§ 3.34 p.m.
§ The Parliamentary Under-Secretary of State, Department of Health (Baroness Cumberlege)
My Lords, I beg to move that this Bill be now read a second time. Being a doctor is tough. Not only is the speed of medical advance frenetic, but those advances have propelled the Government into making dramatic changes in the organisation of the National Health Service. Old certainties, time-honoured practice, historic institutions and centuries of traditions all seem far from secure.
This Bill is not just a minor titivation. It is the acknowledgement by doctors that the great and lasting value that they offer is their integrity and their professionalism. In a time of change they acknowledge and have asked for more powers to uphold their profession. Most people will say, "We trust the doctor". If people trust their doctor, other things fall into place.
The Bill introduces new procedures to further build the confidence of the public and to enable the General Medical Council to deal with those doctors whose performance falls below the standard we have a right to expect. It is part of a range of measures to ensure that, where professional standards are not maintained, effective remedial action is taken whether the doctor practises in the NHS or privately. Where there are shortcomings we wish there to be well understood and effective channels through which people can complain. Patients, their families and friends must have complaints dealt with quickly, thoroughly and fairly. Where justified they should receive an apology, an explanation of what went wrong, an assurance that the same thing will not happen again and action to put things right. In most cases people do not seek financial compensation. Their genuine concern is that no one else should have to suffer what they have been through.
The underlying cause of a patient's dissatisfaction may not always be obvious. Is it the fault of the doctor or the fault of the hospital procedures? Is it poor communication within general practice? Are other members of the clinical team at fault? In the knowledge that complaints procedures are not always clear, in 872 March we published Acting on Complaints, a paper setting out our plans to improve the way complaints are handled as recommended by the Wilson Committee.
We believe that, in order to ensure a speedy resolution, initially at least, it is best for the complaint to be dealt with by the people providing the service. The new complaints procedure will provide for a review by a lay panel. The panel will have a majority of members who are independent and will be advised by clinical assessors. As recommended by the Wilson Committee, there will be a clear distinction between complaints and disciplinary procedures. Where a complaint raises serious disciplinary issues, relevant information will be passed quickly to management or professional regulatory bodies so that they can consider what other steps may be necessary.
Your Lordships recently passed the NHS (Amendment) Bill. That Bill strengthened the powers of the NHS tribunal. A health authority will in future be able to ask the tribunal to suspend a family health service practitioner in order to protect patients before a full hearing takes place. The authority can only do so when it is seeking to disqualify a practitioner from providing healthcare. The scope of this power covers all practitioners in the family health services, not just doctors.
The new GMC procedures in today's Bill will complement existing disciplinary measures. For instance, at the moment NHS procedures do not cover doctors in private practice. Nor can they always prevent a doctor who resigns from one NHS post moving to another NHS post or to private practice. The proposed new powers will cover all doctors whether or not they work in the NHS. I am pleased to say that the General Medical Council has undertaken wide consultation on these proposals and there has been strong support from both within and outside the medical profession.
The General Medical Council has increasingly focused its attention on its role in protecting the public. The Bill will be a fitting tribute to Sir Robert Kilpatrick who has worked tirelessly and given strong, clear leadership during his distinguished six-and-a-half years as president. He retires at the end of August, leaving the GMC in tip-top condition, as any physician should. In its new publication, The Duties of a Doctor, the GMC has made clear that:Patients must be able to trust doctors with their lives and wellbeing. To justify that trust we as a profession have a duty to maintain a good standard of practice and care".It also made clear that doctors have a duty to report cases. It says,You must protect patients when you believe that a colleague's conduct, performance or health is a threat to them. The safety of patients must come first at all times".The Bill is part of the same picture—protecting the public.
Under its existing powers the GMC can address incidents of serious professional misconduct and serious impairment of fitness to practise arising from a doctor's own state of health. It cannot deal effectively with cases where a doctor's overall performance is seriously deficient unless it can pin down the complaint to specific incidents of grave misconduct.
873 The GMC's professional conduct committee must focus on specific, closely defined allegations about particular incidents. The allegations must be supported by evidence which would be admissible in a criminal court. The evidence is tested to the standard of proof in adversarial proceedings—and that is as it should be. However, the GMC receives details of many other cases on which it cannot take any formal action under its current powers; yet the underlying performance of the doctor concerned is very poor or, in the terminology of the Bill, the standard of professional performance is seriously deficient. At present those doctors can remain on the register and the GMC has no power to require them to put right their shortcomings.
The professional performance procedures proposed in the Bill are designed to plug that gap. Complaints may come from patients, their relatives, doctors, or other professionals and organisations. The purpose of the new procedures is to inquire into the underlying causes of any problems that have been reported and get the doctor to put them right. The GMC will consider whether the matters complained of, particularly where there is a series of complaints, indicate a pattern of serious shortcomings in the standard of the doctor's professional performance. If the allegations suggest that that may be the case, the doctor will be asked to have his performance assessed by an independent assessment panel appointed by the GMC. This will include two doctors of the same specialty plus one lay person.
The key role of the assessment panel is to identify whether there are any significant weaknesses in the doctor's performance, to discuss those with him and to give advice on what the doctor might do to remedy the situation. The new procedures could therefore work in some cases without the need for a GMC committee to be involved. However, it is clearly important that the procedures should also work where the doctor does not consent or remedial training is not effective. There is provision for a doctor's registration to be suspended or for conditions to be attached to his registration if this is in the public interest and will help to protect patients. An appeal mechanism is included which will allow a doctor to put his case to a new assessment referral committee if he objects to having his performance assessed.
I commend to the House the short paper prepared by the GMC on its proposed performance procedures. This explains step by step how the system will work. A number of copies have been placed in the Library.
The Bill is short—only six clauses. Much of it makes amendments to the Medical Act 1983. It is not possible to follow through the procedures by reading the Bill by itself. I have therefore 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. I have sent this report to a number of your Lordships.
Wherever possible we want expensively trained doctors to be put back on the right track. But the overriding need is to protect patients. In some cases sanctions may need to be imposed. There will be some doctors who may decide that they should retire. Those cases are provided for in Clauses 1 and 2 of the Bill.
874 Clause 1 deals with the powers of the new committee on professional performance. This committee has been described as the "sanctions committee". The committee will be empowered to impose conditions or to suspend a doctor's registration. It will do this where the doctor's professional performance is seriously deficient and the committee considers that sanctions should be applied to protect the public. Although a doctor may in the worst cases have his registration suspended indefinitely, his name will not be erased—he will not be "struck off". This is a fine but an important distinction, as the intention is remedial. The committee can also impose sanctions where a doctor has failed to co-operate with the assessment.
In cases where a doctor's failings may be considered to be beyond remedial action, the doctor may himself ask for voluntary removal from the register. The doctor may be falling behind with the latest medical techniques which have become the accepted norm and he may realise that it is time "to call it a day". He can then ask to have his name removed from the register. This is the subject of Clause 2 of the Bill.
We realise that less scrupulous doctors might use the provisions of voluntary removal to escape scrutiny of their performance or indeed to evade a conduct hearing. In order to minimise that risk, Clause 2 also provides for a reference back to the relevant committee should the doctor apply at a later date for his name to be reinstated on the register. I intend to bring forward an amendment at Committee stage that will ensure that the GMC has the discretion to turn down the application for removal of a doctor about to be brought before the professional conduct committee.
Clauses 4 to 6 have the usual technical effects. The schedule gives the GMC the power to make rules and regulations; first, to set up the assessment referral committee and the committee on professional performance. Rules will also provide for the constitution and proceedings of the two committees and also of the assessment panels. Assessment panels will be given powers to inspect medical records and, where obstructed, to apply to a magistrate for a warrant. An offence will be created where any person obstructs the work of the panel.
During the passage of the Bill in another place the Government agreed to the insertion of two amendments; first, to give a power to the GMC's health committee to impose indefinite suspension in cases where the doctor has already been suspended for two years. This power is similar to the power to be given to the committee on professional performance. The amendment is now in the Bill. The second promised amendment will extend the powers of interim suspension by the GMC's preliminary proceedings committee. At present the committee can only impose interim suspension for two months. We propose that this period should be six months and that further periods should be imposed if necessary. An amendment will, with the leave of the House, be brought forward at Committee stage.
