HL Deb 03 December 2002 vol 641 cc1098-112

7.21 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Lord Hunt of Kings Heath) rose to move, That the draft order laid before the House on 14th November be approved [First Report from the Joint Committee].

The noble Lord said: My Lords, the order before the House today will bring about major reform of the General Medical Council. In essence, these reforms have been designed to achieve three important objectives. First, to provide better protection and improved safeguards for the public; secondly, clearer and more straightforward procedures in relation to fitness to practice which are in the interests of both the medical profession and the public at large; and, finally, greater accountability and transparency around the working of the GMC itself.

I pay tribute to the GMC for the work that it does and for its specific work on reforms. I particularly mention Sir Donald Irvine, the former President of the GMC, and his successor, Graeme Catto.

The new GMC will be smaller and able to work more quickly in the public interest. It will have quicker and simpler procedures, particularly where a doctor's fitness to practise is in question. There will be far greater lay representation than before and, for the first time, the GMC will be able to link registration with performance through the introduction of revalidation for all doctors.

Proposals for reform have been developed by the GMC itself following careful and widespread consultation with patients and the medical profession. There was overwhelming support for reform in response to the consultation on the draft order.

The order makes a number of amendments to the Medical Act 1983 rather than replacing it altogether. We have tried to keep the drafting as simple as possible but the fact that we are amending the primary legislation in this way means that the order is inevitably a rather complex document.

We said in the NHS Plan that, as a minimum, regulatory bodies must change so that they are smaller with much greater patient and public representation in their membership; have faster more transparent procedures; and develop meaningful accountability to the health service. The order represents a big step forward in meeting those needs.

The order reduces the size of the General Council—or paves the way for such a reduction—from an unwieldy 104 to a maximum of 35. A smaller council will inevitably be required to work in different ways. For example, members of the new council will not have the same role in fitness-to-practice cases as their predecessors. Cases will be heard by panels made up of non-council members and will include both doctors and lay people. The effect of this, together with the opportunity for more non-council members to sit on working committees, will result in a welcome increase in the number of members of the public taking an active role.

The new council will meet more frequently, and this will help the new GMC to respond more rapidly to change and to take forward business more effectively. Lay members currently form only 25 per cent of the members of the General Council. In future, they will make up no less than 40 per cent—14 out of 35.

The links to Parliament are important and the GMC, as a statutory body, will continue to be accountable to Parliament. We have strengthened this link by ensuring that the council reports to Parliament, through the Privy Council, on an annual basis. The Act as revised by the order will now require that the report be laid before each House of Parliament. Like other regulatory bodies, the GMC will come under the remit of the new Council for the Regulation of Healthcare Professionals. This new body will report to Parliament and so help us to hold regulators to account more effectively.

Though detailed, the order does not go into every detail of the governance of the council. A great deal will be dealt with in secondary legislation and will be subject to scrutiny by both the Privy Council and Parliament. The first of these statutory instruments will be the General Medical Council (Constitution) Order. We have already published a draft of this order. The constitution order sets out the numbers of members, how they get selected and their terms of office, including that of the president. It also covers the termination of office for existing members and sets the quorum at 25. These orders will be subject to the negative procedure.

The order places a new duty on the GMC to cooperate, as appropriate and where practicable, with other bodies concerned with the regulation of healthcare professionals. As new clinical roles develop in the health service it is vital that the GMC plays a full part in ensuring that professionals working closely with doctors, perhaps taking over some of the roles traditionally delivered by doctors, meet similarly high standards expected of doctors.

In recognition of the new spirit of partnership with patients and the public, the order places a duty on the GMC to inform the public about its work.

From a public protection point of view, the medical register is perhaps the most fundamental part of the GMC's work. Keeping the register will be at the centre of the new GMC's functions. The order clarifies the GMC's freedom to publish the medical register on the Internet and, at the same time, abolishes the requirement for the GMC to publish an annual register.

