flu symptoms, that the windows should be opened, and that he should be allowed to cool down.
The next day, the boy was admitted to Kidderminster general hospital, where he died the same day. One can understand the devastating effect that that episode has had 706 on my constituents' lives, and how concerned they are to ensure, not that the people involved should be compensated, but that such incidents should not happen to other people, and that those responsible should be brought to book—not necessarily in the court but through an effective General Medical Council—as being guilty of seriously deficient performance.
As I said, I happen to agree with the principles of the Bill. It would be difficult to do otherwise. Obviously, it is right that the purview of the GMC should be extended from merely considering professional conduct and health to wider terms of professional performance. I can understand the arguments, again very well put in the research paper that we have, that the proposals should apply to every sort of doctor, whether he works in a private practice or hospital, or whether he is a locum.
Nowadays, given the fact that medical practice is changing at an exponential rate as a result of new technology and new techniques, it is all the more important that some grip is kept on professional standards. Like my hon. Friend the Member for Birmingham, Edgbaston (Dame J. Knight), and the hon. Member for Newcastle upon Tyne, Central, who ably set out his case, I have some serious concerns about the definition of seriously deficient performance. I have considered part 2 of the GMC's regulations. It refers to conduct and talks about convictions and forms of professional misconduct that may lead to disciplinary procedures. It mentionsneglect or disregard by doctors of professional responsibilities to patients for their care and treatmentandresponsibility for standards of medical care".Paragraph 36 states:The public are entitled to expect that a registered medical practitioner will afford and maintain a good standard"—not the best standard—
of medical care. This includes: conscientious assessment of the history, symptoms and signs of a patient's condition; sufficiently thorough professional attention, examination and, where necessary, diagnostic investigation; competent and considerate professional management".All those would appear to be related to medical duties. They are not related to misconduct whereby one is doing unmentionable things to one's female patients. They are directly related to the standard of one's medical duties. If we are saying that the new committee on professional performance can consider only seriously deficient standards of medical performance, we should take account of the fact that such standards are already accounted for in the conditions on conduct laid down by the GMC.
Therefore, if we are genuinely to extend the purview of the GMC to medical competence, we should do so not just for the most serious cases but for cases further down the scale. That was what the hon. Member for Newham, South (Mr. Spearing) wanted to do when he introduced his Bill. As my hon. Friend the Member for Edgbaston said, he has attempted to introduce such a Bill several times in the past six years.
My difficulty is that, although we had the word of the Minister when he intervened in the speech of my hon. Friend the Member for Chislehurst (Mr. Sims), we do not have anything in the Bill. It is significant that the schedule says several times:The General Council may make rules".707 It also says:The Committee on Professional Performance shall be constituted as provided by the General Council by rules under this paragraph.I am worried not so much about what we see in the Bill as about what is unseen and what will be decided by the GMC and determined in regulations.
The Library briefing says that the General Medical Council, when proposing a third jurisdiction, emphasised thatthere should be an 'equivalence of gravity' between this offence and those of serious professional misconduct and fitness to practice being seriously impaired by ill health.It said that they should be judged on the same standard. Either the Bill duplicates what is available at present, as I demonstrated a few moments ago, or it does not deal precisely with the type of problems further down the scale that many of our constituents would expect it to deal with, if competence and the GMC's ability to examine it was genuinely being extended.
Nor does the Bill tell us—it is left to the schedule—how cumbersome in practice the proceedings under the Bill will be; how quickly, for example, the concerns of someone who makes a reference to the GMC which goes to the committee on professional performance will be met. Justice delayed is justice denied. My constituents to whom I referred a few moments ago have been trying for eight years to find a reason why their son died and who was, responsible. They still have not been able to do so under the existing procedures. If there is to be a significant improvement and if the system is to be effective, there has to be more speed.
Equally, I hope that access will be easier than it is under the professional conduct proceedings. When I investigated my constituents' case I found that only 9.5 per cent. of complaints ever got anywhere near the professional conduct committee, even though in many cases people had been through the gamut of complaints procedures at local and regional level. I have some worries, which the Minister cannot answer now, about exactly how the Bill will work out in practice. Those matters will be left to representations to the GMC on how it interprets its responsibilities under the schedule.
I believe that the Bill will arouse the expectations of the public as to their ability to make effective complaints against what they see as deficient procedures and standards on the part of their doctors. Indeed, it is happening already. Action for Victims of Medical Accidents, which is the leading voluntary body in examining medical negligence cases, tells me that up to last year it had 14,000 cases on its books. I would suspect that it is very much more now. The patients charter, in emphasising patients' rights rather than patients' responsibilities, is all the time pushing people into a position in which their expectations are rising and, therefore, their potentially litigious feelings are being aroused.
We have performance indicators for different consultants or GPs. GPs are in a more competitive position through fundholding or total purchasing and are providing more and more services to their patients. So I should have thought that expectations would be aroused and that the number of complaints which will potentially go through the system outlined in the Bill will significantly increase—certainly way beyond the 100 or 708 150 mentioned by the GMC. That raises concerns about how complaints in the health service are dealt with before they ever reach the GMC.
It is likely that a complaint to the GMC will be at the top end of people's aspirations. Complaint to the GMC will be their ultimate deterrent when they find that the performance of their doctor is not what they would like it to be. I know that the Government have examined the existing plethora of complaints avenues. The Wilson committee has written a document called "Being Heard" which referred precisely to the plethora of complaints procedures—what AVMA called a labyrinth of complaints procedures available to the public.
Although complaints procedures may be available, if there is a labyrinth, one cannot get through it quickly. If people think that there is a labyrinth, they do not go into it in the first place. Therefore, some people who would like to make a complaint—probably a legitimate one—about their doctor may be deterred from doing so.
Existing complaints procedures include formal and informal procedures for family health services authorities, hospital administrative review, the hospital clinical complaints procedure and the health services commissioner. Only then does one get through to the civil courts. So there is a variety of complaints procedures. It is no wonder that AVMA has become more and more popular with patients. They need someone to guide them through the labyrinth.
The Government have produced a document called "Acting on Complaints" only within the last month, in response to the Wilson committee document. It proposes that, where possible, the resolution of disputes in the health service should be local, speedy and far more easily accessible and streamlined than the present procedures. If that comes about, it could have one of two effects. Either there will be more satisfied complainants at the lower end who will not go to the GMC or, as I suspect, there will be more complainants and, as a result, potentially more people will complain to the GMC. So if the system outlined in the Bill is to work effectively and not weigh down the GMC in a huge maelstrom of complaints, the Government must get local level complaint resolution procedures absolutely right.
When one talks about quality in the health service and avoiding problems of defensive medicine—matters which AVMA referred to recently—the more one emphasises quality-led outcomes and the more there is the opportunity for subjectivity about what is an acceptable quality-led outcome. Therefore, there is more potential for making a complaint against a particular doctor who does not come up to that quality-led criterion.
It is not merely a question now of saying, "I had my operation. I was in and out and I got better eventually." People consider what treatment they received before going into hospital, how long they had to wait, what their post-hospital treatment was like, whether they went into the appropriate nursing home or whether they had the appropriate home treatment. All those quality-led outcomes, which are rightly demanded by the public, will lead to greater opportunity for people to complain about doctors, whom they believe should manage their treatment in a particular way.
I was somewhat surprised to read in the briefing paper compiled by the Library that the GMC did not see the new powers as in any way directly related to medical audit procedures in the NHS. The powers may not be directly 709 linked to medical audit procedures in the national health service, but I cannot see how they can be anything but indirectly linked with medical audit. After all, medical audit is about the quality of outcomes and assessing that quality. As I said, if we raise people's expectations of the quality of outcomes and those outcomes are not effectively delivered in every case, people will be more likely to complain about the conduct of their doctors.
In the main I support the Bill, but I am very concerned that the devil, as they say, is in the detail and that what the GMC puts into place, when it looks at the schedules, may not meet the kind of expectations that have been aroused in patients. The problem about arousing—legitimately—expectations of improved service in patients and giving them more rights in the health service is that for every right there is a responsibility. The health service has a responsibility to come up with a particular level of service.
Equally, the public have a responsibility to ensure that they treat their health service appropriately. It is not appropriate—my local doctors have told me of such behaviour—to turn up at the surgery to have a plaster put on, or to ask for a prescription for a medicine which is perfectly easily and cheaply available over the counter, or to ask for advice about nettle rash. Patients should have some cognisance of such activity when they consider their responsibilities to the health service.
Although the Bill rightly makes people aware of their rights and the improved quality of the health service—indeed, they are getting that improved quality from our national health service, which is operating more effectively than ever before—it equally diverts their attention in the long term from their responsibilities in the health service. Only by emphasising people's responsibilities in the health service will we in the long term be able to manage demand for health services which the taxpayer can afford.
§ Mr. Sam Galbraith (Strathkelvin and Bearsden)
For five years in the late 1980s I was an elected member of the General Medical Council. I was an anti-establishment elected member. The British Medical Association used to run slates. I was not on that slate. I was the only non-slate, anti-establishment, pro-patient representative, as it was termed, from Scotland on that GMC elected body. Therefore I hope that my comments will be regarded in the light of the position that I achieved. I was not there to take part in a conspiracy, as has been suggested, or to be part of some coterie to protect other individuals. I was there to ensure the representation of the rights of patients against the establishment.
When we consider the General Medical Council, it is important to realise—I am not sure that we have quite grasped it yet—that it is not just a disciplinary or sanction body but the final disciplinary and sanction body. Other avenues are open to punish or deal with doctors, some of which the hon. Member for Wyre Forest (Mr. Coombs) read out, including the criminal courts, the civil courts and various disciplinary procedures. What is different about the GMC and therefore why there are many complaints about it, although they are not justified, is that it is the body which removes from a doctor the power to practise.
710 The GMC removes the power to practise not only in the United Kingdom, whether in the national health service or private health care, but virtually everywhere else in the world. If one graduates from this country and wishes to practise elsewhere, even for a temporary period, one is asked for a certificate from the GMC confirming registration and good conduct. That power is a very important sanction. The GMC is not just some disciplinary body which tells one that one has been a naughty boy and not to do it again; it can finally erase one's name from the register and deny one's fitness to practise.
While I was on the General Medical Council, I did not serve on the professional conduct committee but on the ethical committee, which is totally different and concerned with such things as ethical positions, in vitro fertilisation, disclosure of information, and so on. I did not have much desire to sit in judgment over my peers and some of their naughty antics. It was, however, clear to me that there was a problem in dealing with clinical competence, within which I would also include the attitudes of doctors to patients: rude, offensive, unacceptable attitudes and bad practice over and over again. While a single instance would not often reach the charge of serious professional misconduct, repeated episodes certainly did and we needed a procedure for that.
When I came to the House I therefore co-sponsored the private Member's Bill of my hon. Friend the Member for Newham, South (Mr. Spearing), which sought to deal with such problems with a lesser charge. I have sponsored such proposals for some time and the House will appreciate that I make my comments against that background.
The proposals in the Bill go some way to deal with the problem as I have perceived it over the years. It was a little demeaning of the Secretary of State to try to pretend that the Bill was all a function of and related to the recent changes. We have been seeking a solution to this problem for as long as I have been in medicine, certainly well before the present Government came to power and long before the current changes. Imperfect as it is, the Bill is probably the best answer available so far, but it is one on which we can improve, so a Bill such as that promoted by my hon. Friend the Member for Newham, South is no longer necessary.
This Bill is about good practice, and there are many ways in which we can ensure good practice. It starts off by the selection of medical students. Selection is difficult because it may be based on academic qualifications, interviews and, headmasters' reports. I do not know the exact answer to that problem and many people who will not make good doctors and who will be professionally incompetent will slip through, even with best practice. Good medical education and training is very important, but still people will slip through.
Good advice is also important. Anyone can be a surgeon; with a little competence it is not hard. Just now and again, however, for reasons of personality, attitude or sometimes dexterity, the odd person who so wants to be a surgeon is not up to it. In the past, some such people were allowed to slip through, but that is no longer the case because strong advice must be taken. Doctors have a duty through training to advise people if they think that they are not up to becoming a surgeon, for example, and they are told to change their specialty. Despite all those 711 attempts to ensure good practice, however, some slip through and some, in fact, were always bad. The Bill deals with those cases and that is why I welcome it.
Nevertheless, I have a number of worries about the Bill, some of which have already been raised. I therefore hope that the General Medical Council—I am sure that it will do this—will monitor the Bill and how it works and that it will report back to the House very soon. I shall now deal with my main concerns about the Bill.
It seems to be assumed that dealing with incompetent doctors is like dealing with sick doctors and therefore the first-rate health procedures in place are very similar. I am not sure that that is all that good a parallel. There are trivial differences to begin with. Most sick doctors at least were well at one time and became sick, whereas some doctors have always been incompetent. Although that may be a trivial difference, it has practical implications and therefore the method of dealing with a sick doctor is not necessarily the same.
Perhaps different grades of doctors should be taken into account. I would be happy if the Minister would explain in Committee who is referred to the various committees. Who is referred to the health committee? Is it drunken, alcoholic consultants or junior doctors? Will junior doctors be referred for incompetence or will it be consultants? Again, that will reflect on public confidence in what is happening and how we can manage the problem.
Another way in which the problem is different from dealing with sick doctors is that patients, health authorities and employers of various sorts are more sympathetic to sick doctors. If a doctor is shown to be sick and has to be sorted out, he or she is given time, help and consideration. But if doctors are just no good and incompetent, should the employer be understanding, retain them as employees and have them in the hospital? The decision will have serious implications for the doctor's contract, how they are dealt with and whether they are retrained. Again, the case is not quite the same as that of a sick doctor.
The hon. Member for Birmingham, Edgbaston (Dame J. Knight) mentioned referral, which also worries me. Contrary to what was said by the hon. Member for Chislehurst (Mr. Sims), who is also a member of the General Medical Council, anyone can refer a case; but again, there is a difference between sickness and incompetence.
If one's problem is alcoholism one might be referred to the GMC via a route that does not affect one's contractual obligations and the employing authority could not question that. For example, one might have been done for drunk driving for a second time—one drunk driving offence results in automatic referral—but one can be treated as a sick doctor without it involving one's contract with the employing authority. If one is an incompetent doctor, however, I see no secondary position. The case must be referred in relation to one's practice and it will be more likely that the contract will be terminated. A hospital has no obligation to retain an incompetent doctor.
There are important differences in the way in which we deal with sick doctors and incompetent doctors, for example, in relation to retraining and who pays for it and their future in the service. If a patient refers a doctor because of incompetence, the case goes to the GMC, but not to the employing authority. If the doctor is found to be incompetent, but is still employed, who will pay for 712 retraining? If the hospital has found a doctor incompetent and sacks him, he is in a different position from a doctor whom a patient has alleged to be incompetent.
