National Health Service Staff

HL Deb 22 March 2004 vol 659 cc546-59

7.31 p.m.

Baroness Knight of Collingtree rose to ask Her Majesty's Government what is their response to the recent report from the National Audit Office on the suspension of National Health Service staff.

The noble Baroness said: My Lords, I have lost count of the number of times that I have raised in Parliament the disgraceful way in which Britain deals with suspended hospital doctors, but I have been doing so for some 16 years. Successive governments have failed to listen but one must never give up trying to right a wrong. Where there is rank injustice and a way to end it, one must just keep on trying.

We treat criminals who have committed the worst crimes in the calendar—murder, rape, violent assault, robbery, child abuse; any crime one cares to mention—with more justice, compassion and mercy than we treat suspended hospital doctors. I hold no brief for incompetent doctors or those who break the law but, of all doctors accused and suspended, about 92 per cent are subsequently found to be innocent.

Suspension comes like a bolt from the blue. The doctor is instantly sent home in disgrace and barred from re-entering his hospital. He is not told what he is alleged to have done. He receives no legal aid; he has no lawyer or friend to help him; there is no appeal. He or she has no idea how long that situation will continue. I know of one case where a woman doctor remained suspended for 11 years.

Since then, a rule has been made that suspension can continue only for what is termed a "binding time". But it does not seem very binding to me. Out of 350 suspensions, hospital trusts have adhered to it only twice. Even being suspended for a year or 18 months—the average is two-and-a-quarter years—can mean the end of a career. Medical advance is too fast for gap years.

It is true that there is now some attempt at retraining but that is by no means always effective, and the cost is not small. In scores of cases, suspension destroys both one's career and one's reputation. Whole families suffer grievously. I know of five suicides and eight deaths from heart attacks which are directly attributable to doctors' suspensions. It is no compensation that the doctor is paid his full salary during suspension. His patients, of course, lose his care and skill, and the NHS is not blessed with such a surplus of doctors that that does not matter.

Last year, the National Audit Office studied this situation, and that led to this debate. The NAO reported last November. I immediately tried for an Unstarred Question and asked for it weekly since then. The report shows that the annual cost of suspension, including clinical staff, is £29 million. The average cost per doctor is £188,000, while clinicians obviously cost less—some £21,400. Therefore, doctors account for three-quarters of all costs. However, that is not all. The NAO total includes neither golden handshakes, which often have to be paid, nor the costs of retraining. Those costs are substantial. We are not talking peanuts here. My case is partly that this is a scandalous waste of scarce resources and partly that we should not treat dedicated, trained professionals so cruelly and unjustly.

In July 2000, I received support from all sides of your Lordships' House for a Bill which would have stopped both the waste and the unfairness. That Bill was a good six months in preparation. I worked with the BMA and the bodies which protect hospital doctors to have the Bill correctly framed, arranged and agreed. The Bill got through this House but the Government ignored it. Instead, they set up the National Clinical Assessment Authority, which was supposed to put everything right. I hoped; I waited; I gave it time. Alas, after three years, it has proved to be an abysmal failure. In its first two years, it dealt with just five cases. I found it rather difficult to drum up much sympathy for the excuse that it needed time to bed down. My theory was that it never got up.

The ruling that trusts "could", not "must", refer cases to the NCAA, together with the fact that trusts are allowed to ignore NCAA recommendations, has rendered this body both weak and toothless. It has an annual budget of almost £8 million but it has neither reduced the number of suspensions nor lessened the time that doctors are kept waiting. In fact, it has tended to increase that time.

Had my Bill, instead of the NCAA, come into being, researchers tell me that, by now, £100 million more would have been available to the NHS. I am bound to say that that figure staggers me. I do not believe that anyone will disagree that it is a lot of money.

Scotland adopted very similar regulations to those in my Bill and they have proved to be most successful. I claim, without blushing, that, had my Bill been permitted to go through and become law, equally we should have seen success in this very distressing matter.