The task facing the GMC to implement these procedures is not a small one. However, we are confident that the new procedures will fill the gap identified by the GMC and enable it to do its job more 875 effectively. The GMC is well on the way to setting up and testing its assessment programmes which will underpin the new procedures but this may take up to 18 months to complete. Nevertheless, we believe that the introduction of the Bill to Parliament has given a clear signal to doctors whose performance is not up to standard that the remedy is in their own hands.
We have been encouraged by the fair wind given to the Bill in another place by the Opposition parties. We nevertheless expect the usual close and challenging scrutiny of the detail of the Bill here in Committee. I hope, and firmly believe, that the Bill should emerge as a valuable addition to the statute book and command widespread support both within and outside Parliament. I commend the Bill to the House.
§ Moved, That the Bill be now read a second time.—(Baroness Cumberlege.)
§ 3.46 p.m.
§ Baroness Jay of Paddington
My Lords, I should like, first, to thank the Minister for introducing the Bill. Although this is a straightforward measure, both the practical arrangements it proposes and the legislative changes which will enable them are complex. I am very grateful to the Minister for the clear explanation she has given this afternoon.
I am also grateful for the detailed written briefing the Government have provided, particularly the document that the Minister referred to which illustrates the way it it intended to amend the Medical Act 1983. The General Medical Council has been extremely helpful. Sir Robert Kilpatrick, the president, has been generous with his time and most courteous in answering detailed questions. In a way, this Bill is almost his Private Member's Bill. I join the Minister in congratulating him on persevering to achieve the introduction of this measure, which follows many attempts by what one might describe as real Private Members in another place to achieve some of these changes.
We all agree that some changes in medical self-regulation need to be made. The Minister has said that this is not a contentious Bill. We on these Benches support its principles and hope that once this House has had the opportunity to consider it carefully the Bill will find its way speedily onto the statute book.
The Bill raises two important issues fundamental to successful healthcare: the need for consistently high standards from the medical profession and the need for patient confidence in the doctors who look after them. The picture for both has changed substantially over the past few years. Doctors have always jealously guarded their right of professional self-regulation but recently this right has been questioned in other fields, such as the law and the police; even legislators have sometimes been challenged to justify their ability to regulate themselves. The GMC has rightly recognised the general pressure to tighten regulatory procedures and to make them less opaque. But at the same time the health professions have been coping with greatly accelerated advances in medical science and technology. These have made it hard even for the most dedicated doctor to keep abreast of every professional development. That is why 876 we on these Benches welcome the remedial nature of the new sanctions that the GMC may impose on a practitioner who is judged seriously deficient.
We are all anxious in this country to avoid the litigious atmosphere that has developed in the doctor/patient relationship in the United States. It is clearly more satisfactory if the spectre of a suit for malpractice does not hang over ever clinical consultation, and yet the patient must have the right to expect the best possible care and some kind of redress if he does not receive it.
Today, patients are encouraged to challenge the tradition that "Doctor knows best" and to question their treatment. In some areas—I would cite obstetrics and HIV-AIDS services as particularly good examples—that has produced noticeable improvements in patient care. But concerns still remain. Despite the new NHS complaints system and the Patient's Charter, individual patients feel somewhat frustrated sometimes when they "want to do something", as they would describe it, about what they see as inadequate or inappropriate treatment.
On the other hand, doctors sometimes feel burdened rather than helped by the pressures of keeping up with continuing medical education programmes and clinical audit procedures, which are designed to keep them up to scratch. It would be pointless to pretend that there are not a very few who are just too indolent or unconcerned to take part in voluntary postgraduate training and education. For them perhaps professional sanctions against bad performance may be the only recourse and it is really this small group that the Bill deals with—a small minority.
The centrepiece of the proposed change is to give the GMC the power to investigate cases where a doctor's professional performance is alleged to be seriously deficient. In proven cases the GMC will be able, as the Minister has already explained, either to suspend the doctor's registration or make it conditional on receiving remedial training. I entirely support this proposal which will substantially widen the grounds on which a complaint may be made.
Most of my questions and comments are largely ones of detail about the mechanics of operating the procedure. I hope that the Minister may be able to answer some of the points in her response this afternoon as some of them are unfinished business from another place. Indeed, in suggesting the amendments that the Government will bring forward at Committee stage, the Minister has already answered some of those points.
One substantial issue which was discussed at length in Committee in another place, but was never really resolved, was the question of precisely measuring and defining a seriously deficient professional performance. It emerged in another place that new codes of conduct will be widely and publicly promulgated, but no details of performance standards were announced and key performance criteria, which are regularly used now in the NHS, were not discussed. I hope that we might move towards more exact understandings before the Bill becomes law.
877 Anyway, it seems probable that whatever criteria of professional performance are used in the future, they are bound to be based mainly on technical skills and knowledge. There are, after all, means of measuring these by objective standards.
Much more difficult, but I believe often equally important to patients, are standards of what one might call "personal conduct". All of us who have heard complaints about doctors know that they may sometimes concern a seriously deficient "bedside manner". Rudeness, dismissiveness, arrogance and indifference could all, in common sense terms, constitute a seriously deficient professional performance. It would be helpful if the Minister could make it clear whether or not the new procedures can be triggered by failures of personal behaviour, not only failures of professional skills. I would add in parenthesis that it is particularly difficult to imagine how failures of personal behaviour, and personality even, if they are to be included, can be measured, and indeed whether or not they could be improved by remedial training. I am reminded of an employer of mine who, several years ago, never mentioned what were described as "irremediable personality faults" in annual reviews simply because they were thought to be unanswerable.
One further matter in this area which needs to be finally resolved is whether or not a one-off episode of a seriously deficient performance will be enough to qualify for GMC investigation. Much of the background briefing and explanatory papers refer to a pattern of poor performance. But again, in common sense terms, it is possible to imagine circumstances where a one-off act of negligence, for example, could be sufficiently catastrophic to be defined as a "seriously deficient performance". When the Minister replies, perhaps she can tell us what exactly the situation is as regards single complaints and whether a complaint about one incident is liable to be treated less sympathetically than one which reveals a track record of inadequacy.
The proposed mechanics of investigation and action by the GMC, once the procedure has been triggered are, I must say, extraordinarily complicated. They are also extraordinarily thorough and therefore must be commended. But one does need the proverbial "wet towel" to follow them, particularly during a hot week in summer.
I wanted to make a positive suggestion that all health authority non-executive members and community health councils, should be circulated with a revised version of the GMC consultation paper on the new performance procedure once the legislation is passed. After all, they are often the first recipients of complaints. But I have to say that I was made so cross-eyed by the diagrammatic representation of the procedures that I thought that the document as it stands might do more to hinder than to help lay understanding. I do recognise that I am personally diagram-blind, but I do not believe that I am unique.
I very much hope that the information about the new arrangements will be widely distributed and understood. I would urge that perhaps professional copywriters or advertisers be employed to make the procedures clearer, and therefore more accessible, to anyone who may wish 878 to use them. After all, one of the basic points about professional regulations is that the systems must be seen to be open and readily available.
There is disquiet on these Benches that hearings under the new performance procedures will be heard in private. There is an odd anomaly in the Bill as it stands at the moment that allows a doctor under investigation to request a public hearing, but not a complainant. That suggests that the GMC and the Government have no objections in principle to public hearings, but simply wish that only a doctor may lift the "in camera" rule. I hope that the Minister will be able to reconsider this or perhaps reassure us, as was indicated in another place, that these arrangements will be kept under review and may be altered once the system has been tested for a time.
If and when an individual case does make its way through the procedural maze of assessments and committees which are proposed, the GMC and the doctor in question have, as the Minister has explained, various options for action. All of these were explored in detail in another place. I was delighted to hear the Minister tell us this afternoon that the right of a doctor facing disciplinary proceedings to remove himself voluntarily from the register, will be circumscribed. As that stands at the moment, it seems potentially open to abuse. For example, it has been suggested to me by a very senior doctor closely involved with the GMC, that a suspect practitioner might well choose to remove himself from the register, lie low for a few years, and then reapply and hope that his past was well forgotten. As the Minister has explained her amendment this afternoon, it will be those doctors facing immediate consideration by the performance committee who will not be allowed to reapply in this way. But it will be very helpful if we can have an understanding about how long the surveillance of voluntary withdrawal from the register will be allowed to continue before it becomes unsurveyed.