What do we mean by incompetence? I hope that the Minister of State will deal with that. One might be an incompetent orthopaedic surgeon, but not an incompetent doctor. One might make a good doctor in some other specialty. Will one be paid to retrain? What of the consultant orthopaedic surgeon who is found to be incompetent? Will he be retrained as a neurosurgeon, a physician or a radiologist? And who will pay? If one is incompetent in one specialty, must one's name be struck off? Or will one be registered for all practice except, for example, neurosurgery? That is an interesting development and it will be interesting for the GMC to consider whether there will have to be different types of registration, with registration of competence but only within certain specialties.
Those are some of my worries about the idea that dealing with incompetent doctors is similar to dealing with those suffering from ill health.
It is right that the method should not be directly related to audit, which the hon. Member for Wyre Forest mentioned. There can be an indirect link, but audit is a slightly different practice. In an audit, a doctor considers areas of practice in which it is not known how he or she is performing and if it is found that there are discrepancies, the matters are dealt with. One might not be good at one procedure, but be better at others. It might be a case of the numbers of such procedures with which one has dealt. If one is not good at something, it will be necessary to change one's practice.
A case might come before the GMC if one was shown to be poor at a procedure but continued to practise in the same way. That would be grounds for referral and it is indirectly related to audit. I hope that the hon. Member for Wyre Forest sees the distinction. It is not that I do not think that audit is important. Its purpose is to detect poor performance, but the action that is taken following that procedure is what matters. If a doctor is bad at one procedure, that does not make him or her incompetent.
The area that worries me, which is in the blue book and is what professional competence is all about, is not competence in a specialty or one area of it, but how one relates to, treats and manages patients. Rude, offensive and bad behaviour must be a basis for referral to the GMC and for being considered under the procedures in the Bill. Such behaviour is bad enough to be considered professional misconduct. In other words, doctors must treat patients with respect and some sort of dignity. Patients must be able to have confidence. They must be able to expect proper clinical history taking, examination, the appropriate diagnostic tests and, if necessary, treatment. Taken as a whole, that is the area with which the Bill probably deals best, and that is why it is not appropriate to deal with it under the heading of serious professional misconduct.
I do not think that there is a conspiracy to protect doctors. That is why I am not worried about the initial stages taking place in private. Anyone who has served on any disciplinary body, as the hon. Member for Chislehurst and I have, will know that there is no attempt to cover up or to protect. Doctors are concerned, first and foremost, to protect patients; secondly, to protect the profession; and, thirdly, to protect the hospital in which they work. 713 Although I have those reservations, which I hope that we shall be able to explore in Committee, I believe that the Bill is an important step forward. It in part solves a problem that we have been trying to solve for many years and I very much welcome it.
§ 7.7 pm
§ Mr. David Congdon (Croydon, North-East)
First, I thank the hon. Member for Strathkelvin and Bearsden (Mr. Galbraith) for his thoughtful speech. I have listened carefully to the debate. Before I came into the Chamber, I had no reservations about the Bill, but various contributions have highlighted some of my concerns.
To put some of the issues in context, we heard from the hon. Member for Newcastle upon Tyne, East (Mr. Brown), the Opposition spokesman, and from my hon. Friend the Member for Chislehurst (Mr. Sims) about the vast range of cases that are referred to the General Medical Council and how few result in a decision of serious misconduct for a variety of understandable reasons.
The hon. Member for Newcastle upon Tyne, East also mentioned consistency between the procedures for dealing with doctors and those for other health professionals. I have some sympathy with that approach. The Standing' Committee should bear it in mind.
We must also consider the Bill in relation to other complaints against doctors and the recent White Paper on the subject. I echo the concerns of my hon. Friend the Member for Birmingham, Edgbaston (Dame J. Knight), who reminded us of the number of complaints against doctors, which are leading to a rise in professional medical insurance. There is a danger that that will lead to doctors not only prescribing defensively, but practising medicine defensively, which is not always in the best interests of the patient.
I pay tribute to my hon. Friend the Member for Chislehurst (Mr. Sims) for his work on the General Medical Council. It is too easy to assume that, when a colleague is appointed to such a body, it involves just the odd meeting. He referred to occasions when he has been in the Library with volumes of reports. I have seen him burdened with those volumes of reports and appreciate his difficult role. He deserves our respect and support.
Whatever we might say about doctors who perform badly or do not deliver the right quality of medical service to their patients, they are in the minority. The majority of doctors do an excellent professional job and I hope that anything that I say subsequently will be put in that context. In discussing complaints, we are in danger of creating the impression that all doctors perform badly, which is not the case.
However, there is a problem with the GMC's current powers. My hon. Friend the Member for Chislehurst said that the cases highlighted in the press usually involve sexual matters and the public have the impression that those are the only cases that are investigated. That does a great disservice to the medical profession because such cases are only a small percentage of those that are investigated. I hope that the new powers will go some way towards changing that perception.
714 As the powers currently available to the GMC enable it to deal only with serious professional misconduct, the Bill limits the sort of cases that it can investigate. Earlier this afternoon, we had an interesting exchange of views about exactly what are the powers in the Bill. I confess that that aspect worried me as I listened to the debate and I decided to take a further look at the Bill. Frankly, it does not tell me a great deal. I realise that a lot of work has gone on behind the scenes to bring forward these proposals and I do not dispute the work that the GMC and others have done, but I am not sure exactly what the Bill, to which the House is being asked to give a Second Reading, really means. That does not stop me supporting it in principle because there are clearly gaps in the current legislation, but I hope that the Committee will examine the Bill in detail and try to deal with some of the concerns that have been raised today.
As my hon. Friend the Member for Chislehurst explained excellently, the gap in the current provision means that, although the GMC may be concerned about a doctor's performance, that performance falls short of serious professional misconduct. At the same time, it may be aware of a pattern of similar occasions on which the doctor has been deficient. As matters stand, the GMC does not have the power to deal with such a case because it can deal only with a single act. I understand that the Bill is designed to deal with that problem.
The interesting exchange this afternoon was about whether the Bill, in addition to giving the GMC the power to deal with serious deficiency based on a pattern of behaviour, provides the power to deal with a single act. The Bill is not clear in that respect.
I was struck by the Library research paper, which said that the hon. Member for Newham, South (Mr. Spearing) had introduced a private Member's Bill in six different Sessions of Parliament to try to deal with that specific issue. He said that a child in his constituency died of meningitis after his GP had said that he could not be bothered to examine him. I have difficulty with such a case because, while the doctor had clearly not performed to the standard that we would expect of him, the question is: how adequately would the Bill deal with such a case? Could the GMC take action only if there were other examples of similar behaviour by that doctor?
I hope that the Committee deals with that issue because in many cases in the health service doctors might not perform at the level that we would expect of them. Some cases will be comparatively trivial but others will be serious and fall within the GMC's current powers. There will be other examples where action should be taken and I urge that the matter be considered carefully, because it might be a single act that falls short of serious professional misconduct, as evidenced by the hon. Member for Newham, South in a previous debate.
No one is in the business of trying to hound doctors and make them behave more defensively than they are sometimes forced to behave now. Rather, it is a question of having procedures in place to deal with a variety of under-performance, whether it is a serious act under the current powers or a less serious act, so that those matters can be dealt with.
It is not entirely clear, particularly as a result of proposals that the Government recently brought forward, what the relationship will be in terms of powers of complaint to family health services authorities and, conversely, powers of complaint to the GMC. I appreciate 715 that the FHSA case is more akin to the employer-employee relationship because it is not direct, whereas the GMC is much more concerned with the professional aspect and has the ability to deregister. I agree with my hon. Friend the Member for Chislehurst that that is crucial, particularly in relation to local doctors. It is no good someone saying that a doctor is not up to standard if that doctor is merrily practising as a locum all over the place and employers are pleased to get shot of him or her. It is important to deal with that issue, too.
Despite what I have said, I support the principles of the Bill because it fills a gap in current legislation. My only concern is whether it goes far enough. If the Minister cannot expand on his earlier intervention when he said that the Bill could deal also with single acts where a doctor fell short of professional performance, I hope that that matter will be dealt with properly in Committee.
§ Dr. Tony Wright (Cannock and Burntwood)
Although all hon. Members who have spoken so far support the Bill in principle, it is interesting that a critique has developed during the course of the debate about some of the problems and deficiencies in the Bill. The Bill deals with "serious deficiency of performance" yet the issue that we are all trying to address, and think that the Bill should address, is what we might call "consistent incompetence". Although we may think that the Bill is designed to deal with consistent incompetence, if it is concerned only with serious deficiency of performance, as defined in normal GMC criteria, we shall ultimately find that it has not solved the problem which we thought we had set out to solve in the first place. That is the heart of the problem with the measure before us.
As Members of Parliament, we must proceed a little gingerly in the realm of self-regulatory activity as we can hardly offer other professions a shining example of how they should conduct themselves. A little humility might even be in order. Although I agree with other hon. Members that the majority of medical practitioners are exemplary in their skill and their commitment, we know that we have a problem that must be addressed. If we do not get it right this time, we will make things worse, not better, because we will have pretended to solve the problem.
One of our initial difficulties is even deciding the scale of the problem involved. The Secretary of State used the same words as the president of the GMC when she spoke about a small number of consistently poorly performing doctors. What on earth is "a small number"? We do not know because it has never been investigated, but it is a crucial question.
On 4 December 1994, the health correspondent of The Observer wrote an article with the headline:Medical Mafia covers up Errors".He reported that a study of poorly performing doctors was about to be published by the Open University Press in a book entitled, "The Incompetent Doctor". That study revealed that of the 95,000 doctors in practice in the United Kingdom, up to 10 per cent. were estimated by some of those interviewed to be a potential danger to their patients. One professor of surgery said:In Britain we tend to turn our backs on these things. It is not easy to recall where people were willing to confront incompetence.716 The study also quoted the manager of a family health services authority who estimated that 10 per cent. of local GPs were "impaired". He confided:It is almost impossible to force a resignation. It just has to be horrendous for anything to happen.
§ Mr. Malone
Before we embark on a route of what I might describe as overestimation, it might be sensible to point out that the GMC has had a certain amount of correspondence about the people likely to be subject to the new rules. Based on its knowledge of the matter, it has estimated that perhaps some 150 or so cases might come before it each year, of which 50 may proceed to further stages. The hon. Gentleman should put that estimate in the context of what we expect from the Bill, which is clearly distinct from the exciting pieces of literature to which he is referring, and which offer estimates of a considerably greater number.
§ Dr. Wright
I am bound to say that I was about to make the same point to reach a different conclusion.
One of the consistent problems highlighted in the responses to the consultation exercise from some of the interested organisations was that they did not know the numbers involved. The Open university study—the figures may be too large—reveals that we have a serious problem that may affect one in 10 doctors. If that is so, we are talking about nearly 10,000 doctors. That is a rather alarming prospect. Let us hope that it is not true, but there is a huge mismatch—the point of the Minister's intervention—between the scale of that problem and the figure of between 100 and 150 cases that the GMC says might come before it as a result of the new procedures.
We should take some care to investigate as far as we can the scale of the problem. We know, however, that we have a problem that has not been addressed. Everyone who knows about it has sought for a long time for something to be done, but response has been consistent inaction. The BMA, in a masterly understatement, has said that the Bill is a long overdue measure. It is, because the problem of poorly performing doctors has been with us for a long time. We all know that the system has not managed to deal with it.
I endorse many of the plaudits bestowed on the GMC, but we should ask why, over the years, the GMC machinery has not managed to bring within its definition of serious professional misconduct all those things that normal people would consider to be serious professional incompetence. That indictment of the system should be put alongside any plaudits and congratulations that might be offered to the GMC today.
The way in which people try to raise queries about the performance of doctors or try to complain as patients or the relatives of patients is a profoundly unsatisfactory business. One of the matters about which I feel consistently most dissatisfied is how constituents who try to raise questions and make complaints about the service they have received from the health service are treated. I am sure that other hon. Members share that feeling. Those constituents are left totally dissatisfied by the outcome of any inquiries made. That is part of the problem that we must address now.
I should like to give four examples of the type of behaviour that I am talking about. Two of them came to my attention simply from my work on the Parliamentary Commissioner for Administration Select Committee, which deals with the health service ombudsman. That 717 Committee has heard evidence from a succession of health service personnel, including doctors, who have come before it because they have been judged deficient in some way by the health service commissioner.
One case from 1992, which was referred to the Committee, involved a consultant at the Royal Free hospital at Hampstead, who behaved quite improperly in a case of child abuse. In fact, it was not a case of child abuse, but he told the mother that he thought that it was. His behaviour was contrary to the guidelines that the Government had just issued in the wake of the Butler-Sloss inquiry following the Cleveland affair. It was a most alarming case and the Select Committee stated:We consider it extraordinary that a consultant charged with revising the procedures in connection with child abuse should disagree with management on the nature of those guidelines.The consultant told the Committee that he did not feel that the guidelines issued by the Department applied to him because, as a consultant, he knew better. We should ask what happened to that consultant. The answer is that he is still consulting away. I am sure that the GMC has not actively intervened in the matter.
The second case before the Committee was even more appalling and involved a consultant at the Manor hospital in Walsall, which deals with many of my constituents. Not only did the consultant fail to tell the relatives of a patient that he was suffering from cancer, but he just happened never to get round to telling that patient the diagnosis. Such behaviour is unbelievable. When the patient's family subsequently complained, the consultant said that he never answered letters from patients and certainly never answered those from solicitors. The Select Committee of the House stated:It was the consultant's responsibility to ensure that effective communication of suspected diagnosis took place; something he signally failed to do on this occasion, not, it appears, for the first time.In other words, that consultant's behaviour followed a consistent pattern, confirmed by the chief executive of the trust. The Committee also said of that case:We see the need for a culture change in the minds of many of the consultants who appear before us.Whatever the GMC and the new proposed procedures may do, they will not bring about a culture change on the part of such consultants.
Another case involves my constituent, Mrs. Ashley, who died leaving her husband in despair at his inability to get her condition taken seriously. His wife suffered from ever-worsening back pain and he had taken her on a number of occasions to the accident and emergency departments, which could not help. When we finally obtained an independent clinical review, the general practitioners did not even deign to give evidence. The consultant to whom my constituent wrote in despair at his wife's condition did not even bother to answer his letter. The independent clinical review said that that was indefensible. Has such a case been near the GMC? Of course not.
My final example is a case involving one of the consultants that I have already mentioned, at the Manor hospital in Walsall. He treated a case as constipation when it turned out to be cancer. One might say that that was simply a misdiagnosis, but the independent clinical review concluded that it was not; it was poor clinical 718 performance, because the man never carried out the obvious tests that would have established what the condition was. So there was never any proper terminal care for the person involved—who therefore lived and died in agony—or any proper care for the family.