When I tabled this Question, there had been no government response to the report. One emerged very quickly, in December, announcing new regulations. I have read them: immediate suspensions are allowed but they should last for only two weeks; doctors should be told what they are alleged to have done; and alternatives to suspension should be considered. Again, it is the use of the word "should" instead of "must" which worries me.

Only this morning, we heard that a hospital trust, which must have been sent those new rules and has certainly had time to read them, suspended a top brain surgeon who took an extra helping of croutons in his soup. Oh, vile crime! Had he been prepared, perhaps, to be a little less keen on croutons, he would have continued in his job. I find that incredible. In my Daily Mail this morning I read that he has been sitting at home fully paid since last week, no doubt thinking about croutons. Heaven knows how much suffering that has caused and will cause to his patients. Once a doctor is suspended, his return is neither quick and easy nor inevitable.

When I heard of this case this morning I found it incredible. I found it so impossible to believe that I telephoned the BMA, which checked it. I have to tell noble Lords that every word in the Daily Mail report is true. If that can happen when the Government have produced their new guidelines and the hospital trust has read and absorbed them, surely the guidelines are useless.

I have a dreadful feeling that I shall have to go on for another 16 years pleading the case for doctors who have been suspended, the suffering they are forced to endure and the amount of money that that costs the NHS. Obviously, what the Government have tried to do, no doubt with every good intention, has been utterly useless. Words fail me.

7.41 p.m.

Lord Clement-Jones

My Lords, as a veteran of debates involving the noble Baroness and this very important area, I pay tribute to her tenacity in raising this issue once again in response to an extremely interesting report from the National Audit Office.

The noble Baroness quoted figures from that report which are hair-raising. That affirms—the point has been made by her and a few others on a consistent basis—that such cases are extremely costly to the NHS, particularly when agency or locum doctors or nurses have to be hired in order to replace doctors and nurses who have been suspended. That may be on a temporary basis but, if the suspension is not quickly resolved, that temporary hiring seems to be almost semi-permanent. Not only is that costly for trusts in those terms, but the money spent on dealing with suspensions cannot go where it should, that is, on treating patients.

The NAO arrive at the figure of some £14 million per year spent as a result of inappropriate suspensions which could otherwise have been spent on NHS services. However, there is some light. I was interested in the comments of the noble Baroness on the December guidance, which was published shortly after the NAO report on maintaining high professional standards in the modern NHS. That makes clear that there are options which go far short of suspension but can restrict practice according to certain conditions and can provide an alternative to suspension.

Doctors and nurses can be selectively restricted from carrying out certain procedures or from working with certain patient types while problems are investigated as quickly as they can be. That then saves trusts from paying for extra or replacement staff and keeps clinicians from losing their skills because of long periods away from work.

Obviously, unnecessary suspensions cause huge detriment. If options exist, a trust should be compelled to explore them before suspension becomes the immediate option. The guidance issued in December wisely keeps patient safety as a priority, but it also emphasises the importance of reducing suspensions that are not necessary. In that sense it must be welcomed.

Suspension is meant to be a neutral procedure, which gives investigators time to examine a particular situation, not a disciplinary action. For physicians and surgeons, whose expertise depends on regular practice of complex and technical procedures, long suspensions can lead to deterioration of skills, potentially causing an even more risky situation. Clearly, suspensions should not be treated lightly or used too liberally. The new guidance, which I welcome, includes many factors that, if they can be implemented and monitored properly, will address some of those problems, especially by putting time limits on immediate exclusions and limiting further exclusions to four-week periods with active reviews.

Programmes that allow doctors, dentists and nurses to return to work as soon as possible and with full support are necessary to ensure that clinicians who are suspended do not drop out of the NHS workforce entirely. These programmes need to be as strong, comprehensive and consistent as possible. In view of the lack of current capacity in the NHS, we cannot afford to lose qualified staff, especially if they have been suspended unnecessarily or for spurious reasons.

