§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Anthony Coombs.]10.28 pm
§ Mrs. Maria Fyfe (Glasgow, Maryhill)
I thank Madam Speaker for giving me the opportunity to raise my constituents' concerns in an Adjournment debate. My involvement in the affair began when two of my constituents asked for my help. They had attended a local dentist by the name of William Duff. They had been given treatments that were both unnecessary and grossly unsatisfactory, creating long-term dental problems and the necessity for substantial remedial work. They had complained to Greater Glasgow health board.
It took months for those cases to be heard while Mr. Duff gave endless reasons not to turn up for the inquiries. In a third case, my constituent did not even receive a response when she wrote on two occasions to the Department of Practitioner Services. Finally, Greater Glasgow health board was faced with an authoritative professional opinion to the effect that my constituents' complaints were more than justified. Indeed, the consultant's professional opinion showed that there was far more cause for concern than had been realised.
Far from responding helpfully and putting matters right, the health board has rejected my constituents' claims on bureaucratic grounds, expecting them to provide evidence that they do not have and cannot reasonably be expected to have. So far, the Scottish Office has not responded any more helpfully, although I gather that legal advice is being sought by the Department in some cases.
At first, I thought that those were fairly routine matters and the regular experience of Members dealing with a constituent's complaint of unfairness by an authority. I now know that, far from my constituents' distress being isolated incidents, a man's career was well known over a number of years to Greater Glasgow health board.
At its meeting on 21 September 1993, the board agreed that the inclusion of Mr. Duff in the list of dental practitioners would be prejudicial to the efficiency of the provision of general dental services. The board's legal advisers submitted representations to a tribunal on 11 January 1994. It was not until February this year that the tribunal directed that Mr. Duff should be struck off every health board list in the country after a Greater Glasgow health board committee found him in breach of his terms of service, much too late to protect who knows how many unwitting patients from this man's greed.
It was greed that lay at the bottom of the matter. Mr. Duff is a fully qualified dentist. The fact that he has been removed from health board lists does not prevent him from working in private practice. Many people, seeking a dentist, might imagine that in paying a private sector dentist they were buying a superior service, but in Mr. Duff's case at least they would be extremely misguided.
As the excellent "World in Action" programme recently pointed out, people think of bacteria as the enemy, not their dentist. Most of the time, of course, they are right. If it had not been for the evidence given to the patients by Mr. McCrossan, who examined their mouths at the dental hospital, and given to me by another dentist, a highly experienced one who teaches postgraduate 128 students, I would not have realised how great was the magnitude of Mr. Duff's wrongdoing and how badly certain patients had been let down by the health board.
I shall give the House an idea of how bad some individual cases have been. Angela Mulhern had work carried out by Mr. Duff in 1993–94. She is now a constituent of the Minister with responsibilities for health. Having no previous history of dental trouble, she now is unable to work regularly, and has had to give up her job and her home. The health board refused to investigate her complaint because she cannot give the specific dates of her treatment. But Mr. Duff has removed her records from the practice. Her treatment has never been completed, so the time bar rule should not apply. She is being told that it does. Mr. McCrossan said of her treatment:I know of no pattern of dental disease which attacks the posterior teeth so severely, yet leaves the anterior teeth unaffected … Not all of the treatment was clinically necessary—generally the quality of the treatment is well below the level I would expect from a competent dental practitioner … Miss Mulhern had no pain before treatment, but has never been free from pain since.I have been pursuing the cases of Moann Russell and Nicola O'Neill for two years with Greater Glasgow health board and the Scottish Office. In Moann's case, the consultant, Mr. McCrossan, wrote:I must question whether the original dentistry was required … I am appalled by the dismally poor quality of the work … It is a tribute to nature that she had no acute symptoms at the time of her visit to me.In addition, the dental service committee found in May 1995 that the treatment claimed for on the GP17 forms did not match that recorded on the patient's dental record card.
In Nicola's case, Mr. McCrossan wrote:Apart from the treated teeth Nicola's mouth is in excellent condition. This sort of treatment plan I would have expected in a badly neglected mouth … Our problem now is to attempt to repair the damage that has been done".Nicola was under age to give her own consent when treatment began with Mr. Duff. The form is signed by one Susan McEwing, a person not known to Nicola.