Indeed, the independent clinical review said that there should be a surgical audit of all the procedures carried out by that consultant at that hospital. Yet, has that case been near the GMC? Of course it has not. I had a letter from the chief executive of the trust, who told me that Mr. So-and-So, the consultant—I shall not give the man's name—"acted properly". That was written before the independent clinical review.
Rightly, the family has written to tell me that the consultant is still practising on my constituents, and to ask what is to be done about him. The answer is that nothing has been done, and the chances are that nothing will be done. Whatever the numbers may be, whether small or large, that man should certainly be counted as one of them, and on behalf of my constituents I want something done about that. I hope that we all do.
We all hope that the Bill will produce improvements but I, like other hon. Members, have some worries. I am worried about the definition of what is serious and what is not serious, and about the inconsistency of definition in that area as opposed to other professional areas, such as that governed by the United Kingdom Central Council for Nursing, Midwifery and Health Visiting. I think that the general rubric of professional misconduct could well be extended to include the kind of routine incompetence that has been discussed today.
I am also worried about the resolute way in which the GMC tells us that it will get into the business of being proactive. It will do nothing to initiate any investigation into whether people are performing properly, but will wait for cases to come to it. No doubt that explains why it says that it expects to deal with so few cases.
In many ways that is the key issue—the general lack of effective clinical monitoring within the system. Somehow we seem to expect the Bill to solve that larger problem, but I do not think that it will. Indeed, I feel rather sorry for the GMC in that respect, because if the GMC cannot play that role, who will? Which part of the system will carry out consistent clinical monitoring?
Another example of a particular worry concerns the clinical performance of many single-handed general practitioners—a worry endorsed by much of the research that has been carried out. Having recently discovered that in my part of the world there are many single-handed practitioners who carry large lists and seem to refer people to hospital at a high rate, I asked my family health services authority what it intended to do about the indicators that suggested that we had a problem with the quality of primary care. The answer was that it could do nothing.
All that the FHSA was doing was to examine prescribing patterns, because that is an initiative designed, quite properly, to cut costs and to achieve uniformity in prescribing. But it does not address the issues of quality and of clinical performance. It should do so, and I worry about that.
The Secretary of State said earlier that doctors had a duty under the internal guidance in the blue books to let it be known if they thought that any colleague was 719 professionally incompetent. Yet clearly that is not happening. If it were, the figures and the evidence that we have discussed would not be there.
I should like there to be a requirement in the Bill to ensure that, as a matter of professional conduct, if a medical practitioner comes across professional misconduct and consistently poor performance he or she has a duty as a doctor to inform the professional body concerned.
Although there is a broad consensus that something needs to be done, worries have been expressed, not only in the House but by the Patients Association, by the Association of Community Health Councils for England and Wales and by consumer groups, about whether the Bill has got it right yet or whether there are areas that still need to be tightened.
I was alarmed to see in yesterday's edition of The Independent an article about the Bill that said:The Bill has been introduced only on condition that the Opposition will facilitate its passage and not try to alter it".I am all in favour of facilitating its passage, but—
§ Mr. Nicholas Brown
Before that idea gets going I shall kill it stone dead here and now. Nobody has said anything about not trying to alter the Bill; we merely said that we would facilitate its passage. Of course we can still try to amend the Bill, but we shall do so crisply.
§ Dr. Wright
I expected my hon. Friend to respond if I gave him a cue, and he did so admirably. Obviously it is the duty of the House to consider measures that come before it critically—and, I hope with a measure such as this, in a bipartisan way. I know that the Opposition will help in that process.
Finally, as several hon. Members have said before, the Bill must be seen in the context of a whole range of measures designed to improve matters in general. The new national health service complaints system, the attempts by the royal colleges to think about recertification and re-accreditation, and the clinical performance initiative are all most important.
I do not want to get distracted, but if only the Government had not been so crazed in their determination to make organisational changes in the health service and to set up a quasi-market for their own ideological reasons, but had simply devoted themselves to the quality agenda all those years, we could have made serious progress on the fronts that impact directly upon the quality of care that patients receive.
We are talking about the oversight of a profession, and one of the arguments that has emerged from the debate, concerning the inconsistency between how things are done in this area and in other areas, might even suggest that the time has come for one body to have oversight of all the professions, so as to ensure consistency. Having listened to the debate I am more persuaded of that case than I was before.
We have come to the end of a road. In another context concerning self-regulation, we were once told that it was last-chance saloon time. Perhaps it is now last-chance surgery time. We must get the balance between professional interests and the public interest right now. I am not yet persuaded that the Bill does that, and we must ensure that it does.
Finally, I shall mention the procedural point. In a motion on the Order Paper some of us have suggested that it would be entirely appropriate for the Bill to go to a 720 Special Standing Committee. The more I have heard of the critique that has developed during the day, the more I have felt that to be right.
It is essential that we spend some time exploring the rationale for the Bill in a bipartisan way, teasing out some of the issues, before we start the usual, line by line, ministerial defence of the Bill that is the disabling feature of so much legislation that is created in this place.
Few measures have passed through the Special Standing Committee procedure since it started in 1980—the Mental Health (Amendment) Bill in the 1981–82 Session, the Matrimonial and Family Proceedings Bill in the 1983–84 Session and now the Children (Scotland) Bill. Those are similar measures to the one before us, in that they needed thorough, bipartisan scrutiny.
I shall conclude by quoting what the distinguished then Leader of the House, Norman St. John Stevas, said when introducing that raft of procedural changes, including the Special Standing Committee arrangements. Speaking about Special Standing Committees, he said thatGovernment Bills which raise substantial issues, not of acute party controversy".—[Official Report, 30 October 1980; Vol. 991, c. 725.]should be subject to that type of arrangement.
The case for that has been made in today's debate. We need a few sessions in which Members who are interested in all that can explore further the aspects that we have begun to discuss today, before we start the usual progress of the Bill. It will be appropriate and helpful if, when the Minister replies, he brings us good news on that front.
§ Mr. Nigel Evans (Ribble Valley)
I am grateful for the opportunity to make a contribution to the debate.
I believe that all of us, as Members of Parliament, are interested in the health service, especially the national health service. We wish to ensure that the high standards that have been reached in the national health service are maintained and improved. The Bill will help to do exactly that.
Many sectors make up the health care industry, in both the private sector and the national health service. I use the national health service; I am a customer of the national health service, and I find it to be excellent.
There are many good news stories in the national health service, which do not receive the coverage that they deserve. My hon. Friend the Member for Croydon—
§ Mr. Evans
As my hon. Friend the Member for Croydon, North-East (Mr. Congdon) said, although some cases cause anxiety and improvements need to be made, that does not detract from the fact that the vast majority of people who work in the national health service at all levels do so to the highest possible standards. However, that fact does not prevent us from drawing attention to cases where they fall below those standards.
The bad news stories always catch the headlines. I have appeared on "Kilroy" a couple of times when the national health service has been mentioned, and the programme makers appear to be able to pack an audience full of people who have gripes about the national health service, when we know that the vast majority who use the national health service regard it highly.
§ Dr. Robert Spink (Castle Point)
Is my hon. Friend aware that in my local hospital, the Southend Health Care 721 NHS trust, the director has done a survey of the letters of thanks that he has received versus the letters of complaint, and that the letters of thanks, which generally go straight to the ward, are pinned on the notice board and are seen by the nurses and staff, far outnumber the letters of complaint that come in from time to time?
§ Mr. Evans
I am extremely grateful to my hon. Friend for making that argument. The vast majority of people—in excess of 90 per cent. of those who take part in polls and have used the national health service—speak highly of it. Yet a small number of those who use it and who find that the service falls below the standards that they expect, make the newspapers. My hon. Friend has just spoken about the letters of thanks. Would it not be wonderful if we could read some of those good news stories in our newspapers from time to time?
§ Mr. Cousins
I am puzzled about what happens to the letters of complaint. We have heard about what happens to the letters of thanks. What happens to the letters of complaint? Can the hon. Gentleman throw any light on that?
§ Mr. Evans
Those letters of complaint are investigated, in the main, but unfortunately most of them receive all the publicity, whereas letters that compliment the dedication of those who work in the national health, service do not receive the airing that they deserve. Unfortunately, that is the case in many sectors, not only in the national health service.
I have anxieties about one aspect of the national health service—ageism. A constituent, Arthur Hornby of Janice drive in Fulwood, has a specific problem. For two years, we have been fighting that case in connection with the bad treatment that he received at Hull royal infirmary. We have not received satisfaction on that issue. My constituent's GP referred him to Hull royal infirmary. It was felt that he should have gone to a cardiac ward there, but he was placed on a general ward. Only after a further heart attack was he referred to the ward where he should have gone in the first place.
We suspect that there has been a blatant case of ageism in that case. We have taken that complaint to several levels. We are still not receiving satisfaction and we shall continue to pursue that case until we can ensure that any examples of ageism are stamped out of the national health service.
§ Mr. Cousins
May I assume that that problem, which concerns the hon. Gentleman, has been handled modestly and without undue publicity?
§ Mr. Deputy Speaker (Mr. Geoffrey Lofthouse)
Order. That is all very interesting, but the hon. Gentleman is straying from the subject of the debate. Will he get back to the debate, which is on the Medical (Professional Performance) Bill?
§ Mr. Deputy Speaker
Order. Whoever wants the hon. Gentleman to raise that matter, if it is outside the debate, he cannot raise it.
§ Mr. Evans
Thank you, Mr. Deputy Speaker.
There are other examples of good news about the national health service that do not make the newspapers. On Friday, I spent all day visiting district nurses in the Clitheroe practice. I also visited Lancashire Ambulance trust and saw some superb news going on there. In the evening, at an award ceremony in my constituency, I met more district nurses operating in my constituency.
I have also visited GPs in the Clitheroe practice and discussed the concerns that GPs have in Longbridge and Whalley. One cannot discount the fact that far more pressure is placed on GPs these days than was the case in the past. The expectations of patients are exerting more pressure on the GPs. GPs are now given more freedom to take more power to help their patients, to prevent them from going into or being referred to hospital. I believe that, in some cases, that pressure and the expectations of their patients lead some of the patients to believe that they are not receiving the due care and attention that they would wish to have. They wish to ensure that the highest standards are met, especially by GPs.
Millions of patients are treated by GPs every year. The vast majority of people who are treated by the 26,000 GPs receive excellent treatment. Not all of that practice will be consistently high, and I believe that that, in some cases, is where the Bill will come in and ensure that standards are raised. The Bill aims to meet that challenge.
That does not mean that, in every case when patients write letters, they have good cause to write. It is simply that the expectations are much greater. People are now given more information about how to complain about the service that they receive. People know how to complain and are doing so, which is good. Patients and customers of the national health service will also want to know that their concerns are being dealt with properly, and the Bill will help to ensure that.
Like other hon. Members who have spoken, I am not saying that the Bill is absolutely right in all its aspects. That is where the Standing Committee will play a role. As the hon. Member for Newcastle upon Tyne, East (Mr. Brown) said, amendments will be tabled, perhaps from both sides of the Committee, to ensure that the finished Bill will be far better than the original one. We shall see what happens in the Standing Committee. It is important to note that the system that is adopted may prevent the need for investigations and complaints in the first place. That would raise the standards of the general practitioners and of those who work in the national health service.
I am sure that we have all received letters from the BMA, which has welcomed the Bill. It has reservations, but in the main it welcomes the Bill. The measure will ensure that the professional standards of all those who work in the national health service are maintained and, in doing so, it will benefit the profession.
The BMA raises some points that need to be considered, including the subject of retraining. The assessment of doctors' knowledge, skills and attitudes in the practice and their retraining will ensure that they are kept up to the required standards. The profession is constantly changing. The BMA wants to know who will pick up the costs of retraining, which is a fair question. Now, nearly £40 billion is spent on the NHS and £800 723 million a year is spent on training. Will the cost of retraining those GPs and others who work in the NHS come out of that £800 million, or will additional resources be made available for retraining? That is one question that must be answered.
How many people who work in the NHS are expected to need retraining? That is something that we need to consider. The profession is constantly changing; new technology is being introduced all the time, and new procedures such as keyhole surgery mean that patients stay in hospital for shorter periods. What will be the retraining costs for such procedures? Will they come within the confines of the Bill? We need to know the facts.
Many people examining our proceedings today will be surprised that we have waited so long for the Bill. Many people will have expected a procedure to have been set up to replace the current everything-or-nothing system. It is clear that the current procedures would not be sufficient to meet the sort of complaints that many of us receive as Members of Parliament. I hope that the Bill will introduce procedures in which people have confidence, so that when they complain about deficiencies, their complaints will be dealt with. Complaints should not fall foul of a system where they are not serious enough to warrant the General Medical Council taking action to correct the problems. The Bill will be extremely welcome if it achieves that aim.
Other hon. Members have mentioned the audit and suggested that the Bill should not involve audit. I agree, but the audit within the medical profession has a role to' play in ensuring that all those who work within the NHS and reach a high standard give a lead to others, so that they raise their standards and we ensure that money spent in the NHS is well spent. Such procedures will include referrals to hospital and the amount of prescriptions currently written by some GPs.
The Bill's effect may be to raise the number of complaints referred to the General Medical Council. An increase in the number of complaints does not mean that standards are lowered—quite the opposite. It means that scrutiny is being improved, which has to be welcomed. The measure must be seen in the context of the pressures currently exerted on the NHS, the demands and expectations that we have of it and the vast amount of good work that is being carried out within it. One has only to talk to people from abroad to discover that they look at what goes on in this country and admire it.
We have the best health service in the world. We have the world's favourite health service and we wish to see it maintained for the future. That is why I welcome the Bill.
§ Mr. Piers Merchant (Beckenham)
It gives me great pleasure to follow my hon. Friend the Member for Ribble Valley (Mr. Evans). I particularly endorse his last few remarks and associate myself most strongly with them. I listened with great interest to the earlier part of his speech. He was right to say that, these days, the spotlight of public attention is very much on health matters generally. Although the Bill deals with one specific and fairly narrow part of that subject—the conduct of doctors in the medical profession—that must be understood to be a matter of concern within a much broader picture. My hon. Friend was right to draw attention to that.
I listened to my right hon. Friend the Secretary of State when she opened the debate. She was right to mention the public's greater expectations. I should like to apologise to 724 the House for missing a short part of the debate after that, but I was sitting on a Standing Committee, where I was required. I was sorry to miss the contribution of the hon. Member for Newcastle upon Tyne, East (Mr. Brown), not just because he is the Opposition spokesman on the subject but because I have listened to him on many occasions with great interest. I know him to have a well-measured approach to all matters debated in the House.
I also regret missing the contribution of my hon. Friend the Member for Chislehurst (Mr. Sims), particularly as he has given long service to the General Medical Council, of which he is a lay member. I also regret missing his contribution, because of his interest in, and knowledge of, health matters, which is considerably greater than mine.