The British Medical Association is still most concerned about the financial implications of remedial retraining, which may be a condition of a new registration for a doctor who is finally judged to be seriously deficient. Apparently, it was originally understood that this retraining would be paid for by the health service. Now it seems that only hospital doctors will be able to be funded. There has been a recent exchange of correspondence between doctor Ian Bogle, the chairman of the BMA Medical Services Committee, and the Minister for Health, since the Bill left the other place. In a letter of 6th June, Mr. Malone states categorically,I do not think it fair to the taxpayer, or to the great majority of GPs who do use the existing provisions to continue their professional development and maintain high standards, for special arrangements to be made for the few GPs who will come under the General Medical Council's new procedures".I believe that that is an unfortunate decision. To start with, it seems to confuse the type of remedial education and training proposed in the Bill with the system for continual medical education as it stands at the moment.
The other point is costs. The costs of the projected retraining are said to be substantial. Apparently, they can be anything between £6,000 and £20,000. It does 879 seem that if GPs have to pay for this out of their own pockets, it will amount to what is a fine, and a very heavy one at that, whereas as the Minister has explained and as is certainly clear from the legislative proposals, the basic idea of the new procedures is that they are remedial and not punitive. The BMA is also concerned that, knowing about the possible personal costs, colleagues of failing doctors may well be deterred from instigating procedures. I ask the Government to think again about that particular arrangement.
Those are all important points and I hope that it will be possible easily to resolve them. The principle of the Bill is uncontentious and very valuable. Its proposals will offer both responsible improvements in self-regulation for the medical profession and a greater sense of confidence for patients who wish legitimately to complain about their treatment. Both are welcome developments in our healthcare system.
§ 3.59 p.m.
§ Baroness Robson of Kiddington
My Lords, I too thank the Minister for outlining the Bill so clearly. Having listened also to the speech of the noble Baroness, Lady Jay, I echo to a large extent many of the questions that she posed to the Minister.
We on these Benches welcome the Bill particularly warmly because the impetus for it came not from the Government but from the General Medical Council itself. Doubts are often expressed about self-regulating authorities. The fact that the General Medical Council is prepared to look for improvements in the law and in its procedures is welcome evidence of the council's determination to achieve the highest standards of medical performance and to provide the best possible care for patients.
The two new committees that are to be set up under the Bill—the assessment referral committee and the committee on professional performance—follow structures in line with the procedures that exist in other professional bodies. The Institute of Chartered Accountants, for example, has an investigatory committee hearing as a first instance, which is followed by a disciplinary committee hearing if that proves necessary. Therefore, the proposed new committees are in line with the practice of existing self-regulating authorities. That two-stage procedure gives members of the medical profession the opportunity to take remedial action through retraining and co-operation in order to avoid referral to the committee on professional performance where sanctions affecting a doctor's registration can be imposed. If those sanctions are renewed twice for a 12-month period, it could lead to an indefinite suspension.
The noble Baroness, Lady Jay, referred to the cost of the remedial training and to the question of who will pay for it. According to the Explanatory and Financial Memorandum, the costs of remedial training will be met by the NHS for doctors in practice within the NHS. I hope that I have not misunderstood that. It is estimated that that will increase NHS expenditure by £530,000 per annum. Like the noble Baroness, Lady Jay, I am concerned about the cost that appears to have to be 880 carried by doctors in general practice. The noble Baroness said that the cost of remedial training would be between £6,000 and £22,000. That is far too great for a general practitioner to carry. Indeed, it would not even be the total cost for a general practitioner because it is likely that while absent from his practice for remedial training he would have to pay for a locum.
I plead with the Government: the NHS should be honour-bound to pay for the retraining of family doctors. That should be done through the family health services authorities. That would ensure that a doctor's attempt to retrain so that he can become a valuable member of his profession does not become a sentence in itself which he is unable to fulfil.
We welcome the government amendments that were introduced on Third Reading in another place relating to the procedures for dealing with doctors who suffer from health problems. Those amendments are welcome because at the moment a doctor who is suspended for health reasons can be suspended only for a period of 12 months and has to appear before the health committee every year if he happens to suffer from a long-term serious health problem. That is upsetting for the doctor concerned and is time-wasting for the health committee of the General Medical Council. We welcome those amendments.
The Minister said that she will introduce amendments in this House—that is welcome—but the Government also undertook on Third Reading in the other place to table an amendment in this House relating to the preliminary proceedings as to professional misconduct and unfitness to practice procedures in order to extend the period of interim suspension. We look forward to considering that amendment in Committee.
I hope that the Minister agrees that the NHS has an important role to play in all of those issues. It is necessary that we improve the flow of information between different parts of the NHS so that when a doctor applies for a job the question of whether he is facing proceedings before the General Medical Council can be ascertained quickly. We all know of cases where such doctors have moved from one part of the country to another and been given a new appointment. That is of particular relevance to the employment of locums within the service. During my years as a regional chairman, I came upon such cases on many occasions and I could spend quite some time talking about anecdotal evidence of consultants and doctors who failed in one way or another, but I shall not do that because it is unnecessary. I very much welcome the Bill and only wish that its provisions had been in force during my nine years with the health service.
§ 4.7 p.m.
§ Lord Walton of Detchant
My Lords, I join others who have congratulated the Minister on the exceptionally lucid and careful way in which she presented to the House the provisions of this Bill which I believe is to be widely welcomed not only by those who serve at present on the General Medical Council but also by the medical profession at large.
881 When I was appointed to the General Medical Council in 1971, I served for some years under the distinguished presidency of the late Lord Cohen of Birkenhead. During the time that I served under his presidency, it became increasingly clear to many of us that doctors were coming before the council's disciplinary procedures committees who were not so much wicked, nor had they committed criminal offences, but who were sick and deserved to be handled very much more compassionately. Subsequently, the Merrison Committee reported in detail upon the regulation of the medical profession, and the General Medical Council was reconstituted.
I should like to take this opportunity to pay a special tribute to a president under whom I served, then Dr. John Richardson, now the noble Lord, Lord Richardson, for the way in which he and the late Lord Hunt of Fawley succeeded in this House in establishing through the Medical Act of 1978, subsequently consolidated into the Act of 1983, the reconstitution of the General Medical Council. They also established for the first time procedures through which it was possible firmly but compassionately to deal with doctors whose health rather than whose conduct was the problem.
The health committee and the health procedures enabled the council to take action in the case of a complaint brought before it by a patient, by someone acting in a public capacity or through other mechanisms by inviting a doctor, in whose case it seemed that it was likely that his or her professional performance was being impaired by reason of ill health, to undergo a medical examination by consultants nominated by the council and, if he or she so wished, a medical examination by a consultant of his or her choice, and then through the work of the council to be able to accept, if he or she so wished, certain voluntary conditions upon the restrictions which might subsequently be imposed upon his or her practice while undergoing treatment with regular examination.
That health procedure, informally introduced, proved to be enormously successful in rehabilitating sick doctors. But where a doctor failed to collaborate with those informal procedures, there was available the health committee to which he or she could be referred. That health committee had the power to suspend that doctor's registration.
Perhaps I may at this juncture say how much I welcome the amendment which was inserted into the Bill in another place because, having chaired the health committee of the council, I found it distressing on a number of occasions to see doctors who were suffering from a long-standing illness and not responding to treatment having to be brought back to the health committee every 12 months to have that suspension renewed. That amendment is one which should be widely commended. It is now in the Bill, allowing a much longer period of suspension. It is something we should all he pleased to see.
Subsequently, under the noble Lord, Lord Richardson, who chaired that council, as one member said, with grace and distinction, it became increasingly clear to me as I served on the professional conduct committee—a successor of the previous disciplinary 882 committee—that there were some doctors who had been referred by the preliminary proceedings committee to the council's conduct procedures who were not so much wicked but whose professional performance fell below an acceptable standard. But it became apparent when I followed the noble Lord, Lord Richardson, as president of the council that the council's procedures did not allow us properly to deal with doctors who fell into that category.
It is true that over the past 10 years or more the medical professional at large has been introducing, with increasing success, programmes of voluntary audit of professional procedures, examining doctors' standards of practice and bringing to their attention in an informal way deficiencies which may therefore be exposed relating particularly to the outcome of illnesses which they have been treating or relating to the way in which they have handled certain clinical problems, but those are voluntary procedures.