Even for those who are eventually cleared of any wrongdoing, the personal stress, possible depression and loss of reputation caused by a suspension may keep them from returning to work even when they are perfectly qualified to do so. So suspension is an issue not just about cost but also about sustaining a strong workforce and being able to provide services for patients at as high a level as possible. If patient safety and patient care are priorities, getting qualified, safe medical staff back to work quickly and efficiently has also to be a priority.

I welcome the very clear statement in the guidance that clear reasons are now needed to suspend doctors. But, as the noble Baroness mentioned, that is all very well and, in a sense, so far so good until one looks at the practice. Like the noble Baroness, I am fairly accustomed—it is one of my rules of life—to questioning what the Daily Mail has to say. I, too, was in contact with the BMA and I, too, was told that the facts of the matter are as stated on the front page of today's Daily Mail. Clearly, the guidance issued in December has not passed the radar of a number of trusts, as we have seen. Surely, that is a matter of considerable concern. I hope the Minister will address that in his remarks.

What interested me about the guidance issued in December was the fact that it was joint guidance. It refers to, the full integration of the work of the National Clinical Assessment Authority (NCAA) in providing advice I o NHS employers on the handling of cases". I do not know whether I misread it, but it did not seem that the NCAA was integral to that guidance; it seemed to have been issued by others involved. Why has not the NCAA been fully integrated in the NHS process for suspensions? Was not that the key reason for setting up the NCAA at the start?

The NCAA's website states that it provides advice about the local handling of cases and where necessary carries out clinical performance assessments to clarify areas of concern and make recommendations on how difficulties may be resolved. That seems to me to be a curiously limited remit.

When we debated the effects of the NCAA on suspensions last March, the NCAA had been in place for only 18 months. One year later, do we know with any more certainty whether the NCAA provides good value for money in its work, or, indeed, in fulfilling the objectives for which it was set up? Many of us felt that it should be an integral part of the National Patient Safety Agency or should be integrated into other regulatory bodies in a more secure way. I wonder whether this is the right model going forward?

Is the NCAA really sufficiently involved? Is it a proactive player in resolving the problems with the suspension process? As a special health authority does it have the necessary powers to deal with hospital trusts in such circumstances? If not, should not the Government propose that it should have such strengthened powers?

The misgivings on these Benches are similar to those expressed by the noble Baroness, Lady Knight. I know that the Minister will say that we are now fully devolved and that I simply want to take control of hospitals. But, in these circumstances, it seems to me that, at the very least, the NCAA should have much greater powers to influence the behaviour of trusts.

I am sure that we are all agreed that, with the NHS already suffering from long-standing staff shortages, the emphasis should be on helping clinicians to develop their skills and practise at their highest levels and providing support at an early stage for staff with performance problems. Hiding problems or waiting until they threaten patients' safety is not the way to proceed.

Many of the questions revolve around the NCAA. I believe that the guidance issued by the Government in December goes in the right direction. What we now need is a much firmer platform and programme for implementing that guidance.

7.50 p.m.

Lord Skelmersdale

My Lords, as my noble friend said, she has been pursuing the subject of suspension of clinical staff for many years now, both in your Lordships' House and in another place. It must have been like a red rag to a bull to be told by successive Ministers to "go away and don't fuss". But fuss she has continued to do and now her activities have been vindicated by the very recent National Audit Office report of 6 November last.

One has only to read the introduction to see that this report makes quite appalling reading. At a time when NHS resources are under such strain, it really cannot be right that cases often drag on for months and sometimes years with highly trained staff left kicking their heels at home rather than doing the skilled job for which they are being paid. To that extent I go along with the noble Lord, Lord Clement-Jones.

It is in everyone's interest—patients, clinicians and the taxpayer—for cases of suspension to be settled quickly and openly. But I am the first to admit that the solution is not easy, although the report makes some commonsense recommendations that bear very careful scrutiny.

Noble Lords know better than I do, but as a newcomer to this difficult subject I can see that there are three sides to it. The protection of patients is clearly one; the protection of the reputation of the hospital trust or PCT is another; and the proper treatment of clinicians is a third. These three sides—a triangle if you like—add up to waste in the health service and often worse—slower treatment for the patients themselves.