I have for some time been critical of the existing complaints procedure and the disciplinary system within the medical profession. When I was first elected as Member of Parliament for Beckenham, I dealt with a case involving a doctor who could fairly be described as incompetent, but who was not so unreliable as to be considered guilty of professional misconduct. I was surprised to discover at the time that, although local remedies existed, there appeared to be no national remedy to deal with the problem—in terms either of discipline or of finding a way to overcome the problem by imposing, for example, retraining. It was that experience that first led me to realise that there was a deficiency in the procedure.
My views were brought into sharp relief by a case which I should like to go into in detail but cannot because I have guaranteed the privacy of the individuals involved, for understandable reasons. It is still outstanding. It has been running for two years and involves what I regard as dubious practice on behalf of a member of the medical profession. The treatment provided was dubious; the way in which it was carried out was certainly dubious.
I was further alarmed to discover while investigating the case that it was by no means the first example of that member of the medical profession behaving in that way. There had been a number of examples and I believe that there have been more since—it is a continuing problem. I took the matter up with the GMC as I believed that that was a way of, if not obtaining a remedy, at least preventing such things from continuing.
Although I have to compliment the GMC on recognising that there was a problem and on being prepared to look into it immediately, at the end of the day it was not able to offer a solution because in its judgment—a judgment that I have to respect—this case did not come within its rules. The GMC suggested that I take the matter to the Department of Health, which I did. I was advised that, sadly, there was no scope for action there because nothing illegal was being done—it might be dubious, but it was not illegal.
I found that, as a Member of Parliament, there was effectively nothing that I could do to prevent what was happening. I could offer only sympathy to the people involved, which was certainly not sufficient. They decided, quite rightly, to pursue a legal remedy and went so far as to get counsel's opinion, but found that in this country, unlike in many others, there was no remedy via the courts and the legal system. I was left with the impression that complaints and disciplinary action relating to the conduct of doctors was, at least in that case, inadequate. I doubt that the changes introduced by the Bill 725 and the regulations that will follow will be sufficient to deal with such cases, but the Bill is at least a step in the right direction.
I have begun by criticising two members of the medical profession, but I have had considerable experience of dealing at many levels with members of the profession and I want to make it clear that I have encountered many who are of the highest quality and offer the highest standards of care, service and expertise. I do not want my remarks to be taken to mean that I am casting aspersions on the profession in general.
It is surely in the profession's interest that its complaints system operates in such a way as to inspire public confidence in the profession generally and ensures that action can be taken when conduct has not been of the highest standard. No profession is immune from having within its ranks people who are not up to the required level of competence, who are not entirely honest or who do not behave as their position requires. Such problems are inevitable because professions consist of human beings. The House should ensure that, as far as possible, there is a way to protect the medical profession's good name against the few bad cases and that public confidence can be retained. I believe that the Bill will succeed in doing that.
My right hon. Friend the Secretary of State said that, public expectations are much higher these days. That is undoubtedly true. She also said that doctors are no longer regarded as paragons. Indeed, people are much more critical now than they would have been even 10 years ago and they require a system that enables them to have their complaints about inadequacy dealt with so that standards are improved.
I am delighted that the GMC has made it clear that it supports the thrust of the changes because, of course, it is far better to reform the profession if the profession is prepared to endorse change rather than having it imposed on it. I pay tribute to the hon. Member for Newham, South (Mr. Spearing), who for many years waged a campaign to change the profession's disciplinary system. To an extent, the Bill is the fruit of his efforts, although I know that he would have liked to go further.
Given the need for swift reform, it is absolutely right that it should be carried out under the present regime of self-regulation. However, were we starting ab initio, I should not feel especially well disposed to having such a heavily self-regulatory system. I speak with some experience of self-regulation, having worked for a while in the advertising industry which operates a system of self-regulation. Although it operates well, it was clear to me that it could not provide all the answers that the public had come to expect. The system was deficient. I was also involved in the setting up of self-regulation for the direct mail industry and came to the same conclusion in that instance.
We need to ask whether self-regulation is sufficient for the medical profession. The hon. Member for Strathkelvin and Bearsden (Mr. Galbraith) spoke effectively on that point. He said that he did not believe that there was a conspiracy among professionals to cover up. I accept that judgment, but I still believe that self-regulation is open to potential criticism. Although I would not accept that there is any conspiracy or whitewash among professionals—indeed, they have reason to aspire to the highest 726 standards—there is clearly a danger that the profession will indulge in self-protection and use the Bill and existing legislation to be cautious, if I may put it like that, when dealing with complaints and criticism. The profession is naturally resistant to change. It does not want any further requirements placed on it in respect of discipline and standards of conduct unless absolutely necessary.
If the public are to be sure that a system is operating properly, they have to believe that everything is above board. If the public think that everything is not above board, even when it is, there is a deficiency in the system. I therefore have some doubts about self-regulation, especially in respect of the national health service, whose professionals are required to obtain higher standards than in, for example, commerce.
§ Mr. Malone
Before my hon. Friend leaves that point, I hope that he will bear in mind that the GMC has a substantial lay element, so it is not quite a closed shop. I am sure that he will concede that the Government are not imposing something on the profession. The GMC fought for the Bill for some time and the Government are glad to be able to support it.
§ Mr. Merchant
I am grateful to my hon. Friend. I said a few minutes ago that the GMC clearly supports the Bill. I was going to stress that, in any event, there is not a system of pure self-regulation in the medical profession. There is a lay element in the Acts of Parliament which gives backbone to the system and which means that the profession is not entirely self-regulating. It is self-regulation built on a statutory framework. It owes its origin to the Medical Act 1858, to which the Bill is related.
We must bear it in mind that that Act was passed at what was perhaps the peak of laissez-faire, so the system is, in essence, Victorian. I do not say that in a critical sense but simply as an explanation. The Act provided a structure in tune with health provision of the time, but times have changed considerably. The public's demands have changed, which is why the Bill is needed to update the system.
I regard the Bill as part of a continuing process. I predict that further changes will be needed in future to take account of yet more changing attitudes. I do not share the somewhat apocalyptic vision of the hon. Member for Cannock and Burntwood (Dr. Wright), who went a little far in talking about the dangers posed by problems in the medical profession. Although I understand his concerns, the Bill is pretty narrow in terms of the changes that it introduces. There will come a time when a broader framework will be required to cover not just those who the Bill covers—registered medical practitioners—but many quasi-medical professionals whose numbers are multiplying and who offer medical services that are now accepted by the national health service. Some of them are regulated by legislation, such the Osteopaths Act 1993 and the Chiropractors Act 1994, which I was delighted to support, but many other mushrooming activities in alternative health care should also be included in the legislation.
§ Dr. Spink
Does my hon. Friend share my concern that the public might be disappointed with what the Bill delivers? It will not be a panacea and resolve every small complaint. People may be looking for rather more. The 727 Bill is a move forward, but there is further distance for us to cover, particularly in improving the way in which FHSAs deal with complaints.
§ Mr. Merchant
I agree with my hon. Friend. He is absolutely right. It is a stage that will be welcomed, but it is a step behind public expectations. His latter point about FHSAs is also absolutely right.
The Bill's major deficiency is that it widens or deepens the authority provided by existing measures only slightly and it does not provide a comprehensive system to cover the complaints procedure via the national health service, to which my hon. Friend was referring, or the quasi or alternative medical professions.
My principal feeling is that the Bill is useful and important because it covers a surprising gap in the present powers. The average member of the public would assume that the current disciplinary system or complaints procedure covered adequacy or inadequacy among the medical professions, incompetence, constant poor performance and faulty judgment. Most people would imagine that any doctor who demonstrated incompetence would immediately be caught by the provisions of his own profession's standards and disciplinary systems. That is not the case. There is a gaping hole in provision.
The present legislation allows for what was described by the rather quaint phrase "infamous conduct in a professional respect". What, indeed, is infamy? It was, defined in 1894 by Lord Justice Lopes who said that it was conductregarded as disgraceful or dishonourable by the professional brethren of good repute and competency".That is a very persuasive description, but it is not sufficient to cover poor, simple incompetence and inadequacy and, in that sense, a gap existed.
The GMC's "Proposals for new Performance Procedures: A consultation paper" went straight to the heart of that. It defines'seriously deficient'—in other words, so blatantly poor that patients are potentially at risk".Surely it is necessary to include in the statutory framework behind the disciplinary system that the GMC operates full scope for that to be covered. The Bill does that, and not before time.
The Bill covers the need to protect the public from deficient performance, but it proposes to do so in a way that is supportive and remedial. The first objective is to protect the public. The second objective is to try to deal with the problem positively by finding a means to raise the individual doctor's standards. Given the potential expertise, the training that doctors have to undergo and the cost, it is surely right that, if possible, a means should be found of rescuing the doctor and putting him back on the straight and narrow.
The GMC is perfectly right to do that. It recommends putting in place a procedure that will be fully covered by regulations under the Bill when it becomes an Act, local assessment and a complex system of ensuring that justice is done, even if the complaint is relatively minor.
The GMC has produced an exceptionally complicated flow chart which, when one follows it through, as I have done, is logical and ensures not only that complaints are properly screened and dealt with in the right way, at the right level and with the right degree of proportionality but 728 that the doctor is given adequate care and attention at each stage to solve the problem, from the point of view not simply of the complainant but of the doctor.
I do not believe that the Bill solves all the problems, but it represents an important step forward. However, I hope that my hon. Friend the Minister can reassure me on one point. It is a contradiction between the judgment of Jean Robinson, vice-president of the Patients Association, and that of the GMC.
Mrs. Robinson was quoted in The Independent as criticising the proposals for not going far enough. She said that the procedureswould involve only cases judged on poorly defined criteria to be 'serious', would operate entirely in private and would provide none of the rights to be represented or to seek a judicial review which are enjoyed by patients bringing complaints of misconduct.Referring to the changes, the GMC document said:They will not form a lower form of the conduct procedures. They are not aimed to attract a new category of complaint to the GMC, rather they will provide a way of dealing with many existing complaints concerning failures in professional performance.I am somewhat puzzled by that. I hope that the Bill addresses the concerns expressed by Mrs. Jean Robinson and does not entirely reflect the GMC document.
If the Bill does nothing more than underline what is already occurring, it does not go far enough. If it goes a step further, as I understand it does, the GMC description is not entirely accurate when applied to the Bill. There is a need for a lower tier of conduct procedures. There is a need for complaints that are not caught by the existing procedures to be addressed. If the Bill operates as it should and if the regulations that follow it are sufficiently tough, that is precisely what will happen. The two new committees that the Bill sets up will do that, but I hope that my hon. Friend the Minister can give us some reassurances to that effect.
The Bill is an excellent measure and I strongly support it. I hope that it passes into law soon. I hope that the regulations that follow will be adequate and will enable doctors and medical practitioners to continue to enjoy their excellent reputation by assuring the public that there are proper procedures to deal with those who do not come up to standard and to ensure that those doctors are brought up to standard, for the benefit not just of their careers and future and those of their fellow professionals but of all the people in Britain who seek and expect the best standard of care from health service practitioners.
§ Mr. Nicholas Brown
On a point of order, Mr. Deputy Speaker. The excellent House of Commons Library briefing note on the Bill has so far been read to the House four times tonight. There is a rule against tedious repetition. How often do we have to hear it read to us from the Conservative Benches?
§ Mr. Deputy Speaker
I am well aware of that particular rule and I have been taking note. The hon. Gentleman can rest assured of that.
§ Dr. Robert Spink (Castle Point)
It is a great pleasure to follow my hon. Friend the Member for Beckenham (Mr. Merchant), who always makes an interesting speech. As I expected, he demonstrated a wealth of knowledge about the subject in the course of his very cogent remarks. It is also a great pleasure to speak in support of the Second 729 Reading of the Medical (Professional Performance) Bill. However, my contribution will be short because, as we heard a moment ago, much has already been said.
§ Mr. Pawsey
I thank my hon. Friend for giving way. Does he find it as extraordinary as I do that there is only one Liberal Member, two Labour Members and not a single Back-Bench member of the Labour party—
§ Mr. Nicholas Brown
As we support the principle of the Bill—which is what should be discussed during the Second Reading—the Opposition parties are trying to make progress while Government Back Benchers seem to be filibustering unduly. I cannot understand why they are doing so, but that is clearly what is going on.
§ Dr. Spink
Mr. Deputy Speaker, you have been listening to the debate very carefully and you will be aware that hon. Members have raised a number of very proper questions which will be dealt with during the Committee stage of the Bill. That is why the debate has proved so interesting and useful. The Minister is taking great notice of it and he is making copious notes. I look forward to hearing his speech.
Both the General Medical Council and the British Medical Association have given their blessing to the Bill. The GMC press notice of 16 March 1995—a significant document which I have taken from the Library research paper and which I do not believe has been read to the House—states:We identified a gap in our powers and I am pleased that Parliament has been asked to fill this gap to enable us to do our job more effectively".That is what we are about tonight.
§ Mr. Congdon
I agree with my hon. Friend and we are all aware that the GMC was behind the Bill; it identified a gap in its powers. However, should we not ask whether there are other gaps that are not addressed by the Bill? There is a danger that we will pass the legislation and, in five years' time, realise that such gaps exist.
§ Dr. Spink
My hon. Friend the Member for Croydon, North-East makes a telling point that has been referred to before and that I will come to in a moment.
In talking about the support that the Bill has received, I must mention the important patient groups and associations which have indicated their support for the general thrust of the legislation, although they also expressed some reservations. Those reservations have been aired tonight, but in deference to the hon. Member for Newcastle upon Tyne, East I will not rehearse them again.
730 In welcoming the Bill, I accept that there are some difficulties in the national health service and that mistakes sometimes occur. The NHS treats millions of patients each year and it would be incredible if occasional misjudgments or even gross errors of judgment did not occur. Thankfully, such events are rare and I pay tribute to the doctors, nurses and even the health service managers, all of whom enable the health service to function properly and provide an improved service to our constituents.
Southend-on-Sea trust hospital is improving the service it provides to my constituents. It treated 17,140 more patients last year and it has treated an additional 700 patients this year.
§ Mr. Deputy Speaker
Order. It seems as though my remarks have fallen on deaf ears. It is very interesting to learn what is happening in the hon. Gentleman's hospital, but we are dealing with the Medical (Professional Performance) Bill. I ask the hon. Member for Castle Point (Dr Spink) to address his remarks to it because we are nearing the point of tedious repetition.
§ Dr. Spink
I am indebted to you, Mr. Deputy Speaker. The Government have raised public awareness that taxpayers should expect good, timely and courteous service from all areas of the public sector, including the national health service. The Bill addresses that point very directly. The Conservative Government have raised patient expectations. The hon. Member for Cannock and Burntwood (Dr. Wright) outlined many of the ways in which patients have received more information and more rights, so I will not repeat those points.