I would, however, reassure the noble Baroness, Lady Jay, with most of whose comments I wholly agreed, that there is an increasing body of expertise now in the medical profession—not just examiners of medical students in final examinations in medicine, both internal and external, but examiners taking part in voluntary audit procedures and postgraduate examinations carried out by the Royal Colleges and their faculties—fully capable of forming, with lay opinion and advice, the assessment panels for which the Bill makes provision—people who are now experienced in assessing professional performance and in being able to assess a doctor's knowledge, skills and attitude. I therefore have every confidence that the assessment panels proposed in the Bill could prove to be extremely effective.
As the noble Baroness said, the Bill's principle features are, first, to establish an assessment referral committee which will consider cases where doctors refuse to agree voluntarily to have their performance assessed. That is in many ways comparable to the voluntary procedures which have been in existence for some years in relation to health. That committee cannot impose sanctions on the doctor's registration, but it can require the doctor to undergo assessment.
In the latter years of my presidency of the GMC, I began to consider whether it was right to think about establishing, alongside the health committee, a competence committee. But I have to say that Sir Robert Kilpatrick and his colleagues on the GMC have come up with something very much better in proposing, as now set out in the Bill, a professional performance committee which will be a "committee of last resort"— a committee to which doctors failing to collaborate with the informal assessment procedures and proposals arising therefrom could then be referred, with the committee having the right to suspend the doctor's registration where his or her performance has failed to improve despite remedial help.
Clause 1 gives that committee its principal powers: conditions may be imposed—conditions which arc not just informal conditions that the doctor is invited to accept, but conditions which will have the force of law. Alternatively, the committee may impose suspension for renewable periods of 12 months.
883 Doctors will of course, as in all of the GMC's procedures, be able to appeal against those sanctions (on a point of law only) to the Judicial Committee of the Privy Council. There is within the Bill a very proper provision in that the committee on professional performance can order immediate suspension, where it is seriously concerned about the low level of performance demonstrated by the doctor, to cover the 28-day appeal period.
The committee will not have the power of erasure from the register because, as in the case of the health committee, the council proposes—I wholly agree with this—that those procedures should not be punitive but remedial in character. Perhaps I may say how glad I was to hear from the Minister that an amendment will be brought forward in Committee. It is clearly important that doctors who are elderly, and whose performance may be failing, should have the right, as under the Bill, to take voluntary erasure from the register (voluntary removal) as an alternative to facing the complicated performance procedures. It is crucial that that provision should not be used by a doctor who is about to face procedures under the conduct regulations relating to conviction or serious professional misconduct. We look forward to seeing the government amendment on that basis.
I welcome the Government's intention to introduce a further amendment to increase the powers of the preliminary proceedings committee in relation to interim suspension and interim conditional registration. At present, when the preliminary proceedings committee of the council forwards a case to the professional conduct committee or the health committee, it can impose, in exceptional cases, interim suspension or interim conditional registration, but for two months only. That period is not long enough to protect the public where there is a prima-facie case of serious professional misconduct. It is therefore important that an amendment be brought forward to extend that period to six months in order to allow the procedures to take their full effect.
Of course the Bill contains only enabling powers. Much of the detail of the procedures will be set out in rules to be approved ultimately by the Privy Council. I commend the enormous burden of work which Sir Robert Kilpatrick and his colleagues in the GMC have carried during the past few years in obtaining the universal approval of these procedures by the medical profession and those in the other health caring professions.
I also commend the Bill to the House. In doing so, perhaps I may ask the noble Baroness for two assurances. The first relates to a defect which emerged in the Medical Act 1978—it was subsequently corrected—or which arose perhaps unintentionally after the health committee was established. It turned out that a doctor suspended under the health procedures might find his or her contract of employment with his or her employing authority ended by virtue of that suspension. May we take it that doctors suspended under this Bill will have their contract of employment preserved and maintained?
884 Secondly, I am aware that the medical profession is concerned about the cost of the remedial training. The cost of those procedures which are to be carried out by the General Medical Council will not be inconsiderable. The cost will be covered by a substantial addition to the doctors' annual registration fee paid to the GMC, and therefore the cost will be a burden on the medical profession at large. Surely, therefore, it is right that the cost of the remedial procedures is borne by the NHS, whether in hospitals or in general practice. I hope that the noble Baroness will give your Lordships an assurance on those issues. I warmly commend the Bill to the House.
§ 4.21 p.m.
§ Lord Colwyn
My Lords, perhaps I may preface my remarks by saying that it gives me great pleasure, first, to follow the noble Lord, Lord Walton, and, secondly, to take part in a Second Reading debate on a government Bill that has received such enthusiastic support from all sides of the House. I too welcome the Bill and I declare an interest in that I am a practising dental surgeon. I shall try to explain the relevance of that a little later. I am chairman of Dental Protection and a council member of the Medical Protection Society.
I support this all embracing Bill, which will go some of the way to ensure that high quality professional performance is maintained by doctors whether they are working in general practice, in hospital or in the private sector. It is centred on standards of care for patients and is doctor-led.
As my noble friend the Minister said, this Bill follows the government document Acting on Complaints, which responded to the Wilson Report, and is very much in line with the new code of openness, which is the policy brought into the NHS by the present Government and my right honourable friend the Secretary of State. Acting on Complaints proposed that the resolution of complaints in the NHS should be local, speedy and more accessible and streamlined than the present procedures.
With the continual changing face of medicine, with new technologies and new techniques, it is important that professional standards are carefully monitored. Professional performance is now a factor in all aspects of medicine and I hope that eventually it will be linked in some ways to performance pay—a way of encouraging doctors to keep up to date. However, some form of accreditation, either in the NHS system or the regulatory body, could well deal with this matter before it becomes a real concern.
Although I tried to listen carefully to my noble friend's opening remarks, I cannot recall whether she covered the cost implications of the Bill. Perhaps that has something to do with a long working relationship with mercury and dental fillings! However, I remember that the noble Baronesses, Lady Jay and Lady Robson, covered the costs. The GMC has indicated that it will fund Stages 1, 2 and 4 of the procedures from the annual retention fee but that it does not consider it appropriate to expect doctors in general to pay for Stage 3 of the procedures; that is, the remedial training. I agree with the GMC and the BMA that the employing body for hospital doctors—usually the NHS trust—and the health 885 authority for public health doctors should pay the full costs of remedial training. I hope that my noble friend can go a little further on this. As we have heard, there is the possibility of an inequity if some GPs have to pay for their own retraining and other doctors are funded by trusts or the regional department of the Department of Health. I should also like to hear how this might affect doctors who purely work in the private sector.
Redeclaring my interest as a council member of the MPS, I should make it quite clear that it is not a cost which—as has been suggested elsewhere—should be met by the medical defence organisations, certainly requiring a large increase in annual subscription already at a high level for indemnity purposes.
Medical defence organisations already undertake comprehensive "risk management" programmes which are expanding. They are available to all members and can identify doctors who are "at risk". This initiative by the defence organisations will minimise the number of doctors involved in this procedure and, it is to be hoped, will reduce the incidence of claims against doctors and reduce costs for the trust, health authorities and the defence organisations themselves.
At present, the GMC has no power to act against a doctor unless it has been found that his fitness to practise has been affected by ill-health, or that he has been found guilty of professional misconduct or convicted of a criminal offence. This defect in self-regulation will be corrected with this Bill and maintain the right for medical professionals to continue self regulation.
I hope that I am not venturing outside the remit of this debate if I ask my noble friend whether the Dentists Act could be opened to enable similar changes for NHS and private members of the dental profession. Doctors currently face a double jeopardy situation, where they may have been convicted and sentenced by the courts or have a finding against them of a breach of NHS terms of contract and a withholding of salary and are then brought before the GMC disciplinary committee. Current NHS regulations in dentistry also can impose a triple jeopardy on health service dentists; a withholding of fees, prior approval restrictions and an automatic referral to the GDC querying competence as well as the inevitable claim for negligence. A similar scheme via the GDC could similarly filter out poor professional performance within the dental profession.
It would also embrace the ever increasing number of private dentists, including third party funded dentists as in the Denplan scheme, so that all dentists could be more fairly dealt with and in the best interests of patients. At present, the only redress a private patient has, is to sue in law alleging negligence.
As my right honourable friend the Secretary of State said in another place, the Bill aims to achieve what many people say that they want when they complain; to inquire into the underlying causes of any problems; and to see that something is done to stop a similar incident happening again.
The Bill should take the heat out of medical negligence claims. Justice will be seen to be done and that justice will be educational not punitive. As with the 886 present system, feedback to the patient still allows a claim for negligence to be considered and taken forward where avoidable harm has occurred.