But patients today want to know far more than whether a doctor is simply on the register. They want to know whether he or she is up to date with current practice. An important change that this order will bring is the introduction of a licence to practise. In future, only doctors who have a licence to practise will be able to treat patients and prescribe drugs. The licence may be withdrawn if doctors fail to maintain their fitness to practise or do not demonstrate, through the GMC's new validation procedures, that they are up to date and fit to practise.

The introduction of revalidation for all doctors is therefore a key feature of the changes we are debating. In future, every practising doctor will have to submit evidence to the GMC, collected over a five-year period, that their practice is up to date and of sufficiently high standard. Provided that they meet those standards they will retain their licence to practise. Those doctors who choose not to take part or who do not meet the required standard will not be issued with a licence to practise.

That process will be supported by the separate introduction of an appraisal system for all doctors working in the NHS. All NHS doctors will be discussing their practice with their employer or a recognised NHS appraiser on an annual basis.

Revalidation will help all doctors to show that they are giving good medical care and will support them to develop and improve their practice. It will also enable doctors to identify and correct any weaknesses they may have. If concerns are raised about a doctor's fitness to practise during the revalidation process, he or she can be referred to the GMC's fitness-to-practise procedures. These procedures—for handling concerns about a doctor's conduct, performance or health—are perhaps the most prominent aspect of the GMC's work.

I should stress that even though the number of complaints against doctors increases year on year, the vast majority of people receive excellent service from committed and caring professionals working to very high standards which the GMC helps to maintain. When things go wrong—as they inevitably do from time to time—it is important to have effective procedures in place for dealing with them.

The role of the GMC is to make decisions on those cases where a problem is so serious that a doctor's registration is called into question. The new GMC will concentrate on the most serious cases, and on those where local action is unable to secure adequate public protection.

It is in everyone's interest that procedures are fast, fair and efficient. The order provides for important changes to the GMC's fitness to practise procedures to ensure that they are just that, and that they maintain the right balance between the legitimate expectations of patients and the rights of individual doctors.

In effect, these changes will mean simpler proceedings and rules, speedier processes, the more meaningful involvement of those who bring cases to the GMC's attention and keeping interested parties informed of progress.

Streamlined fitness-to-practise procedures, together with the changes that we have made to the constitution and governance of the GMC and the introduction of revalidation for doctors fully meet the aims for modernised professional self-regulation. I believe that it is consistent with the changes that are being made with the other regulatory bodies. The new GMC will be more open, more accountable and more responsive to change than ever before.

The GMC has undertaken a tremendous amount of work in engaging the profession and other stakeholders in determining the future of professionally led self-regulation for doctors. Events at Bristol and the publication of the Kennedy report gave this exercise an additional imperative and urgency. Again, I pay tribute to the GMC for its work in taking this agenda forward.

The case for reform in this area has been debated extensively with stakeholders and has been widely accepted. The reforms before the House will ensure not only that the new GMC will be able to respond to the need for reform but that, crucially, it will be able to set the pace of reform. I commend the order to the House. I beg to move.

Moved, That the draft order laid before the House on 14th November be approved [First Report from the Joint Committee].—(Lord Hunt of Kings Heath.)

Baroness Noakes

My Lords, I thank the Minister for his comprehensive explanation of the order. It is clear that it is basically non-contentious, and it has the support of the General Medical Council, which is itself the object of reform in the order. Indeed, it is fair to say, as the Minister has generously pointed out, that the GMC has been active in the development of the ideas behind the order. The GMC is keen to see these reforms progress.

Let me make it clear that we on these Benches support the important principle underlying the order; namely, self-regulation. Control of regulatory processes has always been one of the hallmarks of a profession, and we are glad that the solution agreed between the Government and the GMC does not impair this fundamental rule.

It would be tempting to stop here and say, "Thanks very much, all agreed". The Minister will know, however, that life is rarely that simple and I should like to address three aspects of the order.