As the report makes clear—and virtually all noble Lords have referred to this—the costs of exclusion are high and growing. Between April 2001 and July 2002—the period covered by the report—the annual additional costs of exclusion are £29 million. It is additional because the excluded clinicians are still on the payroll to the tune of some £11 million.

I get the impression from reading the report that suspension is management's first rather than last course of action. My noble friend has in the past told us that sometimes clinicians are not even told they are being investigated. Does the Minister believe that this is still happening?

We hear a lot about patients' rights from the Government, but doctors have rights too. Some years ago a Conservative government, of which I was a member, went to great lengths to persuade the medical profession that clinical audit was in its own best interests. We succeeded and increasing clinical competence is the result; and less competent clinicians have been given extra training, transferred to other duties, or weeded out altogether. That has been a major plank in the NHS management armoury, but can one say that it is working as well as it should?

There are still problems: problems of personality, called in the report "professional conduct", where there are concerns about the clinicians' professional relations with patients; and of course personal conduct unrelated to patients. Perhaps the case my noble friend mentioned would be covered under that. More than half all suspensions are because of these two things.

An investigation should be the first step with a nominated investigator. The clinician should be told immediately that he or she is being investigated and by whom. If the investigator finds that the accusation is justified, can he find a way not to suspend? If suspension is the only option, then management should be at the right level at which to do it. Once suspension is in place, the report recommends steps that should be taken. For example, not only should trust boards be informed immediately, but they should know of the likely duration and forecast cost, updated as necessary, with, it is suggested, a non-executive director to scrutinise exclusions and encourage expeditious management and resolution of cases—something of course we all want.

Two weeks should be long enough to decide whether a clinician has a case to answer. The department has fairly recently, as has been referred to, set up the National Clinical Assessment Authority. The royal colleges have their own clinical assessment teams. Both bodies should be turned to for advice when suspension seems the only option. Is it the norm—to coin a phrase—to consult these bodies when a suspension is imminent? It certainly should be.

It is in nobody's interest that the resolution of the case should take long. There is a problem, though. Even when trusts have completed their investigations and decided to reinstate the clinician, it can take a considerable time to achieve it—a point mentioned by the noble Lord, Lord Clement-Jones. Retraining in the same or another trust may be necessary. Obviously, the more specialist the retraining, the more difficult it is to achieve. I doubt that this is soluble.

So, what is soluble? From what the noble Lord, Lord Hunt, said last time your Lordships discussed the matter, the initial investigation should be speeded up. Of course, we can all agree with that. But, has it? Has today's Minister any information on this? In the 23 months that have elapsed, he should have received some up-to-date figures. What is the current average length of a suspension? Has the length gone down as a result of the internal review by the department, as it badly needs to?

Notwithstanding all this, suspension remains; it has to in serious cases. I am sure that the seriousness of a case should in the first instance be determined by the hospital trust or the PCT in question, with ultimately the help of the royal colleges and the National Clinical Assessment Authority. The message from the department should be—and here I agree with my noble friend—"You must use them; they're there". I think this is part of the trouble: trusts do not actually go to the National Clinical Assessment Authority, which would certainly be a very good reason why, as my noble friend has said, it has conducted so few cases.

I am sure that it is in the best interests of patients that this bottom-up approach is used. After all, it is they who suffer from the inevitable longer waiting lists, or have to find another doctor or dentist, often remaining in pain for longer than is necessary.

We all know that the Government have a commitment to reduce all waiting lists to three months by two years' time; and with 29,000 still waiting more than nine months for treatment, it is not a very good prognosis.

In passing, is the article in today's Times correct in asserting that some NHS trusts are block booking beds in private hospitals to get waiting lists down?