Should this eventually embrace the dental profession, the cost of retraining could be borne by the GDC through the annual retention fee, which might also include a competence payment. I could envisage the introduction of further compulsory vocational training for continuing registration and the supervision of further postgraduate training in order to retain an NHS list number.
During recent years the GMC has modernised itself and simplified some of its registration procedures. It has increased its lay membership to ensure that non-doctors play a full role in its deliberations. If the Government could consider a Dental or Dentists (Professional Performance) Bill, the opening of the Dentists Act would also allow similar changes in the composition of the Dental Council with more lay members so that the public could see that governance of the dental profession is more influenced by patients.
This Bill will be helpful to doctors who, for a variety of reasons, show standards of practice which are not acceptable. The remedy is in their hands and is doctor-led. I hope that it will have a speedy passage through this House.
§ 4.28 p.m.
My Lords, I declare an interest in the Bill; I support it unequivocally. I am extremely grateful for the way in which the Minister outlined the difficulties of the Bill, which are considerable, in such a straightforward and understandable way. I feel greatly indebted to the noble Baronesses, Lady Jay and Lady Robson, who spoke from the Opposition Benches making highly relevant points.
The noble Baroness, Lady Robson, mentioned the difficulties about knowing what is deficient behaviour. Part of the purpose of the Bill is to address that problem. To my mind, the answer is that, as a whole, doctors understand what is good doctoring and understand what is a good way to handle patients. I doubt that it will he possible to be very much more precise than to rely on the doctor's ethos to provide an answer as to what is inadequate and unacceptable conduct.
I have listened to all the speeches with the greatest interest. Each one has touched on an extremely important subject, as did the noble Lord, Lord Colwyn. However, I must confess that I listened with the greatest possible care to the words of my friend, colleague and successor, the noble Lord, Lord Walton of Detchant. I longed to find something that he had left out, but I found absolutely nothing. I longed to find something that he had not made absolutely clear, but the answer was the same. Had I found something about which he was wrong, I should have achieved something that I have never succeeded in achieving in the past 20 years. Therefore, I fall back on the fact that I am a doctor and the few words which I wish to say will be from the point of view of a doctor and not as past president of the GMC.
887 The idea behind this legislation is benign. It is absolutely specific to its basis that the conduct and sanctions which the conduct committee can impose do not come within this particular discussion or Bill. In the first place, what happens? The scanners, one of whom may or may not be the president, although in my case, I was, will look at about 1,000 cases of complaints per year. That figure may now be higher. At present only a very small percentage will be considered suitable to be sent on to be dealt with by the disciplinary mechanism with its preliminary committee and so on.
It was perfectly clear that there was a great gap. It is that gap between unacceptable behaviour, skills and knowledge and serious professional misconduct—which used to be called, rather horribly, infamous conduct in a professional respect—about which something needs to be done.
In my day, the council was doubling its size. There was the Merrison Report and it was not the time to tackle this problem. The noble Lord, Lord Walton, began and did a great deal in terms of thinking about and reorganising procedures. Sir Robert Kilpatrick has done wonderful work. He has managed to talk the doctors into accepting an extension of the GMC powers. It has taken 150 years to do that. Although those of us who wish to see this Bill become an Act have felt impatient as the years have passed and have wanted to see it happen, it has taken a very short time out of that 150 years for the negotiations, which I know have been extremely difficult in relation to certain matters, to be completed successfully.
The noble Lord, Lord Walton, mentioned the health committee, which has been a success. It was set up largely due to the work of the late Sir Dennis Hill, who was a man of remarkable ability and persuasiveness. He had the power to make people trust him. That has worked. Again, its actions have been benign. For the most part, they are carried out peripherally and it is to be hoped that the matters which we are now considering—knowledge, skill and behaviour—will be dealt with peripherally and not have to be dealt with by the new statutory committee.
The setting up of the peripheral mechanism will be extremely complicated and time-consuming. I am sure that Sir Robert's successor, Sir Donald Irvine, will be an ideal person to take on that particular task because he is a general practitioner. In the 150 years that I have mentioned already, he is the first general practitioner to hold the office of president.
Therefore, the wind looks fair. I believe that this legislation will work although it is not an easy matter. I hope that your Lordships will find it possible to expedite its passage so that we can get on with the work.
§ 4.36 p.m.
§ Baroness Macleod of Borve
My Lords, I should like to start my few words to your Lordships by paying tribute to the late Lord Ennals. He was a Member of this House for 12 years during which time I too had the privilege to be here. He did a great deal for the medical 888 profession, for patients and the hospital world in general. I believe that he would have approved of all that we are discussing today.
I thank the Minister for being so cogently helpful in her introduction of the Bill. The measure is extremely comprehensive but, at the same time, short; it is very, very important. We have heard brilliant speeches from professional medical people. No one could have listened to more professional contributions.
I come to the debate as an ordinary but extremely grateful patient. I have been a patient for a long time, having had a birthday the other day. The Bill is important to me and to all people who are interested in the medical profession because it comes from the GMC. It is extremely rare in this Chamber or indeed in the other place for a Bill to receive the overwhelming support of the people whom it is hoped that it will help or put right. Therefore, the Bill is unusual. I hope that it will go through with the one or two amendments which the Minister outlined.
Clause 1 deals with professional performance. It seems to dot every "i", cross every "t" and meet every single hedge before it is galloped over. I hope that the Bill works. I am sure that some members of the legal profession will try to find holes in it, but I do not believe that they will be able to do so.
I should like to know who can report a case if a medical practitioner is thought to be below standard. It worries me that ordinary members of the public—the ordinary patients—would not want to let down the doctor who had probably been very helpful but who perhaps on occasions should, in the patient's view, be reported. How do they do that? How many reportings do the Minister and the department think are likely to be brought before the GMC? Will it be hundreds? I hope so; I would certainly not expect thousands. Moreover, can a doctor's colleagues report him? Can hospital trusts report such doctors? I presume members of the public can. Unless the ordinary person is able to report a doctor, however unwillingly, I fear that some will not be put in the firing line as is intended under the Bill.
I was very interested to read paragraph (7) in the schedule on page 9 of the Bill which says that individuals will not be identified. I believe that to be most important. However, we all know that leaks occur in all parts of public life these days. At the same time, a doctor's whole future and life might be ruined if such identification is possible. I hope that just causes will be found to make it absolutely certain that the hearings will be in private and certainly not with the public being allowed to attend. I was also interested to see that counsel or a solicitor will be able to represent people who are brought before the General Medical Council.
I have very little else to say, but way back in 1952 my late husband was made Minister of Health. He held that position for four years. They were exceptionally happy years, but they were extraordinarily disorganised. We had no money, the doctors were coming out of the forces, and nurses were difficult to find; indeed, the hospitals were way below standard. However, since then, science, technology and motivation—everything that a proper health service, National Health Service or private, has—have increased enormously. I wanted the 889 House to know how proud my husband would have been to take part in the Bill's proceedings here or in the other place. I am certain that the Bill would have had his support had he been with us today.
§ 4.43 p.m.
§ Baroness Masham of Ilton
My Lords, we have before us a Bill which covers a very serious subject. It is both necessary and important. It deals with the doctor's standard of professional performance when it is found to be seriously deficient. FHSA members, hospital trust members, health authority members and CHC members will, I am sure, welcome any progress that the Bill makes towards raising the standard of doctors who fall below an acceptable level.
However, the people who are of the greatest importance are, I think, the patients. I feel that they will benefit most. Patients are the most vulnerable and at risk if they are treated by incompetent doctors. One only has to look at some of the results regarding women who have had breast cancer and were given the wrong dose of radiation: some of them now have useless arms.
When dealing with matters as sensitive as those contained in the Bill, I hope that all the procedures will be undertaken as quickly as possible. It has been of great concern to many people over the years that, when things go wrong when treating patients, there have often been cover-ups. Patients have sometimes been transferred to other hospitals when they have had serious complications. I remember one patient who had been given an epidural when giving birth to her baby in a London hospital. She became paralysed and was transferred, without any medical notes, to a spinal unit.
When one looks at the Bill and sees that there will be remedial training to improve doctors' professional performance, it makes one wonder why it had not been done many years ago. However, the noble Lord, Lord Richardson, explained that to us. I am pleased that the Bill covers doctors working in the private sector as well as those in the National Health Service. All patients need protection whoever they are and wherever they come from.