The first is the restructuring of the GMC. It will be a much smaller council—the number of members will be reduced from 104 to 35 and the proportion of lay members will be increased from 25 per cent to 40 per cent. All of that seems to be going in the right direction of travel. But I do question whether the journey has gone far enough. In particular, when the Government set up the Council for the Regulation of Healthcare Professionals and the Nursing and Midwifery Council earlier this year they chose a different end point for those bodies; namely, a council size of 23 and lay representation just short of 50 per cent.

Will the Minister explain why it is that doctors are different? Is there not just as much need for lay representation on a body involving doctors as there is with other healthcare professionals? And while the reduction in the number of council members to 35 goes some way towards streamlining the GMC's deliberations, I rather doubt that any objective study of the effectiveness of organisational structures would endorse as many as 35 on the governing body. A number of the bodies consulted by the Department of Health came to that conclusion. Indeed, I would not even point to 23, as on the HPC and the N MC, as being the last word in organisational fitness. Can the Minister explain the rationale behind the figure of 35?

Can the Minister give some idea of whether the new structure will be reviewed; and, if so, when? The objectives are clear—greater lay involvement and speedier processes in the public interest. But what if this largish body, with its rather individual governance structure, does not deliver the goods? When will the Government look again at this?

I now turn to a second aspect of the order; namely, the new processes around fitness to practise, and in particular the new investigation committees and fitness to practise panels. I think it fair to say that much of this has met with general approbation, but it has been recognised that much of the detail of how the panels and committees will work in practice will not be known until the rules themselves are published. Will the Minister give an assurance that those rules will be subject to public consultation? The Consumers' Association in particular made this point.

The Minister will be aware that the issue of a warning for less serious offences is a controversial one. This new sanction may not easily be understood by the outside world. Does it mean that a doctor is not guilty, or only a little bit guilty, or what? It does not necessarily sit easily alongside existing clinical governance processes that have been introduced into the NHS with much care and effort over the past decade or so. The Government have pressed ahead with this aspect of the reforms despite the concerns of, for example, the Joint Consultants Committee. Will the Government be keeping this new sanction under review? If so, when does the Minister expect the first review to be available?

The third aspect on which I wish to focus is the issue of revalidation. We fully support the thrust of this proposal, but the devil is in the detail of the rules, as several consultees pointed out. When will the detailed rules be published and will they be consulted on? Again, the Consumers' Association feels that it is important to expose this area to public scrutiny before finalisation.

My principal concern in this area is a practical one. Over the next few years, over 100,000 doctors will be seeking revalidation, plus the new intake from the medical schools and from overseas. The revalidation exercise will work well only if there are robust systems in the NHS on which revalidation can be based. What steps have the Government taken to ensure that NHS appraisal systems will be fit for that purpose, including achieving the elusive element of consistency? Are the Government satisfied that the necessary resources will exist within the GMC to undertake this task?

The Minister will be aware that when the Nursing and Midwifery Council attempted its ambitious process of registration earlier this year, it got itself into a bit of a pickle and the registration timetable went off the rails. Is the Minister sure that nothing of the same ilk could happen with this revalidation exercise? What would he the position of a doctor whose revalidation had been held up for some reason outwith his own control—perhaps as a result of imperfections in registration processes?

I am conscious that this is quite a long list of questions for the Minister, but these are important issues. I stress that we very much want to support the order and hope that the Minister will be able to give constructive answers to our questions.

Lord Clement-Jones

My Lords, as the GMC admits in its annual report, it has suffered criticism over the years. I agree with the Minister and the noble Baroness, Lady Noakes. Given the speed of changes in medical practice and the new elements of regulation that have been needed, many of us admire how the GMC has reformed itself, starting under the presidency of Sir Donald Irvine and then Sir Graeme Catto. Most of that reform has been instigated from the inside. 'With some caveats, therefore, I congratulate them on what we have before us today, the extensive consultation process that they engaged in throughout 2000 and 2001 to get there, and the principles that they have enunciated as being central to the reforms—effectiveness, inclusiveness, accountability and transparency—allied with the principle of professionally led regulation.