The report says that if, during the period it covered, exclusions had been completed in six months, there would have been a saving of £14 million a year. Using the department's own national average unit costs, this means that an extra 2,215 planned coronary heart bypasses, or a mammoth 19,200 inguinal, umbilical or femoral hernia repairs could be done every year. I repeat—extra. My noble friend believes that if her Bill had become law the figure would be at least double. Surely, these savings would fit the Government's ethos better than farming out?

But, to be serious, it was somewhat of a surprise to me to see that only one month after the NAO report was published, the Government published new guidance to trusts on this subject, Maintaining High Professional Standards in the Modern NHS: A Framework for the initial handling of concerns about doctors and dentists in the NHS. The department, the NHS Confederation, the BMA and the British Dental Association signed up to this guidance. No doubt the Minister will use it extensively in his response in a few minutes.

However, I hope he will not be too gung ho. My noble friend and I found it—I suppose I would not misrepresent her if I said—wishy-washy and full of possibilities not instructions. Even one of what the noble Lord, Lord Warner, would doubtless call by the horrible word "stakeholders", namely the BMA, could only say of it that it was a significant "initial" step along the way to addressing its concerns about the current misuse of suspensions. It is clear to me that, if today's Daily Mail article about a consultant being immutably suspended for having a double helping of croutons, about which we have heard, is even half true, the BMA's use of the word "significant" is erroneous, to say the least.

With that sort of behaviour, trusts are cutting their own financial throats. I am sure that a quiet word in the consultant's ear would have saved the trust what will assuredly turn out to be thousands of pounds. The noble Lord's predecessor would be foaming at the mouth about it.

The key to all this is better management in the health service—not only over this issue, but over M RSA and a host of other subjects. I even read today a story that revolved around telling a nurse off for not washing her hands between patients. "That", said one manager to another, "would be harassment".

Those problems will not go away until the Government take a firm grip. I await with eagerness to hear what sort of a grip the Minister has in mind.

8 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Lord Warner)

My Lords, I am grateful to the noble Baroness for bringing to our attention today the National Audit Office report into the management of suspensions of clinical staff in NHS hospital and ambulance trusts in England, published on 6 November last year. I must say that I am full of admiration for her persistence on this subject. I hope that some of what I shall say will be of some comfort—and possibly even some reward for her persistence.

The noble Baroness has asked the Government to respond to the NAO report. I should explain that the NHS chief executive, the Chief Medical Officer and the Department of Health's director of human resources gave evidence at a hearing of the Public Accounts Committee on the NAO report on 28 January. A report from the committee containing its conclusions and recommendations is expected shortly, and the Government's formal response will appear as a Treasury minute following its publication.

As several noble Lords have said, a major development since the publication of the NAO report has been the launch on 29 December last year of the framework document Maintaining High Professional Standards in the Modern NHS: a framework for dealing with the initial concerns about a doctor or dentist. I must say that that was the result of several years' negotiations with the professions. Several noble Lords have chided the Government for not cracking on and dealing with the issue, but I would gently say to them that they would be the first to criticise the Government if we did not negotiate those matters with the professions and their representatives. As noble Lords will know, sometimes these things take a little longer than all of us would like.

The framework has been issued to the NHS under a Secretary of State direction and compliance is mandatory. It represents an entirely new way of dealing with concerns about poor performance of doctors and dentists. It has been agreed with the BMA and the British Dental Association.

The first of the NAO's recommendations is that the Department of Health should review its guidance on the exclusion process to take account of the work of the NCAA and the NAO report findings. I am glad to say that the recommendations contained in the NAO report concerning the management of exclusions have been largely addressed in the new framework. I do not accept the remarks of the noble Lord, Lord Skelmersdale, that the document is wishy-washy.

It is important to acknowledge that the NAO report shows all too clearly the costs of failing to manage the exclusion process effectively in both the effect on the individual clinician and the diversion of resources from patient care. However, it is worth bearing in mind that the £29 million annual cost of suspensions reported by the NAO and mentioned by several noble Lords is a fraction of the NHS payroll of £55 billion. It must be considered in that context. Some of that is the price that we must pay to ensure patient safety. That said, we agree that there are still too many suspensions and that too many still last more than six months, but we believe that we are beginning to see the end of very long suspensions.