The citizens charter movement was initially scorned by Opposition Members, but it is now being studied and copied across the world, for example, in the United States. Tonight hon. Members have referred to a number of alarming cases involving serious neglect in the health area. The Bill should swing the balance of health care in favour of the patient while dealing with problems that occur from time to time in the health service. It will provide patients, the BMA and the GMC with another weapon in their armouries. The hon. and learned Member for Montgomery (Mr. Carlile) referred to that point in welcoming the legislation during debate about the Queen's Speech.
My hon. Friend the Member for Wyre Forest (Mr. Coombs) said eloquently that patients have responsibilities as well as rights and he referred to patients' increasing tendency to abuse those rights. People are making more night calls and they are constantly referring matters of little significance to their doctors. That is placing a burden on the system, doctors are being placed under greater pressure and that is leading to an increase in the number of mistakes that they make. I hope that we will look carefully at ways of inhibiting that development.
A story appeared on the news tonight about a doctor who worked 110 hours. He successfully sued his local health authority and received about £5,000 compensation because he said that he had been put under undue pressure and was therefore at risk of making a mistake in treating patients. If he had made a mistake which had amounted to gross incompetence, the Bill would have swung into effect and enabled him to receive additional training so that he could provide his patients with better care. That is one of the reasons why I support the legislation. We 731 accept that patients have needs and rights and that they should receive the best possible protection from incompetent doctors.
§ Mr. Pawsey
I thank my hon. Friend for giving way and I apologise for interrupting the flow of his speech. He is making an extremely eloquent speech which I know will be noted carefully by all those hon. Members who are in the Chamber and by those who will read Hansard in due course. Does he find it surprising that there is no reference in the Bill to the work of the health service commissioner? My hon. Friend assiduously attends debates in the House and he studies such matters with the utmost care. Therefore, is he surprised that the Bill does not mention the work of the health service commissioner and the way in which he may hear complaints relating to general practitioners?
§ Dr. Spink
I am indebted to you, Mr. Deputy Speaker. Although it was a rather long intervention, it was an interesting and important one. Of course, the health service commissioner plays a pivotal role in these matters, and I look forward to hearing what my hon. Friend the Minister has to say about that when he replies.
Whatever the reason why a doctor might be incompetent—the hon. Member for Strathkelvin and Bearsden (Mr. Galbraith), himself a distinguished medical man, gave a very illuminating account of the various reasons, so I shall not rehearse them—he or she should be given the opportunity to recover and repair. The Bill allows time for that process to take place. The Bill leads the way, therefore, to improving standards of doctoring by allowing time for doctors to retrain. It gives them one or two years—perhaps more—to retrain and represent and be relicensed, so that they can continue their profession. That is absolutely right. The Bill is not just about discipline and punishment. It is focused on driving up the standard of care that patients can expect to receive from their doctors. That is the way it should be.
On a technical note, my hon. Friend the Member for Ribble Valley (Mr. Evans), who made a most interesting and cogent speech, referred to the costs of retraining and asked whether they would come from the general NHS budget or from any other hypothecated budget. The explanatory and financial memorandum to the Bill said that the cost to the NHS of retraining doctors, as a result of the Bill's measures, would amount to about £530,000 each year. I do not think that we should consider that cost as unacceptable or, indeed, that it is an unacceptable demand on the health service budget, as sound benefits will flow from that relatively small expenditure.
§ Mr. Peter Atkinson (Hexham)
I am grateful to my hon. Friend for giving way. What happens if the doctor involved is not a practising doctor but simply works as a locum and moves around the country? What happens, for instance, if that doctor was in private practice? Which section of the NHS does my hon. Friend think would have to cover that cost? Would the local family health service practitioners committee have to foot that bill, even though the doctor was in no way attached to it? There is a problem there.
§ Mr. Pawsey
Once more I apologise to my hon. Friend for interrupting his speech. I draw his attention to clauses 5 and 6. He will be aware, because quite clearly he has studied the Bill in considerable depth, that clause 5 provides that anOrder in Council may bring different parts of the Bill into effect at different times.Yet clause 6 says that the Billwill extend to the whole of the United Kingdom.Does my hon. Friend agree that perhaps there is an argument for some form of pilot scheme to be introduced, perhaps, for example, into Scotland, to see how the Bill operates and to sort out any teething troubles? I would welcome his advice on that point.
§ Dr. Spink
My hon. Friend has clearly assiduously read the Bill, has taken in all its clauses carefully and is considering them. I believe that it is such a good Bill—it takes an important step forward in its contribution to improve patient care and helps doctors who are having problems to recover from those problems in an honest and honourable way—that it should be brought in without a pilot, as soon as possible. No doubt those items can be deliberated on at length in Committee.
I was talking about whether the £530,000 cost of retraining doctors is acceptable or whether it would be an unacceptable burden on the health service, and that benefits would flow from that expenditure and that it was relatively low. The increased effectiveness of doctors as a result of the expenditure on their retraining, and the better diagnoses that they would make, would deliver massive benefits that would far outweigh the very small cost. I do not think that the cost is of any great significance. I believe that it would be money extremely well spent.
I agree with other hon. Members, particularly my hon. Friend the Member for Croydon, North-East (Mr. Congdon), that we need better systems to deal with chronically poor doctors—those who make small mistakes from time to time, who need a small amount of help—rather than the very serious bad performance and outrageously bad professional conduct, which, in a way, are easier to deal with. The Bill addresses those more directly. We cannot avoid the problem of the chronically poor performance, and we must find systems and improved ways of dealing with that.
§ Mr. David Lidington (Aylesbury)
Has my hon. Friend studied the precedent set by the Osteopaths Act 1993 and, dare I say it, the Chiropractors Act 1994, which provide for penalties in respect of conduct by a practitioner that falls short of the standard required of either a registered chiropractor or osteopath respectively? Does my hon. Friend believe that those might serve as useful precedents 733 that the Government might study with a view to introducing something not dissimilar with regard to the orthodox medical profession?
§ Dr. Spink
My hon. Friend makes an important and interesting point, which no doubt will be considered carefully. He comes to the House with a lot of knowledge and has done a great service to society at large through his work with the Chiropractors Act. We pay tribute to him now.
I shall give a specific example of a chronically poor performance. It has not been covered before. You will not be aware of it, Mr. Deputy Speaker, but there has been a lot of repetition tonight, and I deplore that. Indeed, I am trying to avoid it. The example is one of a doctor who falls out with a patient—perhaps there is a personalty clash, or whatever—and decides to remove that patient from his list, but refuses to give a good reason, or any reason, for so doing. The GMC will not take any notice. It is not terribly interested. I have tried to interest it in a difficult case in my constituency, but it has not shown any willingness to become involved. The FHSA sometimes finds that it cannot be of much help. Doctors in the area talk to one another. Other doctors are reluctant to take on the patient. As a result, the patient, who herself was damaged as a result of the medical profession making a bad decision in the first place, may well be causing a nuisance to the doctor.
But that is the nature of it. Many of our constituents cause what might be considered a nuisance to us. They have every right to do that. That is what we are paid for, and we must accept that and deal with it in a proper and professional way. We cannot turn our backs on our constituents, and we do not. Doctors should not turn their backs on their patients, but some of them do. I doubt whether the Bill would deal with that. The committee on professional performance, which is mooted in clause 1 of the Bill, would not be able to deal with that. It would not consider it to be any great professional misconduct issue that it should deal with. Gross misconduct or serious deficiency in performance would not cover the removal of patients from a list. So we have—
§ Mr. Deputy Speaker (Mr. Michael Morris)
Order. I can help the hon. Gentleman. If the Bill does not cover the illustration that he is giving, I am afraid that he is out of order. If he thinks that it might, he would be in order.
§ Dr. Spink
I am greatly indebted to you, Mr. Deputy Speaker; you are absolutely right. However, perhaps we should consider whether the Bill should be extended to cover that matter. I think probably not; the Bill should go forward as it stands because it is an extremely good Bill and we should not delay it. We need to consider other measures to follow behind it. I note that you are leaning forward in your Chair again, Mr. Deputy Speaker, so before you stand up I shall sit down.
§ Mr. Peter Atkinson (Hexham)
I apologise to the House because although I was here to listen to my right hon. Friend the Secretary of State's introduction to the Bill, unfortunately I then had to attend meetings elsewhere 734 in the House and so missed what has clearly been a long and interesting debate. I hope that in my few remarks I shall not be unduly repetitious.
§ Mr. Nicholas Brown
Only someone who has not attended the last two hours of debate could possibly describe it as interesting.
§ Mr. Atkinson
I do not think that I should be tempted to reply to that comment—although I must point out that I hold the Bill in my hand, not the research document from the House of Commons Library.
I join in the general welcome for the Bill, which is an important measure that will do a great deal to improve medical standards in this country. It should be made clear that the Bill is in no way a criticism of the national health service or of doctors. We should say time and again, even at the risk of being repetitious, that Britain has a first-class health service and that the majority of doctors and medical practitioners are of an excellent standard and take great trouble about retraining and keeping up to date with modern trends in medicine.
The Bill is a kind Bill. It is not intended to attack or harry general practitioners who may fall foul of it. Instead, it makes provision to retrain them, to support them and to bring them back into the fold as competent doctors.
I want to pick up a point made by my hon. Friend the Member for Beckenham (Mr. Merchant) about there being some gaps in the Bill. I do not want to be out of order, Mr. Deputy Speaker, but I must say that I believe that in time we will have to extend the process to developing areas of medicine such as chiropractors—something that my hon. Friend the Member for Aylesbury (Mr. Lidington) knows a great deal about—or even bone setters, as they are known, who are increasingly moving into a quasi-medical position.
I speak from a position of considerable luck because I represent a rural constituency. It has isolated communities, but within them there are first-class medical practices, health centres covering most of the constituency and an excellent general hospital. I am sure that the provisions in the Bill will not need to be applied to any doctor in my constituency.
One concern that I have about the Bill is the effect that a vindictive patient might have on a perfectly competent GP. I know that the Bill provides for a screening system, but I am concerned that an individual GP could be dragged before a committee time and again simply because of complaints from a troublesome nuisance patient. As patients learn more and more about their rights—as they should—the odd troublemaker might seek to pursue a vendetta against a GP.
There is also the question of who pays for retraining. That issue should not be left in the air. I appreciate that one of the problems with such a short Bill is that a great deal of the detail is to be left to regulation, which I understand must be approved by the Privy Council. That always causes Members of Parliament to feel slightly ill at ease because we are being asked to approve a Bill that is not complete.
The question of who pays for retraining is important. Doctors may be self-employed, but usually they are employed by the family health services authority. There are also some peripatetic locums who move from one position to another. Who would be responsible for retraining those people? I do not think that the local health 735 authority or the hospitals should take on that retraining. I hope that my hon. Friend the Minister will respond to that point when he replies.
Another point that needs consideration is the appeals procedure. The Bill is complicated, but my understanding is that if a GP felt that he had been wrongly convicted—that is perhaps not the right word—his only recourse would be to the law. There is no opportunity for an accused doctor to disagree with the screening process or the professional judgment of his peers. I wonder whether there should be such a gap in the Bill.
Will the hearings of the General Medical Council's committees be held in public? The GMC's proceedings are usually open to the public. One difficulty could be that, much to the delight of the tabloid newspapers, marvellous stories about doctors in trouble with their patients could be splashed across newspapers—even though the allegations are often totally unfounded. Will doctors who have to appear before the GMC committees be granted privacy when their cases are heard?
Despite those few reservations, I very much welcome the Bill. I hope that the details in the regulations will be more thoroughly discussed in Committee because, as I have said, there is a slight feeling of ill ease that such a short and compact Bill should rely on other people adding to it to make it work.
§ Mr. Robert Key (Salisbury)
I was detained at the start of this afternoon's business, so I look forward to reading the early part of the debate in Hansard. I want to raise some important issues which I do not think have been covered in earlier speeches.
Over the years, Members of Parliament have to deal with many cases in their constituencies. Some can be easily resolved, but more usually they cannot. When a professional conduct case is involved, it is usually beyond the competence of a Member of Parliament to make a judgment, any more than a Health Minister can make a judgment on a clinical matter. That is no different from the behaviour that the British people would expect of lawyers, accountants or any other professional person. It is the whole essence of professionalism. Standards apply to a profession and we expect people in that profession to maintain them. I was fortunate enough to be a teacher for 16 years before I entered the House and I learned the essence of professionalism in the world of teaching.
The cases with which we have to deal as Members of Parliament vary widely, and sometimes we are fortunate enough to gain some professional insights. I served as a member of the Medical Research Council, where I saw what many would regard as the rather esoteric end of the market. However, it gave me an enormously important insight into the challenges facing the medical profession, both in this country and elsewhere.
Some of the cases that our constituents bring to us turn out to be not quite what they seem. That is why I warmly welcome the Bill. It will help us in our role but, above all, it will help citizens who feel aggrieved and it will help those members of a profession who may occasionally have unwarranted charges made against them. Sometimes cases are brought before us and there is incomplete information. A patient is aggrieved, he disbelieves his GP and he wants to take the matter further. Only a few weeks ago, I was told of a constituent whose mother had 736 allegedly died of bed sores in hospital. Of course that was not the position, but the relatives felt aggrieved. I regret that the symptoms were much more serious, but, all told, it was a hard time for the family concerned.
There is the occasional malingerer and the occasional example of a night-time call-out when a doctor reluctantly gets out of bed and travels miles in rural constituencies. Like my hon. Friend the Member for Hexham (Mr. Atkinson), I represent a rural constituency, and I know how it must feel. No doubt, doctors there can incur the wrath of their patients when appearing less than enthusiastic at the prospect of a journey of some miles to visit someone who is unwell. In all those cases, the patient may feel aggrieved, and occasions may arise when professional misconduct takes place. Generally speaking, however, that is not the case.
The danger involved in politicians talking too much about the issue is that they give the impression that professional misconduct is commonplace when the reverse is the truth. In my experience, it is extremely exceptional to have any serious case—the sort of case that might be covered by the Bill in relation to professional performance in the medical profession. We should be careful.
We need to deal with one or two other issues, on which I should be grateful for the advice of my hon. Friend the Minister. The first involves the question: what do we mean by "professional conduct?" One of the things that has interested me in my constituency is the improvement in the past decade in medical services provision focused on the village health centre. That has made an enormous difference to the quality of life in general, and particularly to the medical quality of life for tens of thousands of my constituents.
A substantial building programme has taken place. There are more than 100 villages in my constituency, many of which boast a good primary health care facility. The financial arrangements under which those health centres have been built put a considerable responsibility on the professionalism of doctors who are partners. Does the Bill and the concept of professional performance extend to the financial management and responsibilities of those health centres?
Should something go wrong with the complicated mortgage structure of some of those centres, might professional performance be called into question? Would it bring the profession into disrepute if, for example, a partner who had gained substantially because of the capital increase in the value of the building made off with the loot, so to speak, in a way that might be regarded as underhand?