Throughout, however, we must remember that the essence is to ensure good medical practice and that the system has the confidence of the public, patients and professionals. We welcome the changes, rather more unreservedly than the Opposition Benches in terms of the changes to governance. Specifically, I do not believe that one size for a regulatory body fits all. We welcome the fitness-to-practise changes and the introduction of revalidation. We also welcome the fact that the GMC will now have its report laid before each House and that the protection of the public will now be explicitly at the heart of the GMC's activities.

Key, too, is ensuring that there is no duplication with other clinical governance, appraisal systems and quality assurance systems, whether carried out by the Royal Colleges, the NPSA, the National Clinical and Assessment Authority, health authorities or NHS trusts; otherwise, that will simply add to the burden on doctors without producing benefit. Professor Ian Kennedy, the new chairman of CHAI, talked of doctors being free of the "confetti of interference". As he said, they must be free from the pressure of multiple visitations by a variety of bodies. I am reassured by the conversations that I have had with the various agencies, but I would like to hear the Minister's assurance on that point.

My one serious regret about the order is the way in which it is drafted—the Minister touched briefly on that. It is a nightmare. I speak as a lawyer quite used to reading regulations. The drafting, without any available concordance, is a model of how not to draft legislation. It has not been made easy to comprehend the changes made; it has almost been made as difficult as possible in the circumstances.

My concerns about the order are essentially practical. I wish to discover what groundwork has been done to introduce it. I have a series of questions, and I apologise in advance for throwing them at the Minister. I know that, in his usual capable fashion, he will have anticipated half of them and I have no doubt that he will be able to answer them.

To what extent were the revalidation process pilots carried out? How many doctors took part? How much time have the Government calculated will be taken up by assessors and individual doctors during, and in preparation for, the assessment? How many, and what percentage of, doctors failed the revalidation pilot process and subsequently were offered warnings, additional guidance and advice by assessors? That is an important factor in assessing the benefits of revalidation. What extra resources have been, or will be, made available by the Government for the revalidation process? The process requires locums to be engaged to meet patients needs. Will the GMC have the requisite resources to deal with fitness to practise cases in a timely fashion?

Under the new electoral system, why is the GMC setting up different regions? Will the GMC handle future complaints on a regional basis also? An important point relating to Schedule 4(3A)(1) on page 36 is that the continuity of the presence of members of the investigation committee, the interim orders panel or the fitness to practise panel is not required when hearing cases. So it appears that members of the panel do not have to be present throughout a hearing. How can that be valid? Surely, in those circumstances, a defendant has the right to know that those hearing evidence against him or her have heard all the evidence and have been present throughout the case. That may be a misinterpretation, but I hope that the Minister can clarify it.

I notice that now, consistently throughout the legislation as amended by the order, as a result of the interpretation Act being changed, the definition of registered medical practitioner in every case includes a fully registered person who holds a licence to practise under the Act. Is that consistent throughout the legislation? The very long list of legislation makes that point in a very confused manner.

I shall now discuss registration and changes to Section 19 of the Medical Act 1983. We had a lively debate in this House in June as part of the National Health Service Reform and Health Care Professions Bill prompted by St George's University School of Medicine in Grenada. As anticipated in the reply to my amendments by the noble Lord, Lord Filkin, Section 19 is indeed being changed so that there will no longer be the status of recognised university qualification for EEA nationals. This means, I assume, that under the terms of the new section all students who are UK nationals, since they are not exempt, will have to take PLAB and IELTS rather than the GMC being satisfied that certain institutions have provided sufficiently high-quality pre- and post-clinical medical training. As I pointed out in the debate in June, it seems perverse to do that when there are high-quality institutions around the world where quality of training can be assured. I very much regret—both for those institutions, which could attract many more UK aspirant doctors, and for the individuals themselves, who will now have to jump through more hoops—that the approach that we on these Benches suggested back in June has not been adopted.