Mairi Patrick's case became known to me only recently. Mr. McCrossan commented:the vast majority of the work is of poor quality, far below what I would expect".The health board has refused to pay for re-treatment because her complaint was made later than the 13-week limit.
Mr. Duff first came to attention in 1987, when he was fired by the dentist who employed him at that time. His treatments of at least 10 patients were set out in a damning report to Ayrshire and Arran health board, but it had no responsibility to tell anyone else.
§ Mr. Gordon McMaster (Paisley, South)
Earlier tonight, after my hon. Friend had some publicity about her Adjournment debate, I received a telephone call from Nicholas Gilmour, who, in 1987, was a constituent of mine and attended the same dental practice as I do in Johnstone, where I have had nothing but excellent treatment. He tells me that William Duff worked in that practice in Johnstone and that he was given three crowns, two of which were unnecessary. He had to undergo very painful operations. In 1987, Argyll and Clyde health 129 board was involved. Mr. Gilmour was taken to the Scottish Office home and health department to be examined. I wonder why nothing was done then, in 1987.
§ Mrs. Fyfe
My hon. Friend raises an important point. It shows that three health boards have had experience of that dentist, yet because there is no obligation to transfer information, that kind of thing can go on and on until it is finally stopped. Like my hon. Friend, I wonder what happened on that occasion.
After the experience with Ayrshire and Arran health board, Mr. Duff moved to Maryhill. About 20 of his cases were subsequently referred to Greater Glasgow health board for action by the regional dental officer. Some of his patients had been treated with a substance called endomethesone, which contains a steroid and a mummifying agent. The latter's effects wear off up to two years later. It hid the continuing presence of infection in the patients' teeth, which flared up later. Mr. Duff was using it as a quick fix, because careful treatment to remove all the infection took more time, and time was money to him. There was no way a patient could know that, which is reason enough for the time limits on hearing complaints from patients to be reviewed once again, as even the recent reform would not necessarily take account of that.
In one year, Mr. Duff received £450,000 from the national health service, and more than £1 million in two and a half years. Average gross income per annum is £90,000, which, after deduction of expenses, leaves a dentist with an average income of £37,000. Mr. Duff was always at the top by far in the Scottish league table of dentists' incomes from 1992 to 1994. Very reasonable suspicion of Mr. Duff's care and attention of his patients was naturally aroused in the profession. Those people knew that he could not be making that money and taking the care required. Questions arose about the possibility of false claims for work that had never been done.
Mr. Duff made a practice of getting patients to sign the form authorising treatment at the start of treatment, and in at least some cases that I know of, they did not sign at the end. When one member of the health board—a member of the Scottish Dental Practice Board —raised that matter, one might think that surely Duff's number would be up. But no. That person's repeated threats of resignation from the health board fell on deaf ears, because the lay members of the board—that quango appointed by the Secretary of State— supported Duff. Their attitude, apparently, was that his high earnings showed that he must be a good business man and that his production line was more efficient than the rest. One might say that the whole affair gives a new meaning to the saying, "No gain without pain." Mr. Duff's gain meant other people's pain.
This is not a completely isolated case. There are fears among those who care about quality in the NHS that Mr. Duff, whose story is well known to dentistry students in Scotland, might have influenced a number of younger dentists to try to get away with it. In 10 years he has made enough to buy a house worth £220,000, in Kilbarchan, and a BMW estate and a Land Rover Discovery, both with personalised number plates.
My complaint is not that there are rich pickings for the unscrupulous, nor is it a complaint about dentistry in general. Thankfully, most of us can and do trust our 130 dentists. First, I want the Minister to deal with the failure of Greater Glasgow health board to respond with the flexibility that it had at its disposal—even under the old complaints system that existed before April 1996—to make amends to my constituents and to ensure that they receive the most appropriate treatment, where possible, without the expense that they cannot afford.
I agree with the British Dental Association that it is much better for a patient's complaint to be resolved as soon as possible. It is time that our system ensured that.
Secondly, it is necessary to review the monitoring system to ensure that standards are upheld, and that the NHS is not paying either for non-existent or shoddy work. The Scottish Dental Practice Board should notice if a dentist has an unusual prescribing pattern, and should be able to insist on cases being heard by the health board without delay, but at present no such safeguard exists.