I believe that retraining will be paid for by the National Health Service trusts. But general practitioners, as self-employed contractors, would have to pay for any retraining themselves. Surely it would be possible for FHSAs, or the new health authorities, to help them with some training schemes. I would be grateful if the Minister would explain how the GMC will decide whether the complaint is a performance or a misconduct issue. Do not many complaints involve both?
I should like to bring to your Lordships' notice the very real problem in our society of alcohol and drug abuse at the workplace. Only last week, while listening to my car radio, I heard that doctors were one of the highest professional categories at risk of having alcohol problems. Very often doctors, many of them general practitioners, have an alcohol problem which they may hide even from their colleagues. That can affect their competence. If a train driver, a pilot or a bus driver was found to have an alcohol problem, would he not be suspended? Is this not a very real problem when doctors have responsibility for people's lives? Further, is that 890 not serious professional misconduct which can make a doctor incompetent? So many people with a drink problem will not recognise that they have one. How does one deal with rehabilitation if someone refuses to admit that they have a problem?
Can the Minister say whether that very real problem will be covered by the Bill? I believe that all doctors in medical schools should be given training as regards addiction so that they can address the issue, not only for their patients but also for themselves and their colleagues. I am glad that retraining is an important part of the Bill. But it seems necessary for the GMC to be able to put conditions on a doctor's activities for a period when he or she is restored to the register after having been struck off. Otherwise, does the Minister not agree that such people could slip back into bad habits? Will there be a monitoring system?
So many patients trust their doctors without reservation. With the responsibility of this important Bill before us, should not your Lordships make it as safe as possible? I hope that we can do so. I should like to conclude by asking the Minister one further question. Will there be such a Bill for dentists? That question was also posed by the noble Lord, Lord Colwyn.
§ 4.50 p.m.
§ Lord Harmsworth
My Lords, I wish to speak briefly in support of the Bill. In my view it provides the General Medical Council with powers that can only be beneficial in dealing with the complexities of any situation where not only the interests of patients but those of practitioners need to be safeguarded. It provides the GMC with the kind of refinements of existing powers which, with the benefit of hindsight and practical experience, have become evident over the years and have now crystallised in the form of the measures in the Bill. Unless I am mistaken in my understanding of the position in relation to Clause 2, I suspect that the wording will require a little tightening. I have been in touch with the private office of my noble friend the Minister in that regard. Changes, however, must wait for later stages of the Bill. The Bill has been well received in another place by the major parties. Further endorsement is hardly required from me, but I wish the Bill well.
I, like other of your Lordships, have found tremendously helpful the consolidation of the Bill with the relevant parts of the Medical Act 1983 as provided by my noble friend the Minister and her department. I well remember times of yester-year when I would sit at my desk cutting and pasting little bits of legislation in order to make more quickly intelligible seemingly unravellable cross-references in Bills and Acts. I wonder why, with all the modern technology about and the huge power of even the most humble secretarial word processing software, it is not possible, within reason, immediately to consolidate every instrument in this way. How much more simple would life become for the humble politician and his professional advisers if that were so? But that is another story.
891 I extend my congratulations to the Minister. May the Bill get a fair wind.
§ 4.52 p.m.
§ Lord Milverton
My Lords, I rise to welcome the Bill and support Her Majesty's Government. It seems to me that the Bill gives assurance both to doctors and patients that where there is a complaint or dissatisfaction one way or the other both believe that there is a fair foundation for a hearing and a proper result will come from it. That is important both for patients and the whole of the medical profession.
Performance is important not only in very serious, complex illnesses but in minor ones. Who is to make a complaint? I suppose that I could have made a complaint based on one experience. On my way home from the House I intended to visit my daughter who was then in London. To that end, I was on my way to Notting Hill tube station. I do not know whether I slipped on something or, as the doctor whom I saw afterwards in Bath thought, I was mugged. Whatever the cause, one minute I was walking along and the next I was on the ground. I tried to get up and completely passed out.
When I came to I found myself sitting on the pavement propped up with several people around me. An ambulance was called and I was taken to a hospital, the name of which I will not give. I thought I had made it plain to those in the hospital that I believed that I had done something to my arm or shoulder. The net result was that they thought I had suffered a heart attack or something like that. At about 11 o'clock at night they discharged me on the basis that I was all right when I knew that I was not. When I was told to get dressed I knew that if I did not lean against the bed I would probably fall over. I had to ask the nurse to help me. I could not get home that night and went to see my daughter. The moment that I spoke to her through her Entryphone she knew that something was wrong. The next morning I nearly passed when getting in a taxi. My wife and doctor had been informed. My wife met me at Gillingham station. As soon as I saw my doctor he spotted that I had a broken arm.
I have great respect for the medical profession and for health service hospitals, but how can that happen? I have heard of other instances of people who have been discharged in similar circumstances or a wrong diagnosis has been made. I hope that such incidents will become less common. For someone to walk round with an untreated broken arm for 24 hours is a little disconcerting. When I was X-rayed at Bath hospital I had a pretty bad break and another problem. I do not quite know how I managed to get home, because I could not hold my arm up; it was just dangling down. How I got dressed the next morning I do not know. I believe that doctors and nurses should be able to diagnose a broken arm. Unfortunately, it occurred when a world cup soccer competition, or something similar, was taking place. England was playing that evening. They thought that there was nothing wrong with me, having treated me for a heart attack. I hope that the Bill will further professionalism in hospitals. I believe that what 892 happened to me was a disgrace. When I told people about it they were astounded. My doctor could not believe it.
I wish the Bill well and that all of the good things that have been said about it will happen. I also hope that the suggestions that have been made to the Minister by the noble Lord, Lord Walton of Detchant, will be taken into account. I believe that the British Medical Association, like the General Medical Council, is happy with the Bill and has only a few suggestions to make. If those suggestions can be incorporated into the Bill it will be all to the good.
I congratulate the Government. I also welcome the amendments with which the noble Baroness will deal on behalf of the Government.
§ 4.58 p.m.
§ Lord Pearson of Rannoch
My Lords, many of us who work in the City of London are often, I am afraid, automatically a little suspicious of self-regulation. But I have listened to the whole of this debate and join wholeheartedly with all noble Lords who have welcomed this Bill. A point which does not seem to me to have been made, perhaps because it is too obvious to make, is that the very existence of these new procedures will do much to concentrate the minds of the very few doctors in our excellent medical profession who are not doing their stuff. I think that it would go a long way to reduce a certain arrogance, which I have unfortunately found personally in some of those doctors, leading to the very many cases of appalling medical treatment with which all of your Lordships are familiar.
I have only one slight worry about the Bill as drafted, which concerns the difficulty which people who are perhaps not used to public arenas may have in bringing complaints. It may be that I am speaking particularly for those in isolated rural areas where the fear of complaining against a local doctor is a very real one. Often that allows such doctors to continue in practice for very much longer than they should. In that respect I join with the noble Baroness, Lady Jay, in finding some of the procedures rather complicated. It was there that my innate suspicion of self-regulation came into play, and I wondered whether in the lengthy debates which no doubt produced this Bill the procedures perhaps became more complicated than they need have done.
Certainly I worry about the question of a public hearing. I understand that it is only the doctor who can request a public hearing. That seems to me a very real dilemma. Of course public hearings are good things, but public hearings can very much discourage the kind of people who I feel should be encouraged to complain about some of the treatment they have received.
I do not know the answer to the problem I pose. Perhaps it is a problem for the guidelines when they eventually emerge. Or perhaps it is a question of making sure that the new procedures receive very wide publicity when they have been enacted, in the clearest possible terms.
I look forward to any comments my noble friend may have on those few remarks and join with all other noble Lords in welcoming the Bill.
§ 5.1 p.m.
§ Lord Rea
My Lords, in winding up from these Benches I should like first to thank the noble Baroness, Lady Macleod, for her tribute to my noble friend Lord Ennals. All of us, not only on these Benches but in the whole House, will miss him greatly, both personally and for his contributions to your Lordships' House. He was a champion of the downtrodden in all countries of the world. At his funeral a moving message from the Dalai Lama was read out.
There is little new that I can add to the remarks—all supportive of the Bill and certainly of its intentions—made from all sides of the House. In my view this is a good example of how a profession should regulate itself, although I accept the remarks of the noble Lord, Lord Pearson. Perhaps the noble Baroness will comment on the complexity of the wording of the Bill.