I have two final comments. First, the consultation on these regulations has been a model. I very much hope that the consultations carried out over other medical reform, such as the establishment of the medical education and training board, which will have major implications for doctors, will follow a similar process.

Secondly, it is deeply ironic that, while we are establishing an important new fitness-to-practise regime for the United Kingdom through the order, the proposed new directive on mutual recognition of professional qualifications will potentially drive a coach and horses through the regime and allow totally unregistered doctors to work here for 16 weeks. In contrast to some member states, the Government have not been energetic in resisting these proposals. I hope they will become much more vigorous. I very much look forward to hearing what the Minister has to say.

Lord Patel

My Lords, I support the order. I shall try to be brief. I declare my interest. I am a fully registered doctor and a member of the council of the General Medical Council. For the past four years I have been a member of its education and professional conduct committee and I have also been a member of the interim orders committee.

The medical profession supports the order and the amendment to the Act, which will introduce a streamlined structure reducing the size of the council. It will also introduce revalidation for a doctor's licence to practise medicine and streamline the current fitnessto-practise procedure, including the separation of investigation and adjudication.

All the changes proposed have been discussed and discussed. I remember the many hours and days that we spent doing that. They have gone through an extensive consultation process. The medical profession is keen to have a system of professionally laid regulations that command the confidence of patients and doctors.

I will conclude by quoting the GMC president, Professor Sir Graeme Catto, who said: This order is an important milestone in the GMC reforms. We are on schedule to deliver the changes that we have proposed". The current officers and the council are well aware of the need to deliver all the changes on time. I have no doubt that the changes required to registration and recognition of training and experience of overseas doctors will be addressed by the GMC in the light of the changes proposed in the order.

It is not my role to answer many of the questions raised, but I assure your Lordships that most, if not all, have been discussed by the GMC and it will deliver them.

Baroness Emerton

My Lords, I speak as a former lay member of the General Medical Council. I served for a five-year term and was present at the beginning of the discussions on the reform of the council. I fully support the order and congratulate the GMC, the Minister and the Government on it.

Reform of the council was long overdue. Decision-making was tortuous, because of the time taken by having over 100 people present. The reduction in size will assist in the speed of decision-making. The increase in lay membership is also important.

Will the Minister clarify that the lay membership does not exclude other health professionals participating? Healthcare practice today is a team process. There is value in having other health professionals participating on bodies. Just as the nurses and midwives council has other health professionals present, I hope that the presence of lay members on the new council will include some healthcare professionals, although not many, because it is important that the lay representation covers the wide public interest.

The provisions in the order for the revalidation of doctors will benefit the practitioner, the patient and the public. That is crucial in any regulatory body. Fitness to practise is the key with the regulatory system. The order sets that out. There is much still to be done on regulation, but it is a miracle that we have got to this stage. I support the order.

Baroness Finlay of Llandaff

My Lords, too, support the order. I declare an interest, as I am also registered with the General Medical Council as a practising doctor. I commend the Government on their open approach to consultation in drawing up the order. It has been not just consultation, but reconsultation with open channels of communication, resulting in the whole profession understanding why the changes are happening. These changes are being introduced remarkably peacefully and with a wide degree of understanding. They are also being welcomed by the profession.

I reiterate the request from the noble Lord, Lord Clement-Jones, that this open process of consultation should be built on and used when other changes, such as those relating to education, are being looked at. The smooth transition that we have seen has much to commend it and will bring about the necessary changes to raise standards across the board.

The revalidation processes are a major step forward and are recognised as necessary within the profession. They have to be done with sensitivity and with sense so that clinical time is not eroded. Those women—two thirds of our graduates are now women—who wish to should be able to have time out to raise a family for one, two or three years and then re-enter the profession. Those who wish to pursue other educational avenues should be able to broaden their horizons and then continue with their clinical practice.