Thirdly, Mr. Duff's patients have consistently had to refute misrepresentations of the facts, and have had endlessly to deal with the fact that their evidence has been officially ignored. I therefore want an independent investigation of each complaint that has been raised against Mr. Duff.
There is much more to tell, but time does not permit it. Incompetence was not the reason for his patients' sufferings: Mr. Duff is a fully qualified dentist. The reason was his determination to get as much cash as he could out of the NHS.
The NHS was brought into being 50 years ago to help people gain a standard of health that poverty had historically denied most of them. It is unacceptable that patients today are denied justice, because they cannot afford either court action or the cost of re-treatment when a practitioner has betrayed their trust. I trust that the Minister will be minded to respond in full to those requests.
§ The Minister of State, Scottish Office (Lord James Douglas-Hamilton)
I congratulate the hon. Member for Glasgow, Maryhill (Mrs. Fyfe) on raising some important matters and begin by making the obvious point that if the General Dental Council erases the name of a dentist from its register, that dentist cannot practise. Practising in those circumstances would be a criminal offence.
I should also mention that 50 to 80 per cent. of the gross earnings of many dentists relate to expenses. That may be the case with this individual.
The hon. Lady has asked me to look into various matters. Tomorrow, I shall study what she has said in great detail, because some of the matters are complex. I shall try to give a full explanation of what has happened and why, and of what is likely to happen in the future.
Happily, the occasions on which such complaints are made are few. The great majority of dentists are committed to their profession and to using their skills for the benefit of their patients. That is why it is important that there should be robust procedures to deal with dentists who fail to provide care to the high standards of skill and probity that we rightly expect.
The Scottish Office recognised that the previous procedures were unsatisfactory in a number of respects, and the hon. Lady has described some of them. We therefore instituted a review of the NHS complaints 131 procedures by a committee chaired by Professor Alan Wilson. The Wilson committee reported in May 1994, and recommended radical change, the most fundamental of which was the principle that the consideration of complaints should be separate from the handling of discipline. New arrangements based on the Wilson committee's recommendations were introduced in April 1996. I shall return to them later.
The events relating to the concerns expressed by the hon. Lady took place during 1993– 94. It is a basic principle of our system that changes do not apply retrospectively. The handling of complaints about Mr. Duff must, therefore, be governed by the regulations in force at that time.
I have every sympathy with the hon. Lady's constituents. Indeed, as she mentioned, one of my constituents has also complained about Mr. Duff, so I know that it has been a very distressing experience, but the regulations in force at the time cannot be ignored.
I shall explain the regulations. Until 1 April of this year, complaints and questions of discipline about dentists and other family health service practitioners who provide treatment under the NHS were dealt with under the same system. It involved referral to statutory service committees where appropriate and, in the most serious cases, referral to an NHS tribunal.
The rules governing the time scale within which complaints had to be made were laid out in the NHS (Service Committees and Tribunal) (Scotland) Regulations 1992, which state that a complaint must be made within six months of the end of the treatment that gave rise to the complaint, or within 13 weeks of the cause for complaint becoming known to the complainer, whichever was the sooner.
Any complaint made more than six months after the date on which treatment ended was, by virtue of that fact, a late complaint, and for a late complaint to be investigated by a service committee the patient had to show, for each and every day, that there was good reason for the delay in submitting the complaint. The onus was on the patient to show that he or she could not have known earlier that there was cause for complaint, and that they made the complaint immediately they were so aware unless they could show good reason, such as bereavement or illness, for each day they delayed further.
It was, of course, open to patients to appeal to my right hon. Friend the Secretary of State for Scotland against a health board decision to dismiss a complaint on grounds of lateness. In such cases, the Secretary of State is precluded from considering the merits of the complaint. The only question that he can address is whether the lateness of the complaint was justified.
I have dwelt on those points in some detail because many of the issues that the hon. Lady has raised revolve around the question of lateness. In particular, she accused Greater Glasgow health board of inflexibility in its handling of cases relating to Mr. Duff. As I have explained, the health board must apply the regulations as they stood at the time, and they do not allow for much latitude.
132 I shall now deal with the question of complaints against Mr. Duff. I understand from Greater Glasgow health board that it received many complaints about Mr. Duff from patients during 1993.