I have no evidence that that has ever happened, but, as primary health care increasingly receives substantial sums of money from the taxpayer, it is not unreasonable to ask whether professional competence in the medical profession extends not just to the service and the bricks and mortar of a practice, but to the extremely expensive software and computer equipment, and to the ancillary staff, who are so important in an advanced health care system such as we have now. That issue should be explored.
§ Mr. Lidington
I find myself in considerable sympathy with my hon. Friend's line of argument. Does he think that, when dealing with conduct, the Committee that will be appointed after, I hope, Second Reading is given to the 737 Bill, might amend the Bill to include a clause on conduct falling short of the standard expected of a doctor, much akin to the clauses already included in the Osteopaths Act 1993 and the Chiropractors Act 1994?
§ Mr. Key
My hon. Friend raises an important issue and I tend to agree with him. For example, clause 1 refers to the committee on professional performance finding that a fully registered person has been "seriously deficient", but in what respect? That needs to be explored in Committee. I have no doubt that it will be, and it is important that it should be.
§ Mr. Lidington
Again, the two Acts to which I alluded and which relate to professions that complement orthodox medical practice have something to teach us. They distinguish between incompetence in the practice of the medical discipline concerned and misconduct more broadly defined. The Chiropractors Act, for example, refers to someone being found "guilty of professional incompetence" and distinguishes between that andconduct which falls short of the standard required of a registered chiropractor".That distinction is already embodied in those two Acts and Ministers might wish to consider it in Committee and during the Bill's later stages in the House.
§ Mr. Key
Paragraph 9 of the schedule to the Bill, states:In Part III of Schedule 1 (Committees of the General Medical Council) after paragraph 21, there shall be inserted the following paragraphs".They mention the assessment referral committee and the committee on professional performance. Even that, however, does not really help us or get us far. I dare say that my hon. Friend the Minister will have some answers for us on what exactly is meant by professional performance. There was perhaps a danger in assuming that, when the General Medical Council identified a gap in its responsibilities, that gap would be easily filled. It may not be easy even to decide what the gap is, let alone whether the Bill fills it.
As I have said, any professional misconduct by the medical profession is exceptional. I, too, pay tribute to the high standards in the national health service. I have always relied on it. I have no interest to declare as a subscriber to a private health scheme because I am not. The only private insurance that I have is with my dentist, who decided voluntarily a couple of years ago that he wanted to go down that road. He made the right decision. It proved good value for money for my family because, apart from anything else, as someone who only last Saturday reached his 50th birthday, my teeth are pretty rotten, and my three children have, I think, one filling between them, so the dentists will do themselves out of a job if they are not careful. I have no financial interest in the matter. I and my family believe that the NHS is superb.
I have come across one serious and tragic case. I shall not refer to it in detail because it is still running, and I fear that it will run and run. It involves the death of a child. That constituency case has brought home to me the gravity of professional misconduct or, indeed, misjudgment and it has led me to examine in some detail exactly what happens to a member of the medical profession when something goes wrong.
738 Again, lest it be assumed that the Bill has identified a gap that we can easily fill, I draw the attention of the House to the fact that, with the increasing complexity and technological involvement of the medical profession, it is sometimes very hard to identify which link in a chain might be at fault or, indeed, guilty of professional misconduct.
It is clear that there is a chain of many links and that things can so easily go wrong. In my constituency case, for example, when the child was first taken into hospital the nurses perhaps did not examine the child as quickly as they should. At that time there was not an absolutely standard procedure laid down for all cases in which a patient suffering from suspected poisoning was brought into the hospital. So time was lost. A doctor was not fetched by the nurse. The pathology department was short staffed because it was a Saturday. Part of the kit was unavailable. A computer link to another hospital north of the border was down because of a technological problem and, again, it was a Saturday. And the consultant was not fetched early enough because the earlier steps had not been followed.
The independent professional review revealed that one person could not clearly be held to blame. There was a series of deficiencies in procedure. Not only the medical profession but the administration was at fault because no administrative procedure had been put in place to cope with the situation in the first place. Moreover, the case was not brought to the attention of the chairman of the trust until nearly two years after it all happened.
Cases in which there may well have been some professional misconduct can sometimes take a long time to investigate, and justice is therefore harder to apply. There is a long chain between the patient, the administration, the nurses, the junior doctors and the consultants.
§ Mr. Peter Atkinson
My hon. Friend has fixed on a particular point. He mentioned the business in clause 1 about where professional performance is found to be seriously deficient. In the example that he has described, would he say that any one of the doctors could be called seriously deficient?
§ Mr. Key
Yes, I would, but that is not for me to judge. That is precisely why the General Medical Council exists. It is a serious point. The length of time between the incident which led to the death of the child and the revelation of what had gone wrong meant that junior hospital doctors had moved on to other jobs elsewhere in the country. So the national health service trust in which the incident occurred was not in a position to discipline the juniors involved in the case. We therefore return, despite the chain, to the need to have a General Medical Council and for it to have adequate procedures. That is why I support the Bill, despite my reservations.
The case in my constituency is not over. That is why I have not referred to it in any more detail. The overriding problem for me is, first and foremost, the enormous distress to the parents that things went wrong and justice was not, at least in their eyes, seen to be done. Secondly, there is the enormous strain on the medical profession. It was not a case of a criminal being identified by a jury and retribution being meted out. It was not like that at all. It was a case of deficiencies on the part of very professional people who had been victims of consequential events. Misjudgments were made. The independent professional 739 review pulled no punches: it said that notice should be taken of some things that some nurses, some junior hospital doctors and some consultants had done. We are not at the end of that particular story.
We should not treat the Bill lightly and simply assume that it will plug the gap which even the General Medical Council has identified. We are dealing with unusual circumstances here. Of the many thousands of cases with which hospital doctors and consultants cope every week and every month, in only a tiny handful do things go wrong.We must ensure, first of all, that the likelihood of things going wrong is minimised. Secondly, we must ensure that when they do go wrong, the machinery exists to put them right without victimising people or stigmatising professionals who have not been guilty of any misconduct.
The provisions in the Bill buttress a system which is quite exceptional in that it leads right up to the Privy Council for appeal. We should be immensely proud of that because it means that we regard the professionalism of medical people in this country as of the highest importance. That means that we have not only the best health service in the world, but the highest standard of doctors. That is why people want to train in this country.
It is the duty of the House to ensure that we support the Bill so that the highest professional standards will always be maintained and the reputation of medicine in this country will be one of which not only we but the whole world may be proud.
§ 9.5 pm
§ Mr. Nigel Spearing (Newham, South)
I whole-heartedly endorse the closing remarks by the hon. Member for Salisbury (Mr. Key). Indeed, I find myself, uncannily, in an almost parallel position. I too had 14 years in education and had to deal with a lot of pupils, families and illness. I probably share the hon. Gentleman's approach to Parliament. Fortunately, the Bill has no party or even any national health service content in principle at all. It is Parliament doing its job for the public.
I too, unfortunately, had a constituency case involving the death of a child. Instead of a chain of unfortunate circumstances, as the hon. Member for Salisbury described, my case concerned one general practitioner who was clearly and very badly wrong. Justice was not done and it resulted in an identification of the gap that we are hoping to fill with this Bill. I too have reservations about the Bill. I cannot say that I support it wholeheartedly. It is good that there is a Bill, whether it be this Bill or the procedures that have been outlined I am not quite so sure, for reasons that I shall now make plain.
I have one other thing in common with the hon. Member for Salisbury and that is being late for the debate. I am very sorry that I was not able to hear the opening speeches. Some hon. Members will know why and others will find out why if they look at today's Order Paper. The Select Committee on European Community Legislation sat for three sessions in Brussels today with Commission personnel and our ambassador there. All the discussions were about 1996 and the change. I have been trying and have managed, through the good offices of colleagues, to be in two places in different countries at once.
This debate is about the regulation of a very important profession—such matters, incidentally, of course also relate to education—which needs protection. Obviously, 740 anybody who is in a critical position—such as a medical practitioner, a nurse or a combination of nurses and doctors—may always be blamed. It is a natural reaction. But we also have to protect the public. This Bill and the Medical Act 1983 to which it is attached should mark that proper balance. Parliament on behalf of the public must strike that balance.
Such a balance was struck in the Merrison report of April 1975, which is worth putting on record. Paragraph 10 reads:We have suggested that the regulation of the profession can be looked upon as a contract made between the public and the profession. It is important to understand in this context that the GMC is merely the instrument for the proper supervision of this contract and that it derives its authority, and its being, from legislation. The legislature—that is, Parliament—acts in this context for the public, and it is for Parliament to decide the nature of the contract and the way it is to be executed.That sums up the spirit of the debate and what we are about.
The trouble is of course that in respect of Alfie Turner, there was no justice, or any for his family. He was a lad from Canning Town who, 12 years ago now, died tragically. He may have died anyway. The case is well known. The great bravery of Mrs. Stafford from Silvertown is also well known. At some risk to herself, she shopped the doctor concerned after the General Medical Council did not deal with him properly.
That deficiency in procedure prompted my private Member's Bill, which has been before the House for nearly 10 years. The GMC has not accepted it, but it has helped to promote the long discussions and detailed consultation in the medical profession, which has resulted in this Bill.
My private Member's Bill was supported, among others, by Dr. Maurice Miller, a former Member of Parliament who is known to many Members present. It was also strongly supported by the hon. Member for Cambridgeshire, South-West (Sir A. Grant), who has joined me to table a motion to refer the Medical (Professional Performance) Bill to a Special Standing Committee.
As many hon. Members have said, this is not a simple matter. I suggest to the Minister that the procedure of taking evidence and deliberating in such a Committee prior to the formal Standing Committee, which is now available to us, is tailor-made for considering this sort of important relationship between a profession and Parliament. I hope that the motion will be given due consideration. The Government Front-Bench do not have to do anything, but must merely say nothing if I am able to move it. Perhaps we will have better legislation as a result.
My private Member's Bill had the support of the right hon. Member for Peterborough (Dr. Mawhinney), the Secretary of State for Transport, who was then a Back Bencher and who knows a thing or two about medicine. It was also supported by my hon. Friend the Member for Strathkelvin and Bearsden (Mr. Galbraith), who is an eminent consultant.
I am unable to give the Bill under consideration direct support because, as I explained when I moved the Second Reading of my private Member's Bill on 3 March 1987, there is a lacuna in the present procedure for what we might call conduct and discipline. Under the present arrangements, a doctor must be found guilty of what is 741 termed serious professional misconduct, even if he is to be put on conditional registration, which is the main feature of the performance procedure.
I want to question the link—there must be one—between conduct in one incident and a general level of performance. Perhaps it is easier to assess it from one incident than from a period in which there has to be a serious deficiency in performance.
The word serious is very flexible. It gave rise to the terrible situation in the Alfie Turner case, when Dr. A was not willing to examine or treat the boy, or even call for an ambulance when he was virtually unconscious, and would not even take his temperature. Alfie Turner died of meningitis three days later. The doctor was found not guilty of serious professional misconduct and walked out of the General Medical Council with only a stain on his character. The GMC did not even have the power to put him on conditional registration. My Bill, which has not yet been accepted, would have allowed it to do so.
Enough of my Bill because we now have a Bill before us and that is very important. We should have some reservations about it, however. The first reservation should be about its format, as it has three or four principal clauses, which will trigger off a complex procedure. It took me quite a long time to fathom it out in the official documents. The procedure is not contained in a single diagram but in three diagrams of some complexity. No doubt those familiar with the GMC and the medical profession will be able to understand it. That complexity is another reason why we should study the Bill in a Special Standing Committee for three days, as we are allowed.
My second reservation concerns the screening procedure and I am sorry that I was late today as I know that one hon. Member present knows about it. I should have thought that it was controversial to have a single screener, or a screener with reference to just one other person. The process of screening complaints from any quarter will be replicated in the parallel procedure for performance, currently found in the realm of conduct. I have heard it said—we shall no doubt find out in Committee whether it is correct—that members of the GMC's preliminary purposes committee cannot consider cases which the screeners have already dismissed. That may have been changed by now; if not, I hope that it will be changed because it is not good procedure.
Those of us who have been in local government or on Committees of the House know that a chairman's action can be looked at and, even if it cannot be reversed, it can at least be revealed or further endorsed. Unless someone in such a crucial position is open to subsequent inspection, the public have cause for concern. Under the procedures to be adopted, the decisions of one or, at most, two screeners should be open to subsequent examination. After all, if someone writes to a member of the GMC and asks why a case did not come before it, that member should at least be able to look at the case, perhaps in confidence, to see why it was dropped. I do not think that can happen now.
Since introducing my Bill, I have received many letters about delays from all over the country. If someone complains to the GMC, it naturally puts the matter off if the complaint has gone to the family health services authority or one of the learned colleges of medicine. That 742 may be all right, but I have heard many examples where complaints have been brushed off, and the GMC's public relations in that respect do not always induce public confidence.
I have referred to the complexity of the diagrams on procedure. I make no specific complaint that the performance procedure as distinct from the final stages of the disciplinary procedure are held in private, as there may be an argument for that. The problem is that, once a complaint has been considered, and even after the screeners have said that there may be a case, the complaint can be dropped in at least three subsequent parts of the procedure before it reaches the proposed statutory committee—the assessment referral committee—and will not necessarily reach that committee at all. Although there may be nothing wrong with that, if it is not open to GMC members to consider those complaints, the public have cause for concern.
The hon. Member for Salisbury mentioned appeal to the Privy Council. That is confined to the conduct line of investigation but will be complicated if we are to have two parallel forms of investigation. Although the conduct of a doctor who is guilty of a criminal offence or some other misdemeanour that is not medical must be investigated, we now have no less than four committees: the preliminary purposes committee; the professional conduct committee; the assessment referral committee; and the assessment of professional performance committee. We also have the possibility of appeal to the Privy Council. Unless what is happening in those investigations is crystal clear and open to an extent, even if doctors are anonymous, I fear that difficulties may arise.
I should like to refer to the financial memorandum at the beginning of the Bill. I do not think that we should necessarily worry that doctors who are recommended for some form of retraining should receive it at public expense. I am not sure that that is correct, unless they are employed by the NHS, but I do not want to pursue that. I am interested in the estimated sum, because I cannot understand how it was arrived at. Perhaps the Minister will be able to tell me that when he replies. How do we know how many doctors will go through the retraining process? What standards of serious defective performance will be set by the various committees? How many doctors will be eligible for some sort of retraining or other acceptable courses before they reach the later stage in the retraining process? I cannot see how it was possible for anyone to make a realistic estimate of the amount contained in the financial memorandum. The sum will be paid per annum at the current cost, so what will happen later?
I am not arguing that it is wrong to give money for the retraining of doctors, but someone with a great deal of relevant experience said to me, "By George. Many of these doctors are getting on a bit and haven't kept up." I wonder how capable they are of benefiting from the sort of courses that will be offered. Such doctors may need something more, such as support from their colleagues, or something more subtle than a retraining course. We should ask a lot of questions about those financial arrangements.