All the evidence that we have seen over many years is that those who take time out and then return to clinical practice do so with their clinical practice enhanced. The practitioners who have caused concern are those who have not taken time out from clinical practice, but have continued to practise without updating themselves and without auditing their own practice. Flexibility will be very important to maintain a vibrant workforce.

There are some exciting examples of appraisal already occurring—not simply straightforward appraisal, but 360 degree appraisal and learn appraisal, with input gained from all members of the team. The flexibility to allow that innovation and creativity is important.

It is also important to reflect the wide range of duties and responsibilities that exist within the enormous envelope called medical practice. It goes from very high tech and complex practice right through to broad, generic, front-line practice, as one sees in some areas, particularly in the community. It would be impossible to transpose one set of practice into another where there are very highly specialised areas of scientific practice, particularly those doctors who work in specialised areas of laboratory medicine.

To conclude, I commend the processes that have gone on behind the order and I support it. There is one small area that I should like the Minister to clarify, because it may not be as clear as might be helpful. Article 6(2) concerns full registration of EEA nationals by virtue of overseas primary qualifications. Will the Minister confirm that the General Medical Council will not be obliged to grant full registration in every case and that the order gives the council discretion in deciding whether it thinks fit to grant registration to the applicant, to ensure that the process of registration is truly based around fitness to practise?

Lord Hunt of Kings Heath

My Lords, I welcome all noble Lords who have contributed to this interesting debate. I echo the comments of the noble Baroness, Lady Noakes, and the noble Lord, Lord Clement-Jones, that there is broad support for the proposals in Parliament and among the medical profession, as the noble Baroness, Lady Finlay, has indicated. I again pay tribute to the GMC, to the work of the noble Lord, Lord Patel, who has played a positive role, and to members of the GMC past and present. The noble Baroness, Lady Emerton, has played a distinguished role.

There is clearly support for the concept of professional self-regulation to ensure public confidence. The Government also support that wholeheartedly.

I apologise to the noble Lord, Lord Clement-Jones, about the drafting issues that he raised. I agree that this is a lengthy and complicated order, because of the way that it has been done, through amending the Medical Act. I hope that the broad thrust of our proposals comes through clearly.

The noble Baroness, Lady Noakes, thought that a committee of 35 was too much. Indeed, I believe she considered a committee of 23 too much. Sometimes a committee of two is too much. Clearly, there is a delicate balance to be drawn between enabling us to have enough lay people to carry the profession with us and having some people nominated from the medical education world. Inevitably, one arrives at a figure higher than might be desirable. I agree with the noble Lord, Lord Clement-Jones, that one size does not fit all. In picking up the point raised by the noble Baroness as to why the GMC has only 40 per cent lay members while the NMC and HBC have 49 per cent, I believe that there are two points to be made. The key change is that the GMC will have a substantial and much increased lay voice. The exact arithmetic would matter only if regulators took decisions by votes which divided along lay versus professional lines. Experience shows that that does not occur.

The main reason why the GMC's proportion of lay members differs from the NMC and HBC is that, unlike them, it has separate places reserved for educators. In view of the discussions we have had over the past 12 months about the importance of medical schools, I believe that noble Lords will agree that it is right that it should have places. But we wanted also to ensure a majority on the council for elected medical members in order to preserve the principle of professional self regulation. It is for that reason that we have reached a figure of 40 per cent of lay members.

The question of the electoral base was raised by the noble Lord, Lord Clement-Jones. I understand that the Liberal Democrats are obsessive in their interest in the minutiae of electoral matters. Indeed, I am reliably informed that it is considered that the GMC took a rather Liberal Democrat approach to the proposals it is making for its electoral system.

Lord Clement-Jones

My Lords, it is much more like an old-fashioned gerrymander to me.