§ Mrs. Fyfe
If the Minister will undertake to examine closely the cases to which I have referred, he will see that they are not generally time-barred because of individual circumstances. I did not have time to explain earlier, but if he studies the cases I think he will find that they should have been considered and have been wrongly rejected.
§ Lord James Douglas-Hamilton
I will study what the hon. Lady has said very closely, but I must operate according to the same criteria for all constituents, regardless of the constituency from which they come. Whether a case is time-barred is a matter of legal interpretation, and I must follow the best advice that the Scottish Office lawyers give as objectively as possible. I will study what the hon. Lady has said very closely, but I act on the basis of the best information that we now have available. I shall deal with each case individually because, as the hon. Lady will appreciate, there are many cases of this kind.
The volume of complaints of a potentially serious nature was such that the board took the step of referring Mr. Duff directly to an NHS tribunal on 11 January 1994. The case was protracted, both because of the volume of evidence and because the proceedings were adjourned for a time when Mr. Duff was unwell. Mr. Duff ceased to practise in the summer of 1994. The tribunal, under the chairmanship of Mr. W. C. Galbraith QC, issued its report in February this year. It found that Mr. Duff had been in breach of his terms of service on many counts, and directed that his name be removed from the dental list of the health board. It also directed that Mr. Duff's name should not be included in the list of any other board.
I understand that, in addition to the cases that were covered by the tribunal, 18 subsequent complaints were looked into by Greater Glasgow health board's dental service committee. In 15 cases the complaint was late and against the criteria that I have explained this evening. The health board decided, on the ground of lateness, that those cases should not be investigated. In five of those cases, an appeal was made to the Secretary of State. One is awaiting determination, three have been dismissed, and one case was allowed. Three were dismissed because grounds for lateness were inadequate and did not meet the criteria. The one case that was allowed is now being investigated by Greater Glasgow health board. I have again gone into some detail because it is important to realise that these cases are complex. Each has to be considered on its merits and the outcome of each can be different, depending on the individual circumstances.
In three cases that were in time, the service committee held that the complaints had been made timeously, and these cases include those of the hon. Lady's constituents. In both cases the health board decided, on the recommendation of the dental service committee, that Mr. Duff was in breach of his terms of service on some counts but not on others. The complainants have appealed against the findings adverse to them, and Mr. Duff has done likewise. Appeals in these hybrid cases are complex and, as I have explained, they must be considered in terms of the regulations in force at the time. 133 I regret that the appeals by the hon. Lady's two constituents, Miss O'Neill and Mrs. Russell, have not yet been determined. Appeals are dealt with as far as possible in the order in which they are submitted. The efforts required to put in place the new system for patient complaints and practitioner discipline meant that resources had to be diverted and, unfortunately, a backlog of appeal cases arose. Since the summer, that backlog has been substantially reduced. The cases in question are now being looked at urgently, and decisions will be taken shortly. The House will appreciate that I cannot give any indication now of the likely outcome, but I undertake to inform the hon. Lady as soon as decisions are made.
§ Mr. McMaster
My request is simple. The Minister has undertaken to look in detail at the cases in Greater Glasgow health board. Will he also look at the case of Nicholas Gilmour in Argyll and Clyde health board and at cases in Ayrshire and Arran health board?
§ Lord James Douglas-Hamilton
Yes, and I shall write to the hon. Gentleman in due course. I will not give a snap answer.
The hon. Lady has raised concerns about the freedom of dentists to continue to practise in the NHS while they are under investigation by a tribunal, and about their ability after disqualification to practise as assistants or deputies. I can reassure her on both counts. First, since Mr. Duff's failings came to light, the powers of the tribunal have been extended. By virtue of the National Health Service (Amendment) Act 1995, the tribunal has power to suspend a practitioner, if that is necessary for the protection of patients, pending full consideration of the case.
Secondly, removal from the dental list means that Mr. Duff may not practise in the NHS as a principal or as an associate. All health boards and trusts in Scotland have been notified of the disqualification. The disqualification applies throughout the United Kingdom and other health departments have been informed. In addition, regulations require that he may be employed as a deputy or assistant only with the consent of the Secretary of State. There have been no such applications on behalf of Mr. Duff, and he is not allowed to practise in the NHS.