The Bill has had a long gestation, as both the previous Presidents of the General Medical Council have indicated. Much of the thinking has emanated from the General Medical Council itself. The final form of the Bill is largely the work of Sir Robert Kilpatrick, the recently retired president of the GMC.
The extension of the powers of the General Medical Council to suspend doctors whose performance in their role as trusted advisers to the public is seriously deficient will be welcomed. It has already been welcomed by many doctors, the representative organisation of the medical profession—the British Medical Association—and many organisations representing patients.
Almost every citizen has been or will be at some point in his or her life a patient. There are times when a patient has to surrender his or her autonomy to a doctor or surgeon. Therefore, trust is essential. By allowing anyone to inform the General Medical Council when they suspect that a doctor's practice is seriously defective some power is put back into the hands of the patients. However, as the noble Baroness, Lady Macleod, said, some patients may feel reluctant to come forward if they are to be named. They would not necessarily like the doctor to know that it was they who made the complaint. Can the noble Baroness say how that might be covered and whether it would be possible for a member of the public—a patient or a patient's relative—to make a complaint and remain anonymous?
If they are certain of their ground, doctors can anonymously inform the General Medical Council when they feel that one of their fellow practitioners is letting the profession down through incompetent or dangerous practice. Thus the profession is enabled to act as a watch-dog over its own members. In itself that should help to maintain good standards. No doctor who is practising adequately and as trained, both as an undergraduate and throughout his or her professional life through postgraduate education, need fear that provision. However, that provision might possibly be misused. Can the noble Baroness say whether a doctor falsely or malevolently charged with incompetence and then cleared by the assessment referral committee will ever know who reported him or her to the General Medical Council? It might be difficult to conceal that information as most doctors work in a fairly closed professional community.
894 I should like to pick up some points made by other noble Lords and reinforce their remarks.
I turn first to the question of the cost of retraining those doctors who are suspended and thought likely to benefit from further remedial training. My noble friend Lady Jay, the noble Baroness, Lady Robson, the noble Lord, Lord Walton, the noble Lord, Lord Colwyn, and the noble Baroness, Lady Masham, asked how the costs were to be met. Will they be met by the trusts, by local health authorities—which now include FHSAs—or from some other source? In the Explanatory and Financial Memorandum it is stated that the cost of administration of the new measures will be met by an £8 increase in the annual retention fee that doctors pay. As 100,000 doctors are registered that means that an extra £800,000 will be collected. The sum of £500,000 is mentioned as the possible cost of retraining doctors who are suspended. I hope that the noble Baroness will be able to address that point.
The noble Baroness, Lady Robson, put forward a very important point; namely, that it should be possible for health authorities and other employing authorities to know quickly who has been suspended so that they do not make any mistakes.
The noble Lord, Lord Walton, raised the question of the contracts of employment with trusts or other bodies within the National Health Service of doctors who are suspended for re-education. How will those be preserved while the doctor undergoes remedial training, how long will they be maintained, and can they be put into cold storage? I would be grateful if the noble Baroness could address the problem.
In conclusion, we on these Benches can assure the noble Baroness and the House that we wholeheartedly welcome the intention of the Bill. A few points need clarification, as I outlined, and I hope that the noble Baroness can reassure us so that amendments at the Committee or Report stages can be cut to a minimum.
§ 5.10 p.m.
§ Baroness Cumberlege
My Lords, I am grateful to your Lordships for your wisdom, knowledge and constructive contribution to this debate. That is not surprising when there is such a body of expertise present in the House. Noble Lords are aware of the tragic consequences that can arise when a doctor's performance does not reach the standards required. I sense this afternoon that there is a consensus that it is only by having sound arrangements that we can ensure that the interests of patients are well protected.
I shall try to pick up some of the points made during the debate. First, I wish to thank all noble Lords who have supported the Bill—I think that is probably every single speaker—but particularly those from the Opposition Benches. The noble Baroness, Lady Jay, asked what constitutes "serious deficiency". Serious deficiency in professional performance is a departure from good medical practice, whether it is covered by the GMC guidance or not; that is, sufficient to call into question the doctor's registration. I appreciate that that is a rather woolly definition, but I understand that the GMC already publishes guidance on standards of professional conduct, known as the blue book. The 895 book's full title is Professional Conduct and Discipline: Fitness to Practise. It is available to doctors and the public alike. The GMC has reviewed its advice to the profession to reflect the introduction of these performance procedures. It will publish the book again in the autumn. I hope that then it will become clearer.
The noble Baroness also asked whether one episode of serious lack of performance could trigger a GMC investigation. The performance procedures will look at a doctor's general standard of professional performance and not at individual incidents. Generally, I do not think that it will be apparent from a single instance whether there is a pattern of professional performance. However, where a single case involving a catalogue of errors or a single complaint about a series of incidents indicated that a doctor's standards of performance might be detrimental to patient care, that could trigger the performance procedures.
We very much welcome the noble Baroness's suggestion that we should send clear guidance on GMC procedures to health authorities and trusts. I think that that was also a point picked up by my noble friend Lord Pearson. There is a firm intention to communicate clearly to all employers and to health authorities how the procedures will work. The precise details though will need to be considered by the GMC, probably in consultation with the NHS Executive.
§ Lord Pearson of Rannoch
My Lords, with the leave of the House, would it be possible for the guidelines to be available further down to the general public than local health boards and so on? It is at the general public level that the people about whom I am worried need guidelines in clear language.
§ Baroness Jay
My Lords, before the Minister replies, could the guidelines also be in language which is understood by members of the public, who may also be members of the health authorities or community health councils?
§ Baroness Cumberlege
Yes, my Lords, I am aware of the NHS jargon which permeates every document that we try to produce. My noble friend and the noble Baroness have made a good point. Perhaps we could take it away, think about it and come back at Committee stage. I am sure that we would wish to involve people like community health councils, other organisations and consumer bodies because it is clearly no use having good systems when people do not know about them and when they are hidden from public view. I am sure that our intention is shared, and perhaps we could come back with more practical proposals during the course of the Bill.
I should like now to address the issue of whether the hearings should be in public or in private. Our intention is that the hearings of the committee on professional performance will be held in private unless the doctor wishes otherwise. I know that comparisons have been made with conduct procedures where hearings are held in public. However, the conduct proceedings address specific wilful acts and omissions by doctors and the standard of proof is different. We therefore feel that at 896 this time it is not appropriate to draw such comparisons, and the performance procedures are more akin to health proceedings.
The GMC has already consulted specifically on the merits of public and private hearings. The result is generally in favour of private hearings, but at the Commons Committee stage a clear commitment was given that the GMC would review the operation of the committee on professional performance three years after the first hearing. That commitment remains and I am sure that the issue will be addressed again.
The noble Baroness asked about standards of personal conduct—rudeness and those kinds of issues—and whether that would also trigger the new procedure. In principle, yes, it would. But it is unlikely that isolated incidents would do so. The complaint would need to suggest a pattern of behaviour which was offensive to patients. No one would surely want to suggest that occasional instances of, say, impatience would call a doctor's registration into question. It is a matter of getting the balance right.
On the question of voluntary removal and whether doctors facing a performance committee hearing could lie low, as it were, for a few years and hang on, the amendment that we intend to bring forward at Committee stage will give the GMC powers to prevent a doctor taking his name off the register. This will be done where professional conduct, not performance proceedings, are contemplated or are in train. In performance matters, it is intended that doctors should be able to remove their names from the register if they so wish. Conduct is wilful and performance may not be. Therefore, a doctor whose performance is deficient should be able to come off the register because the aim is the protection of the public, not a public example being made of the doctor.
The noble Baroness also asked how long allegations will be kept on file. The GMC has set no time limit at this moment. Any arbitrary cut-off point would, we think, be undesirable; rather, the seriousness of the complaint should in part govern how long such information should be kept on record and reconsidered when the doctor applies for re-registration.
I wish to thank the noble Baroness, Lady Robson, for her warm welcome to the Bill. I know that she speaks from a distinguished career as a former regional chairman. I agree with her that the Bill is overdue. She asked, among other things, about remedial training costs, as did my noble friend Lord Colwyn, the noble Lord, Lord Walton, and other noble Lords. Our view is this and it is quite straightforward. We feel that doctors have a responsibility for ensuring that they keep up to date with current practice. The handful of doctors who will come under the GMC's new procedures should not expect the taxpayer to pay extra costs if they fail to maintain the standard of professional performance and level of competence achieved by their colleagues. Hospital doctors can discuss with their employer the need for support to undertake remedial action. That might include time off and the cost of courses, but it is entirely at the employer's discretion.