Lord Hunt of Kings Heath

My Lords, noble Lords would know more about that than I. The point is that the body has arrived at a system of five election areas in England based on postal districts. That is because it is taking the postal codes of every member of the GMC. It was divided up into five areas and that is why there are some quirks with Coventry and Warwickshire not appearing in the same electoral division.

But that surely is matter for the GMC rather than we politicians. I believe it is best left to it. One of the reasons it followed the route of regional election constituencies is that at the last election I believe over 300 candidates stood and all electors were given a list of over 300 candidates. That proved to be somewhat trying for the electorate. This system will be much easier. For the noble Lord's interest, they are multimember constituencies using the single transferable vote system.

I say to the noble Baroness, Lady Emerton, that as regards a definition of lay membership, it has always been possible—and remains so—that other members of other professions could be nominated as lay members of the GMC. The balance of views which we have received in the consultation is that the nomination of lay members should be for those who speak up best for the public and patients. But that in no way rules out the possibility of a nurse being appointed. No doubt that will be very carefully considered.

As regards the question of restructuring, I was quite surprised by the noble Baroness, Lady Noakes, wishing us to review urgently and perhaps restructure again. Usually, she accuses me of restructuring far too many times. But the point to be made about that and her comments about fitness to practise is that it is one of the joys of a Section 60 approach. It does allow for changes to be made in the light of experience without having to go for primary legislation. I assure her, and I have been assured, that all these matters will be kept under review by the GMC. The noble Baroness is absolutely right in that these matters need to be reviewed in the light of practice. If the GMC comes forward to the Government and indicates that more changes need to be made, we shall listen to that very carefully indeed.

The noble Baroness, Lady Noakes, asked about appraisal and revalidation. I very much agree with her. The appraisal of all doctors and the revalidation process is a mammoth task. I would not underestimate the challenge facing the GMC, individual members of the profession, as the noble Baroness, Lady Finlay, has indicated, and the NHS itself. Clearly, we have to do all we can to make sure that this system is bedded down as effectively as possible.

The GMC is planning to issue instructions, information and guidance about the new arrangements in April 2003. I can give the noble Baroness the assurance she requires that the GMC is required to consult professional bodies representing the medical professions. In addition, it has given a clear indication that it will consult more widely, as it has done already in developing the proposals in this order. I certainly agree that the amount of time spent on appraisal and revalidation is important. I am told that the actual time for appraisals differs from individual to individual. But anecdotal evidence suggests that the average time commitment for appraisal is a minimum of four-and-a-half hours up to six-and-a-half hours. That includes between two and four hours for preparation. We recognise that there will be a learning curve and that the time commitment in the first year of appraisal may be higher as trusts and individual doctors adapt to the new system. But all of us who have been involved in appraisal will recognise that it does take time and probably ought to do so, and that the benefits are there both for the individual and the organisation provided that it is done effectively.

I do not have all the information that the noble Lord, Lord Clement-Jones, asked for such as the number of doctors in the pilot schemes. I shall try to get that information. Perhaps I may ask the GMC to write to the noble Lord directly in relation to revalidation. I am told that the pilot schemes have been very valuable and that the GMC is still considering some of the results. I shall seek to find as much information as I can on that matter.

I agree with the noble Lord on the issue of duplication. In my opening remarks I referred to the need for the GMC to pick up the most serious cases, but we must hope that NHS trusts will be able to take a more vigorous approach at local level to sorting out some of the issues that would not be classed as serious but nevertheless can become a running sore.

I know that noble Lords have been concerned for a long time about the number of doctors suspended. The establishment of the NCAA is an important process of trying to turn that around. I am convinced that it is to the benefit of the NHS and doctors to try and nip some of the problems in the bud at an early stage.