In terms of practising outside the NHS, decisions about a dentist's fitness to practise are matters for the General Dental Council. The tribunal's findings have been reported to it and I understand that it will consider them shortly. Whether Mr. Duff's certificate to practise should be withdrawn altogether is a matter for the General Dental Council. It has the power to erase a dentist's name, which means that the dentist cannot practise and, if he does, he commits a criminal offence.
§ Mrs. Fyfe
As it is clear that knowledge of this dentist's conduct became known to at least one health board as early as 1987, will the Minister undertake to look at how it is possible for patients to go on having such mistreatment before matters are resolved? I hope he will agree that this has taken far too long to reach a conclusion.
§ Lord James Douglas-Hamilton
I have made inquiries as to why it took so long. The only thing that I can say is that it is always easier to view events more 134 clearly with hindsight. The board did not receive complaints from patients until late 1993. Concerns before that were about possible irregularities in payment claims and the board conducted a detailed six-month investigation early in 1993. That, coupled with complaints from patients, convinced the board that the position was sufficiently serious to warrant direct referral to an NHS tribunal, which was done in January 1994. I have no doubt that there are lessons to be learnt after episodes of this nature and I will ensure that the hon. Lady's remarks are forwarded to Greater Glasgow health board.
As I have said, since these unfortunate events, the Scottish Office has acted to introduce a new NHS complaints procedure. The purpose is to provide a simple, flexible, impartial and easily accessible system for the public, as well as being fair to NHS practitioners and staff. Local resolution is the key to the success of the new procedure. The provider of the service—the NHS trust, GP practice, dentist, pharmacist or optician—will respond to the complaint and try to provide an answer that satisfies the complainant. That will be speedy and informal.
If the complainant is still dissatisfied, a non-executive director of a trust or health board, called a convenor, will review the complaint in consultation with an independent lay person. The convenor may decide to ask the provider to make a further attempt to resolve the complaint, perhaps through conciliation, to set up an independent review panel to consider the complaint, or to inform the complainant that everything that could reasonably have been done has been done to resolve the complaint. Panels will have an independent lay chairman and a majority of members completely independent of the service provider. The panel will be advised on clinical matters by independent clinical assessors.
If the complainant remains dissatisfied with the response from that process, there is recourse to the health service commissioner, whose powers have been extended by virtue of the Health Service Commissioners Act 1993 so that he can consider clinical complaints, complaints against primary care services practitioners, and complaints about services provided in the independent sector of the NHS. The new system will support the commitment of professionals and staff to achieve a high quality of service.
To ensure that the new system is operating efficiently and effectively, guidance has been issued to all health boards, NHS trusts and primary care services. Training programmes that are supported by extensive, centrally prepared material are in hand in all trusts and health boards for front-line staff, convenors and lay members as appropriate. Health boards have reported that training seminars have been organised for primary care practitioners, as well as for their own staff.
Although health boards have been asked to be flexible when considering complaints made outwith time limits, they are expected to maintain a balance of fairness between complainant and practitioner. Where it is suspected that the events in question amount to a breach of the terms of service, a health board must refer the matter for investigation within 28 days. If a matter comes to the attention of a health board other than as a result of a complaint, action must be taken within 13 weeks. In certain cases concerning dentists, the period is six months, as before. Late referrals cannot proceed. Those provisions are simpler and fairer. 135 There have been amendments to the Dentists Act 1984. The General Dental Council is the regulatory body for the dental profession and is charged, under the Act, with promoting high standards. They include a requirement for dentists to undertake annual continuing professional education and a proposal to establish a statutory career redevelopment scheme for dentists operating within and outwith the NHS who are identified as requiring to improve their competence. The council also proposes that, 136 where there is a finding of serious professional misconduct, its professional conduct committee should impose conditions on a dentist's registration as an additional disciplinary sanction to those in place. That can involve erasure or suspension. Erasure means that he cannot practise at all.
I hope that I have managed to allay some—
§ The motion having been made after Ten o'clock, and the debate having continued for half an hour, MR. DEPUTY SPEAKER adjourned the House without Question put, pursuant to the Standing Order.
§ Adjourned at two minutes to Eleven o'clock.