897 GPs are in a different position. They are independent contractors, responsible for meeting their own practice costs, including the costs of maintaining their professional skills and knowledge, as are doctors in the private sector. Doctors are already eligible to receive a postgraduate education allowance if they undertake regular training. In our view, the few poor performers should not expect to be paid more if they fail to take advantage of what is already available.
§ Baroness Robson of Kiddington
My Lords, will the Minister allow me to ask a question? The fact that a doctor has taken advantage of the postgraduate education allowance and used it will never prevent him from not performing according to the medical practice that is expected. It is a completely different type of education. It is not remedial for something that is wrong with his whole 'outlook; it is general postgraduate education and it is different.
§ Baroness Cumberlege
I accept that, but the point that I am making is that there is an annual provision for GPs in order to have training. I do not know what the cost of the remedial training will be in every instance over the course of a year. It may well be that the allowances for that year would cover those costs. However, we are saying that if they do not, we feel that it is reasonable that the general practitioner should carry the costs—as indeed I am sure other professionals in other walks of life who require career development, or as in this case additional training, would carry such costs.
The noble Baroness also asked whether there was a better system for sharing information about doctors, especially about locums, who face the GMC procedures. All NHS employers should check a doctor's references, including his or her contract with the General Medical Council. The NHS guidance is very clear on this matter. We have recognised particular concerns about locum doctors. Indeed, the Chief Medical Officer chaired a locums working group to address the problems to which the noble Baroness referred. The working group's report has been issued for consultation. Officials are currently assessing comments made on it. Among the report's recommendations is a UK-wide alert system which would trigger procedures should there be concern about a locum's performance. The GMC may also be advised of that.
We share the sentiments of the noble Lord, Lord Walton, in praising previous presidents of the GMC, and not least the noble Lord, Lord Richardson, who so changed the remit of the council when he prompted Parliament to introduce the Medical Act 1978. The noble Lord knows the issues so well, and his encouragement for the Bill is therefore very highly prized. I know that behind the scenes over many years he has influenced some of the thinking behind the Bill. I hope that through his many positions of influence the noble Lord will disseminate these proposals.
The noble Lord asked about doctors suspended on performance grounds and whether their NHS employment contract will he preserved. A number of other noble Lords raised the same issues. The answer is yes, in the sense that the suspension does not terminate 898 any contract of employment, or indeed arrangements with GPs, to provide general medical services by operation of law—that is, automatically. Rather, the matter is left in the hands of the relevant FHSA or employer. If the facts leading up to the suspension are serious enough, they may lead to a doctor's dismissal or de-listing. But this is not automatic. The whole matter is left to the FHSA or the employer, as is the case in connection with suspension, for instance, by the health committee.
My noble friend Lord Colwyn, the noble Baroness, Lady Robson, and a number of other noble Lords raised the question of costs. The explanatory memorandum states that the cost to the NHS is £530,000 a year. The costs of administering the new procedures will be met by the General Medical Council. Costs will arise from the running of the two new statutory committees, the setting up of the assessment panels and the general support provided by GMC officials. These costs will be met by the medical profession through the annual retention fee. It is expected that when the procedures have been fully implemented, the net increase in the retention fee to cover these costs will be something like £8. For GPs, because of the operation of the GP contract, part of that rise, amounting to about £250,000 per annum, will be met by the NHS. Our estimates of the total cost to be met by the NHS are higher: £530,000 a year. That is because some of the costs of remedial training will, as I have said already, be met by the NHS.
My noble friend Lord Colwyn also asked whether other professions should introduce similar provisions for self-regulation, as did the noble Baroness, Lady Masham. The answer is yes; but it really is up to them to do the preparatory work. In this case the Medical (Professional Performance) Bill arose from the GMC initiative, following a lot of consultation and debate with the medical profession. Should the General Dental Council, or indeed any other health professional regulatory body, wish to develop proposals for change, the Government will of course be interested in them.
I sensed that a degree of frustration was exhibited by the noble Lord, Lord Richardson, in having his fox shot by the noble Lord, Lord Walton. I know that feeling very well indeed: I followed the noble Lord, Lord Walton, on many a platform. I do not think that the noble Lord, Lord Richardson, need have been so modest. His perceptions and insights have greatly enriched this debate, coming as they do from someone who has had a remarkable, distinguished and honourable career in medicine.
My noble friend Lady Macleod is right to paint a picture of the NHS when her husband, lain Macleod, also a remarkable man, made such an impact on the service. He is still extensively quoted—indeed, as recently as last week, when my right honourable friend the Secretary of State for Health made a major speech at the Royal Society of Medicine.
My noble friend asked who will be able to report a case to the GMC, as did the noble Lord, Lord Rea. We expect anybody to be able to make a complaint: patients, professional colleagues, NHS Trusts—anybody. It is an open door. My noble friend asked how many complaints 899 were expected. The GMC feels that the number of cases referred to it requiring assessment will be between about 100 and 150 per annum.
I am not quite sure that I fully understood the points made by my noble friend Lord Harmsworth. I am very happy to discuss them later should he wish. If he wishes to table amendments at Committee stage, we shall consider them fully. I believe that my noble friend wondered whether Clause 2 as drafted gives the GMC the powers to make rules as it considers necessary. Following consultations with the professions as to the details, the GMC has said that it will make the rules under Clause 2 once the consultation has taken place. Perhaps I may clarify this later with my noble friend.
The noble Baroness, Lady Masham, raised the issue of doctors with alcohol problems and whether that constitutes serious professional misconduct. Alcohol problems are generally taken under the GMC health procedures and are dealt with already through that mechanism.
The noble Baroness also asked whether the GMC would decide whether a complaint related to misconduct or poor performance. Basically, it is the screener who will first consider whether by its nature a complaint falls within the scope of serious professional misconduct. That is concerned with one or more incidents or events which are in themselves sufficiently serious. Performance procedures, on the other hand, will generally be invoked by a pattern of deficiency within which each incident or event is not itself sufficiently serious to challenge a doctor's registration.
My noble friend Lord Milverton gave us a graphic account of some of the problems that can occur. Of course we try to ensure that mistakes are not made; and that is where training is so important, both initially and at postgraduate level. I am sure, however, that my noble friend, who probably has more experience of dealing with human frailty than most of us, will recognise that we cannot all be perfect.
The noble Lord, Lord Pearson, raised the issue of how difficult it is to bring a complaint, especially perhaps in a rural area where the GP is well known by individual members of the population. I believe that that issue was also raised by the noble Lord, Lord Rea. In principle, there is nothing to stop a patient remaining anonymous, at least in the early stages. The focus of the procedures is on the assessment of a doctor's performance as a whole, not on a particular complaint. But if there is a hearing, the patient need not appear if he or she does not wish to do so.
The noble Lord also raised the issue of whether doctors should know the name of the complainant. I believe that that will depend on the case, but I shall come back to the noble Lord as I do not know the answer.
I am sure that there are a number of points that I have not addressed. I shall read Hansard very carefully, pick them out and write to individual noble Lords if I have missed some of them. In conclusion, the Government believe that self-regulation is the best way to govern a 900 profession. It is perhaps a question of "Physician, heal thyself". The profession itself knows what standards its members should meet.
I am sure that your Lordships will wish to support the medical profession in its vigilance to uphold standards and its desire to have the powers to exclude those who jeopardise the integrity of their profession. I believe that it is immensely encouraging that doctors have recognised that the empathy between doctor and patient is even more important when scientific and technological advances enable doctors to offer treatments that are at the bounds of comprehension and the limits of moral and ethical acceptability.
This is an important Bill. It is part of our commitment to make sure that the National Health Service delivers the highest possible standard of care and professional performance. Our changes mean that patients in future will have even greater confidence than they had before in the treatment that they receive and, once this Bill is enacted, in the doctors who deliver that care both within the NHS and outside it. I commend the Bill to your Lordships.
§ Lord Colwyn
My Lords, before my noble friend sits down, may I ask whether she has any information about the timing of the future stages of this Bill?
§ Baroness Cumberlege
My Lords, that is an extremely difficult question. I shall have to go to the usual channels and find out. I do not know.
§ On Question, Bill read a second time, and committed to a Committee of the Whole House.