The noble Baroness, Lady Noakes, asked what would happen to a doctor whose revalidation was delayed through no fault of his own. I am advised that the doctor would retain the licence to practise unless it had been withdrawn if the doctor had been referred to a fitness-to-practise panel. The licence does not expire; it is not time limited. It is clear that the intention is that revalidation should take place on a five-year basis, starting in 2005.

The cost to the GMC of operating revalidation is estimated at approximately £8 million per year. The cost to individual doctors is a matter to be decided. As your Lordships would expect, when it comes to fee structure the GMC will be seeking doctors' views. I have no doubt that there will be a healthy response.

In response to the noble Baroness, Lady Finlay, I confirm that the GMC has discretion in the matter. That discretion must be exercised reasonably, but it is clear that the GMC must have regard to its responsibility to protect the public interest by ensuring that only those doctors fit to practise are allowed to do so.

The noble Lord, Lord Clement-Jones, asked about admission to the register. The practice in the UK is that a doctor needs to be placed on the medical register by the GMC. That can be through the UK primary medical qualification, plus a satisfactory preregistration house officer year. For a person with a primary medical qualification from outside the European Economic Area, the GMC is required by law to satisfy itself that he has the necessary knowledge and interest. That is normally done by requiring such doctors to pass the International English Language Testing Scheme examination.

EC law prevents us from applying such a requirement to people qualifying in the EEA, but employers have a responsibility to ensure that anyone they appoint knows enough English to do their job properly. I can reassure noble Lords that the GMC has begun a fundamental review of registration, due to report in May 2003, which will lead to consultation on any changes recommended. I can also assure the House that if the law needs to change, the Government would consult on a draft of any new provision under the Section 60 order procedure.

I know that there is concern about the 22 Commonwealth medical schools, graduates of which up to now have had privileged access to the UK as if they were graduates of UK medical schools. I am aware of some of the issues and problems that that policy entails. It has discriminated against all other medical graduates from the Commonwealth, from Canada, Nigeria, or Pakistan, and against doctors from anywhere else in the world. It has often amounted to indirect racial discrimination. There has never been objective evidence that those 22 medical degrees were better than one, say, from Harvard. In future, all doctors from outside the EEA will have to provide the same objective evidence of competence at the point of entry to the register.

The noble Lord, Lord Clement-Jones, referred to St George's University School of Medicine. That issue has been raised with the department before. I will chase up the matter and respond to him directly, as it is important.

I was asked about delays in registration. I understand that noble Lords want to be assured that some of the problems that the NMC inherited from the UKCC., which I am glad to say are now being tackled with vigour, do not arise in the case of the GMC. I have two points to make. There is no doubt that currently in proceedings against doctors there have been long delays within the GMC. Our hope is that the restructuring brought about by the order will enable many of those delays to be tackled.

I am assured that if a doctor's paper is in order, registration from the UK or the EEA can be accomplished by the GMC within a fortnight. The problem seems to lie with doctors outwith, who are having to prove their specialism, which can cause delays. No doubt the matter will be looked at by the GMC and other regulatory bodies. Not only the GMC is involved in those cases.

I very much welcome the spirit of consultation which noble Lords have commended, and for which I thank noble Lords. There is a suggestion that this spirit should be applied to the Postgraduate Medical and Training Board. I do not quite understand why noble Lords should think that the Government's spirit of openness and consultation has not applied to discussions on the Postgraduate Medical and Training Board. I reassure noble Lords that there is a joint working group with at least six royal college presidents in membership. We shall be working very hard through the joint working group to ensure that, when we bring the relevant order before your Lordships, it will have been thoroughly tested and consulted upon.

The noble Lord, Lord Clement-Jones, raised an issue which the noble Baroness, Lady Finlay, has raised before—the issue of mutual recognition. I did not quite understand the noble Lord's suggestion that the Government have been slow to act. As I said when this issue was raised previously in your Lordships' House, we have concerns which we are raising in Europe.

I hope that I have covered most of the points raised. This is a very good order, and I thank noble Lords for their support.

On Question, Motion agreed to.