I referred earlier to the format of the Bill and I should like to do so again, because of the procedural implications more than anything else. Although the Bill has relatively few clauses, designed to amend the Medical Act 1983, 743 the schedule to the Bill contains about 50 amendments—I accept that some may be minor—to the 1983 Act. Apart from the clauses, the schedule contains two chunks of amendments to be incorporated in the amended 1993 Act. I reckon that those amendments will create a few new complex sections in that Act when they are either laboriously changed in ink or in "Halsbury", or some computer has a go at it.
It might be worth while—it may be dealt with in another place—if the relatively few sections in the Act relating to doctors' performance were repealed and replaced by an entirely new section. It would be rather like replacing a unit in a complex piece of electronic machinery instead of trying to tinker with it by changing just odd parts. The meaning of the amended Act would then be clear. Unless that is done it will be extremely difficult to follow the new law. That might mean a feast day for lawyers, doctors and the Medical Defence Union, but it would not be right for us to leave legislation in such a tatty state.
The MDU expressed an interest in my amending Bill. I wrote an article about it in the Journal of the Medical Defence Union issue number one of 1991, in which I said:The Bill in essence is as much in defence of the reputation of the profession as a whole, since it would promote confidence in it that doctors deserve and the public have a right to expect.I suspect that that principle should be applied to the 1983. Act, as amended by the Bill, as much as to my own honourable effort.
I called my Bill the Turner-Stafford Bill because it was dedicated to two constituents; one, alas, dead while the other lady is still alive. One of the biggest lacunae in today's Bill is its failure to match what my private Member's Bill sought to provide.
Here we have two streams of procedure, a conduct procedure and a performance procedure. There is a triangle, and if one of the preliminary screeners says, "This is conduct; we ought to do this through the conduct leg of the procedure," and the procedure goes through as it did in the case of Dr. A, and in the end the doctor is found guilty of not having done this, that or the other, but his omissions are not considered to have amounted to serious professional misconduct, he cannot even be put on conditional registration. That is what happened with Dr. A.
If, on the other hand, the person controlling the original king points—the first screener—says, "Let us do this under the performance procedure," the case goes all the way through the performance channel and the committee says, "Dear, dear, there has been a serious lapse in performance here," the doctor will get retraining or be put on conditional registration. I consider that the better way of describing it, because the result should be remedial, not penal; we want remedies but not necessarily penalties. In that case the doctor would get something that it would be impossible for him to get under the present law if the case were dealt with under the conduct procedure.
Paraphrasing the legal language, my Bill simply said that if what a doctor had done did not amount to serious misconduct, but was nevertheless conduct unacceptable in a medical practitioner, the GMC would have the power to put him on some sort of conditional registration, however mild. The exact details could be tailor-made for the situation.
744 However, the GMC said that it did not want those powers. I now suggest—and I shall take the matter up in Committee—that if such a situation arises the conduct committee, which already exists, should have the power to refer the case back to the performance committee, saying that there had been no serious professional misconduct but that there had been a lack of performance. That would amount to what my Bill would have brought about. Although the GMC was against the idea at the time, I hope that it will reconsider.
The suggestion could form the basis of one of the amendments that we make to the Bill in Committee. I hope that the Committee will be that suggested in my procedural motion, which I hope the House will support as the most appropriate way of dealing with this important Bill, which not only affects all of us as members of the public, but affects all our constituents and also the noble profession of medicine.
§ Mr. Nicholas Brown
With the leave of the House, Mr. Deputy Speaker, I should like to respond to the debate—briefly, because I know that we are all anxious to hear the Minister's responses to the questions that he was asked not once but many times.
In my opening remarks I was uncharitable enough to observe that the governing party was padding the debate out and to allege that that was done to avoid exposing the Secretary of State to more contentious debates on health care. The debate has provided a fair amount of evidence to support that contention; it has been good-natured and well-informed, if somewhat repetitive.
The first Government Back Bencher to speak was the hon. Member for Birmingham, Edgbaston (Dame J. Knight); she was the first of several hon. Members to pay tribute to my hon. Friend the Member for Newham, South (Mr. Spearing) for the part that he has played over the years in repeatedly trying to bring before the House the issues addressed by the Bill.
The hon. Lady praised my hon. Friend and his supporters on both sides of the House for their endeavours, and she also mentioned the meningitis case to which my hon. Friend referred. Her words found widespread acceptance in the House when she asked what we could do about a doctor who said that he could not be bothered to see his patient. I must admit that I am pretty sceptical about how much retraining would help in such circumstances, yet retraining is a key feature of the Bill.
The hon. Member for Edgbaston expressed a fear that our health service would approach the American model and become more litigious. I agree with what she said about that, although I fear that the Government's national health service reforms take us in that direction, rather than help avoid it.
In a powerful contribution, my hon. Friend the Member for Newcastle upon Tyne, Central (Mr. Cousins) delivered himself of a highly critical and well thought-through critique of self-regulation. The Government have made it pretty clear that it is the legislation before us, amended as best we can in Committee and on Report, or nothing. They are not considering a more radical reform of the profession or professions.
My hon. Friend the Member for Newcastle upon Tyne, Central expressed uncertainty about the use of language in the Bill. He concentrated on the meaning of the word 745 "serious" and mentioned the number of procedural stages and the influence of old boy networks. The argument about language was well taken up by my hon. Friend the Member for Strathkelvin and Bearsden (Mr. Galbraith), who made a similar argument, although about the word "competence". Both words are important. Obviously, the way in which those terms will be defined in practice will set the standards for the profession, and it is right that we tackle those issues now and in detail during consideration in Committee.
That brings me to the contribution of the hon. Member for Chislehurst (Mr. Sims), who told us helpfully and fully of his work on the PPC. I pay tribute to him for that work. He rightly spoke of the importance of the laity in the work of the General Medical Council. However, although he expressed support for the principle of the Special Standing Committee procedure, which Labour Members would like to be followed in that case, he said that he did not consider that it was applicable in those circumstances, because there had been such widespread and thorough consultation.
I am sure that what the hon. Member for Chislehurst says is true, but let me say to him, as gently as I can, that Members of Parliament, especially members of the Opposition, have not been a part of that consultative procedure. If legislation is to pass through this place, it is for the elected Members of Parliament to satisfy themselves that the legislation is properly structured—not for all the outside interests to be so satisfied, and to come to Parliament and treat us as though we were a rubber stamp. Our constituents would not want us to be treated in such a way, and it would be demeaning to this place if we ever allowed ourselves to be treated in such a way.
I advocate crisp but mature scrutiny of the details of the legislation, once concise expert opinion has been heard—the same concise opinion to which people in the profession have already been exposed. I consider that that would serve Parliament better than the adversarial Committee procedures that I believe are the ones that the Minister favours—although I wait to be surprised and perhaps even encouraged.
I make the Minister an offer. I guarantee that, if the procedure that we wish to be adopted is accepted, we shall co-operate fully with that procedure and the Bill will not be unduly delayed. Indeed, that promise was made to him during the Queen's Speech by my right hon. Friend the Member for Derby, South (Mrs. Beckett).
The hon. Member for Wyre Forest (Mr. Coombs) got his teeth into the briefing notes so ably prepared by the House of Commons Library, although he diverted from them to accuse some patients of unreasonably becoming ill, thereby placing pressure on the national health service. [Interruption.] I hope that I do not do his contribution an injustice, although I hear from the groans of his hon. Friends that I may have paraphrased him unfairly. It is nevertheless the case that there is increasing pressure on the national health service, which shows up in the statistics for complaints and in the much smaller statistics relating to the GMC's ability to cope with complaints.
We had a powerful contribution from my hon. Friend the Member for Cannock and Burntwood (Dr. Wright), who discussed the extent of the powers in the Bill, made the case for the Special Standing Committee procedure 746 that we support and especially placed emphasis on the importance of definitions—an argument that was made by every Opposition Member who spoke.
We then began what I can only describe as a parliamentary filibuster. Conservative Members followed each other and spoke to the briefing notes. The hon. Member for Ribble Valley (Mr. Evans) condemned high-profile complaints and then treated the House to an example of a high-profile complaint. The hon. Member for Croydon, North-East (Mr. Congdon) read the Library note adequately, but he was rehearsing what the hon. Member for Edgbaston had said earlier.
The hon. Member for Beckenham (Mr. Merchant) got his parliamentary revenge on me and my former colleague, the late Harry Cowans, for having kept him up late at night in 1984 on the Rates Bill. He clearly harbours a grudge and undoubtedly remembers the inadequate whipping by the Government during the passage of that Bill. He was followed by the hon. Member for Castle Point (Dr. Spink), whom I must congratulate on having managed to find and then read to the House the one bit of the Library briefing note that other Conservative Members had not yet read. At that stage I found myself thinking, "Why me?"
The House will recall that last week I attended the passage of a private Bill when I represented, on my own, the parliamentary Labour party as my hon. Friend the Member for Hackney, South and Shoreditch (Mr. Sedgemore) delivered a two and a half hour defence of Bart's hospital. At least he did it with elegance and enthusiasm. Attending parts of today's debate was not like watching paint dry but like listening to it. Even the Minister's parliamentary private secretary fell to reading Scallywag—as far as I could see from here, it was the latest edition. Presumably he was checking to see if the Minister for Health appeared in it. I do not know whether that is part of his parliamentary duties—[Interruption.] The Minister obviously does not appear in it.
The hon. Member for Hexham (Mr. Atkinson) raised a perfectly good point about accountability. The General Medical Council is not responsible to the Secretary of State for Health; it is responsible directly to the Privy Council. Parliamentarians on both sides of the House are right to be especially vigilant when there is a suggestion that the royal prerogative is to be used rather than a decision of the House.
Every point having been made umpteen times, the hon. Member for Salisbury (Mr. Key) returned to an earlier theme. He would not have known that he was returning to an earlier theme as he entered the debate pretty late and apologised for doing so. He asked what was meant by professional misconduct. The discussion about definitions is at the heart of today's debate. The key question is how should a profession be regulated. I say as gently as I can to the House that it must involve professionals, even if only professional advice. The laity are also important—a subject that we shall want to examine in Committee—because they are there to represent the public interest.
The debate's second theme involved the meaning of the key terms in the Bill. As my hon. Friend the Member for Newcastle upon Tyne, Central asked, how is "serious" to be defined and why is the word "serious" necessary? My hon. Friend the Member for Strathkelvin and Bearsden made exactly the same point around the use of the word "competence". We were asked whether a single incident would be sufficient under the new procedures or whether 747 a doctor's performance over time was to measured under the new procedures. I understood the Minister to say that there were circumstances in which a single incident could of itself bring the new procedures into play. We shall wait to see the sort of cases that will emerge. It is important that we understand that a single incident could trigger off the procedures.
Will the Minister tell us whether the Government intend to legislate for the other professions? In my opening remarks I listed the phrases that pertain to disciplinary actions involving the other national health service professions, and a response from the Minister tonight would be helpful.
I conclude by making a plea around the procedural point. It would reflect credit on the House if we dealt with this issue, on which there is no division on principle between us, in a non-adversarial way in a Special Standing Committee, thus enabling people to give evidence to us so that we could make our decisions on the basis of it. It is a suitable Bill for that procedure, and I make the Minister this pledge: if he adopts that procedure, we shall do everything that we can to facilitate it and make it work as it should rather than to frustrate it or use it in a partisan way.
§ The Minister for Health (Mr. Gerald Malone)
I must first refute the scandalous suggestion made by the hon. Member for Newcastle upon Tyne, East (Mr. Brown) that the contributions made by Conservative Members were anything other than extremely constructive. I listened to all of them with care. My hon. Friends, like the hon. Gentleman's colleagues and the hon. Member for Argyll and Bute (Mrs. Michie), contributed to an excellent debate on a complex subject and each raised a number of novel points, to which I shall respond.
I must also point out that, had it not been for my colleagues carrying the debate when there were no Opposition Members here to do so, the hon. Member for Newham, South (Mr. Spearing) who, with his usual courtesy, had alerted my colleagues and I to the fact that he was hoping to speak but could not be here until late, would have been thwarted, returning to the Chamber only to find the debate had finished. I, for one, am pleased that he was able to make his valuable contribution.
§ Mr. Nicholas Brown
I must apologise. I had not realised that the governing party was deliberately keeping the debate going so that my hon. Friend the Member for Newham, South could contribute. I apologise to the Minister and thank him for filibustering in a debate on the Government's own legislation.
§ Mr. Malone
It was a happy and slightly unforeseen consequence of my hon. Friends' enthusiasm.
I am extremely pleased to be able to thank the hon. Member for Newcastle upon Tyne, East for his remarks in support of an important Bill and for saying that, ultimately, the Bill will pass through Committee with reasonable dispatch, subject to discussion of the very many issues that will be raised in Committee and to which hon. Members of all parties have alluded. I hope that the circulation of the notes on clauses will assist detailed discussion of the Bill later.
Hon. Members raised a wide range of concerns about the responsibilities of the General Medical Council as well as their views on the Bill. I shall try to deal in detail 748 with as many as possible and comment on some aspects of the Bill that have not been raised in great detail—and there are some, although the hon. Member for Newcastle upon Tyne, East may not think so.
When my right hon. Friend the Secretary of State opened the debate, she mentioned the importance that the Government attach to the GMC's new procedure. I am happy to wind up the debate, but I must make it clear that the Under-Secretary of State for Health, my hon. Friend the Member for Bolton, West (Mr. Sackville), who was here at the beginning of the debate but was unable to remain until the end because he had commitments elsewhere, will take the Bill through its remaining stages.
Several hon. Members mentioned the possibility of a Special Standing Committee. The Government believe that there has already been thorough consultation on the Bill's subject matter. The GMC has issued two consultation documents and we believe that little would be gained by using the Special Standing Committee procedure in this case. I listened with some care to the hon. Members for Newham, South and for Newcastle upon Tyne, East on this subject, but, following the consultation process, it is clear that the Bill is supported by a wide range of professional groups and patient groups which comprise the type of people who would come before such a Committee. They have made their position clear. The remedial approach is supported by professionals; it is preferable to putting doctors through adversarial proceedings of conduct hearings, which are regarded as punitive and would require criminal standards of proof.
As those important matters have been extremely well aired by the GMC in the two consultation documents, it is the Government's view that a Special Standing Committee would not be entirely appropriate as the purpose of such a Committee is to raise novel issues that were not canvassed before the Bill reached Second Reading.
§ Mr. Spearing
In the bipartisan atmosphere, I thank Conservative Members for bringing to the debate facts and matters that have been transferred from another part of the building and that otherwise might not have been recorded in Hansard. Does the Minister agree that nothing will change the Standing Committee stage? All he is saying is that we are not to have the preliminary of up to three mornings. He says that it is not worth it. How does he know? How can he prejudge what extra might emerge in those Select Committee hearings?
§ Mr. Malone
I am not trying to prejudge that. There has been a substantial consultation process that is adequate for the Bill to proceed.
§ Mr. Malone
No. I have a substantial number of points to address in the remaining 15 minutes, not least some of those raised by the hon. Gentleman.
I cannot give the undertaking that the hon. Gentleman Newcastle upon Tyne, East sought. I turn directly to a number of points that he raised. First, he asked about the role of the screener. I repeat that the screener, who will be a medical member of the GMC, will decide whether there is sufficient evidence to support an allegation of seriously deficient performance. He will examine the evidence submitted to him and, if necessary, will seek additional information.
749 A complaint can be dismissed only with the concurrence of a lay screener. The Government believe that that will afford protection to complainants in that their complaints cannot be dismissed by one individual alone. That provides substantial reassurance.
The hon. Gentleman also asked whether retraining is the answer if a doctor is persistently poor. A doctor must be given a chance to mend his or her ways. The Bill is not punitive, but designed to bring people back into line.
The assessment process may be the first time that a doctor is brought to the point of accepting that his or her performance is poor. Training may not be the sole answer. That point was raised by the hon. Member for Newham, South, who said that it might be a fairly complex matter. There may also be a need for counselling or for a period working under the guidance of another doctor. If a doctor does not improve, or performance is found to be so poor that there is a danger to the public, the matter can be referred immediately to the committee on professional performance, which can impose sanctions, conditions or suspension.
The hon. Member for Newcastle upon Tyne, East also asked about the reinstatement of doctors who had voluntarily removed their names from the register, consequential to the powers in clause 2. If a doctor subsequently applies to have his or her name reinstated,, the application for reinstatement will be considered by the appropriate committee of the GMC.
The hon. Gentleman also raised the important issue of meetings in private. Rules will provide that the assessment referral committee will meet in private. One of the reasons for that is that the proceedings before that committee are preliminary in nature and should be held in private, as are the preliminary proceedings committee of the GMC, which considers conduct matters.
I am sure that the hon. Gentleman will have recognised that the Bill provides that rules will be made determining whether proceedings before the committee on professional performance, which is the main committee in respect of the legislation, will be in public or private. Initially, the GMC has taken the view that it would like them to be in private, but it will keep the matter under review. In any event, the doctor who is the subject of the proceedings will be able to demand that the proceedings be public if that is what he or she wishes.
The hon. Gentleman also mentioned other professional bodies and inconsistent powers, to which he asked me to refer specifically in my winding-up speech. He is correct in his summary of the powers of other health regulatory bodies. They differ to some extent and none parallels exactly the GMC's new performance procedures. The Bill results from a medical profession initiative and we would be very interested in proposals for change that any other professional bodies may choose to develop and bring forward. However, such proposals must be developed as carefully as the GMC's measures and should include public consultation, which was a very important element of the GMC's preparation for the Bill. At present, we have no plans to introduce legislation, although we would be prepared to consider the matter if other professional bodies put such proposals before us.
I now turn to the excellent speech by my hon. Friend the Member for Birmingham, Edgbaston (Dame J. Knight), who raised a number of points that I shall address 750 directly. She asked, rather pertinently, what clause 1(9) of the Bill means. How will people—for example, employers—know that a doctor has been suspended? That is an important question.
§ Mr. Malone
My hon. Friend will doubtless be glad to hear—as she endorses its importance from a sedentary position—that, if a doctor is suspended, his or her name will still appear on the register simply because the name has not been erased. The registrar of the GMC will ensure that a note appears against the doctor's name to the effect that suspension has taken place or that conditions have been imposed on registration. Anyone who makes a search of the register—as employers should do—will discover what the position is.
Access to the register will also be improved. The GMC is actively exploring ways to make the register more accessible in its up-to-date form, which will be important as matters proceed fairly quickly. For example, it will be made available on the Internet—how fashionable can one get, Mr. Deputy Speaker?—or on CD-ROM. I assure my hon. Friend that the register is checked regularly by employers—12,000 last August—to ensure its effectiveness. It is an extremely active register and I hope that my hon. Friend is reassured by my comments.
A number of hon. Members raised the issue of seriously deficient performance. There is no clear definition beyond that in the Bill which, as I said to one hon. Gentleman, is not unusual when drafting legislation of this sort. However, I shall explain what is intended for the future. The GMC will issue guidance setting out the standards of professional performance that will be expected of doctors. It currently gives similar guidance on professional conduct and medical ethics in the blue book, as the hon. Member for Newcastle upon Tyne, Central (Mr. Cousins) mentioned. Future definitions will be advanced in the blue book or its equivalent.
Once guidance is available, the GMC will have a clear yardstick against which to measure a doctor's performance and it can therefore decide whether a doctor has been seriously deficient in his conduct. In addition, I am assured that the GMC will publish the details of the outcome of performance hearings. As the process develops, a clear body of knowledge will build up to which people can refer in much the same way as a body of case law develops in other areas.
My hon. Friend the Member for Edgbaston also raised the question of overseas doctors. She asked whether language difficulties could count as serious deficiencies in performance. I think that that would be unusual because language ability is tested before registration is granted. However, if communications problems prevented a doctor from competently examining a patient, taking a clinical history and explaining treatment plans and things of that sort, it would constitute a serious deficiency in performance—although I think that such an occurrence would be extremely unlikely.
The hon. Member for Newcastle upon Tyne, Central suggested that the profession was too protected. Under the Bill, anyone may send information to the GMC on a doctor's performance—patients, employers, health authorities or other doctors. I disagree with him that it is a profession that is protecting itself. It is an open procedure and I believe that the rest of the House has recognised it as such.
751 I congratulate my hon. Friend the Member for Chislehurst (Mr. Sims) on making an extremely important contribution to the debate, as I am sure he will to the Committee. He knows a tremendous amount and is well-versed in these matters. The next time I pass him in the Library and see him behind a pile of books, I will know what he is doing. It was good of him to enlighten us.
The hon. Member for Christchurch (Mrs. Maddock) stated that the ultimate sanction of erasure would be available under the Bill. I would like to point out to her that it will not. I would not like her to harbour any illusion on that point. A doctor cannot be erased under these procedures. A doctor can only be suspended or have conditions attached to registration.
My hon. Friend the Member for Wyre Forest (Mr. Coombs) was concerned that the devil is in the detail of the Bill—as it is with so many other pieces of legislation that come before us. The rules that will be made by the GMC are subject to detailed scrutiny by the Privy Council after consultation with Department of Health lawyers.
My hon. Friend the Member for Croydon, North-East (Mr. Congdon), and a number of other hon. Members, asked whether a single act that fell short of serious professional misconduct could be dealt with by the proposed procedures. I said at the time that the answer was yes, and I confirm that. That single act may trigger the action, but the action itself as it goes forward will look at the outcome of the assessment process. Of course, the assessment process will not be based on the single act but will look far more broadly at the track record of the doctor.
§ Mr. Malone
No, I am not. I am saying that the single incident may trigger the procedure, but clearly, by its nature, the assessment process does not look just at the single incident that has been raised. It is expected that an iceberg of problems will be revealed once the assessment committee begins to look at it.
Perhaps the hon. Gentleman will pursue that matter in Committee, as I want to move on to a few other points, particularly that raised by the hon. Member for Strathkelvin and Bearsden (Mr. Galbraith). I think that I am the only hon. Member to pronounce his constituency correctly this evening. Doubtless he will be grateful for that. He raised the point that a doctor may be an incompetent orthopaedic surgeon but be all right to practise in other areas. He asked what could be done about that. The GMC will be able to place specific conditions on a doctor's registration.
The hon. Member for Cannock and Burntwood (Dr. Wright) asked whether the GMC should treat doctors who ignore concerns about a colleague's conduct, health or performance as guilty of serious professional misconduct. The GMC will take action, I can assure him, where it discovers that a doctor is not fulfilling a professional obligation, as outlined in the GMC blue book. So that will indeed happen.
A number of my hon. Friends raised other points later in the debate. I should like in particular to deal with the point raised by my hon. Friend the Member for Castle 752 Point (Dr. Spink), who asked why there was no reference to the role of the health service commissioner in the Bill. The GMC is, of course, an independent statutory body and is in no way related to the health service commissioner, who can take an interest only in the NHS.
A number of other matters were raised on the Bill. I cannot refer to them now, but doubtless they will be raised in Committee.
The measure has not simply been sought by the GMC but been endorsed by the Government and the Opposition parties. That is quite right. It is an important measure, not just for the medical profession but for patients, who will be reassured by the fact that there is unanimity on both sides of the House about the principle of the Bill, although amendments might well be tabled in Committee. I am delighted to support the measure, to bring it to the House, to make a real improvement, not just for patients but, in the proper context, for the medical profession. It is better to retrain doctors who become less competent, rather than to penalise them. I recommend the Bill to the House.
§ Question put and agreed to.
§ Bill read a Second time.
Motion made, and Question put forthwith pursuant to Standing Order No. 61(2),
That the Bill be committed to a Special Standing Committee.—[Mr. Spearing.]
§ The House divided: Ayes 37, Noes 133.753
|Division No. 135]||[10.00 pm|
|Beckett, Rt Hon Margaret||Loyden, Eddie|
|Beggs, Roy||Lynne, Ms Liz|
|Beith, Rt Hon A J||McFall, John|
|Betts, Clive||Maddock, Diana|
|Brown, N (N'c'tle upon Tyne E)||Mahon, Alice|
|Chisholm, Malcolm||Maxton, John|
|Dalyell, Tam||Michie, Bill (Sheffield Heeley)|
|Davidson, Ian||Oakes, Rt Hon Gordon|
|Donohoe, Brian H||Powell, Ray (Ogmore)|
|Dowd, Jim||Prentice, Bridget (Lew'm E)|
|Fatchett, Derek||Rendel, David|
|Foster, Rt Hon Derek||Ross, William (E Londonderry)|
|Foster, Don (Bath)||Skinner, Dennis|
|Galbraith, Sam||Taylor, Matthew (Truro)|
|Gordon, Mildred||Tipping, Paddy|
|Gunnel, John||Wright, Dr Tony|
|Jones, Barry (Alyn and D'side)||Tellers for the Ayes:|
|Kirkwood, Archy||Mr. Harry Barnes and|
|Lewis, Terry||Mr. Jim Cousins.|
|Aitken, Rt Hon Jonathan||Budgen, Nicholas|
|Amess, David||Burns, Simon|
|Arbuthnot, James||Burt, Alistair|
|Arnold, Jacques (Gravesham)||Butcher, John|
|Atkins, Robert||Butler, Peter|
|Atkinson, Peter (Hexham)||Cash, William|
|Bates, Michael||Churchill, Mr|
|Biffen, Rt Hon John||Clark, Dr Michael (Rochford)|
|Booth, Hartley||Congdon, David|
|Bottomley, Peter (Eltham)||Conway, Derek|
|Bottomley, Rt Hon Virginia||Coombs, Simon (Swindon)|
|Bowis, John||Cran, James|
|Brandreth, Gyles||Davies, Quentin (Stamford)|
|Brazier, Julian||Day, Stephen|
|Bright, Sir Graham||Dorrell, Rt Hon Stephen|
|Brooke, Rt Hon Peter||Douglas-Hamilton, Lord James|
|Browning, Mrs Angela||Duncan, Alan|
|Dunn, Bob||Mitchell, Andrew (Gedling)|
|Evans, David (Welwyn Hatfield)||Monro, Sir Hector|
|Evans, Nigel (Ribble Valley)||Neubert, Sir Michael|
|Faber, David||Nicholson, David (Taunton)|
|Fabricant, Michael||Onslow, Rt Hon Sir Cranley|
|Fox, Sir Marcus (Shipley)||Paice, James|
|French, Douglas||Pattie, Rt Hon Sir Geoffrey|
|Gallie, Phil||Porter, David (Waveney)|
|Gardiner, Sir George||Powell, William (Corby)|
|Garnier, Edward||Robathan, Andrew|
|Goodson-Wickes, Dr Charles||Roberts, Rt Hon Sir Wyn|
|Gorman, Mrs Teresa||Robertson, Raymond (Ab'd'n S)|
|Greenway, Harry (Ealing N)||Ryder, Rt Hon Richard|
|Greenway, John (Ryedale)||Scott, Rt Hon Sir Nicholas|
|Griffiths, Peter (Portsmouth, N)||Shaw, David (Dover)|
|Hague, William||Shersby, Michael|
|Hamilton, Rt Hon Sir Archibald||Sims, Roger|
|Hargreaves, Andrew||Spicer, Michael (S Worcs)|
|Haselhurst, Alan||Spink, Dr Robert|
|Hawksley, Warren||Sproat, Iain|
|Hayes, Jerry||Stanley, Rt Hon Sir John|
|Hendry, Charles||Stephen, Michael|
|Hicks, Robert||Stern, Michael|
|Howard, Rt Hon Michael||Stewart, Allan|
|Hunt, Rt Hon David (Wirral W)||Streeter, Gary|
|Jenkin, Bernard||Sweeny, Walter|
|Johnson Smith, Sir Geoffrey||Sykes, John|
|Taylor, Ian (Esher)|
|Jones, Robert B (W Hertfdshr)||Taylor, John M (Solihull)|
|Kellett-Bowman, Dame Elaine||Thompson, Patrick (Norwich N)|
|King, Rt Hon Tom||Thurnham, Peter|
|Kirkhope, Timothy||Townsend, Cyril D (Bexl'yh'th)|
|Knapman, Roger||Twinn, Dr Ian|
|Knight, Mrs Angela (Erewash)||Viggers, Peter|
|Knight, Greg (Derby N)||Walker, Bill (N Tayside)|
|Knight, Dame Jill (Bir'm E'st'n)||Waller, Gary|
|Knox, Sir David||Wardle, Charles (Bexhill)|
|Kynoch, George (Kincardine)||Waterson, Nigel|
|Lait, Mrs Jacqui||Watts, John|
|Lawrence, Sir Ivan||Wells, Bowen|
|Legg, Barry||Wheeler, Rt Hon Sir John|
|Lidington, David||Whittingdale, John|
|Lightbown, David||Willetts, David|
|Lloyd, Rt Hon Sir Peter (Fareham)||Winterton, Mrs Ann (Congleton)|
|Luff, Peter||Winterton, Nicholas (Macc'f'ld)|
|Lyell, Rt Hon Sir Nicholas||Wolfson, Mark|
|MacKay, Andrew||Wood, Timothy|
|McLoughlin, Patrick||Yeo, Tim|
|Mans, Keith||Tellers for the Noes:|
|Martin, David (Portsmouth S)||Mr. Sydney Chapman and|
|Merchant, Piers||Dr. Liam Fox.|
§ Question accordingly negatived.
§ Bill committed to a Standing Committee, pursuant to Standing Order No. 61 (Committal of Bills).