The work of the National Clinical Assessment Authority and the Chief Medical Officer's special adviser have made significant inroads into the problem. Despite what the noble Baroness said, we believe that the establishment of the NCAA in 2001 to provide support and advice to NHS employers on the management of poor performance has had a significant impact. In the first two and three-quarter years of operation, the NCAA received more than 900 requests for help. Many of those cases were dealt with through advice and continuing support and did not require the authority to undertake a detailed assessment of the doctor. So there was an attempt, using prevention rather than cure, to stop problems occurring.

Baroness Knight of Collingtree

My Lords, I am grateful to the Minister. Would it not have been more efficacious to have given the NCAA the power to say, "You must do this", instead of, "You should"? When we consider the history, so often trusts have not done what the NCAA would have liked them to have done. Indeed, they do not have to report a case to the NCAA at all; they can go on suspending people. If they had to report a case, would that not be more helpful?

Lord Warner

My Lords, my response to the noble Baroness is to ask her to let me develop the rest of the Government's case. I would further say that the new framework document was issued only on 29 December and it is not mandatory until 1 April, so there is still time for us to see how the new arrangements work. I shall try to deal with her question in some of my responses.

There are three key strands of the NCAA's work that are aimed at tackling suspension. The first, and our priority, is preventing inappropriate suspension in individual cases. It is not true to suggest that the NCAA is doing nothing. An analysis of cases between April and September 2003 showed that the NCAA was able to recommend an alternative to suspension in 85 per cent of cases where suspension had been considered—that is before the new framework comes into effect. If I may say so, that does not suggest that trusts are not listening to the advice given to them by the NCAA.

Lord Skelmersdale

Yes, my Lords, but how many of its suggestions to the various trusts and organisations in those 85 per cent of cases achieved results? Two.

Lord Warner

My Lords, noble Lords opposite are eager to ask me questions. If they could just contain their eagerness, I could deploy my case, as I listened patiently to them. They may get the answer to some of their questions, if I could be allowed to continue what I was going to say.

The second key strand of the NCAA's work is aimed at tackling ongoing, long-term suspension. Through the intervention of the Chief Medical Officer's special adviser, a significant number of those long-term cases have been resolved. Finally, there is the identification and sharing of good practice throughout the NHS. It is not just an issue of short-term suspensions; it is a more comprehensive approach by the NCAA to the problem.

The authority predicts steady growth in referrals to it resulting from the key role that it will play in the new procedures for managing exclusion. It is not true, as was suggested, that trusts do not go to the NCAA. About 75 per cent of NHS employers have made use of its services so far. I acknowledge that that is not 100 per cent, but not all have doctors suspended. As the new framework becomes embedded in local procedures, the number is bound to increase.

The National Audit Office fully supports our view that NHS employers should seek the advice of the NCAA in all cases concerning doctors. That is implemented by the new framework, which states that the NCAA should be consulted and contacted at an early stage, when action on clinical concerns is considered, and that the NCAA must—a word that the noble Baroness is keen on be consulted, where formal exclusion is being considered. We have provided an element of dirigisme in our approach.

I shall use two short case studies to demonstrate how the NCAA has contributed to public protection and worked in the interests of doctors to help to prevent an unnecessary suspension taking root. They are real cases, not hypothetical. In the first, it had been agreed that the NCAA should undertake a full clinical performance assessment of a doctor about whom there were performance concerns. The NCAA fast-tracked the assessment due to the nature of the concerns. During the part of the assessment where the doctor's clinical practice was observed, it became apparent to the assessors that there were serious deficiencies in the doctor's clinical capability that compromised patient safety. The assessment was immediately halted, and the referring body was advised to suspend the doctor and refer the doctor to the GMC. The advice was taken, and the doctor was suspended and referred to the GMC within five days. So, the public were protected. They are not all cases involving doctors who need not be suspended. Action needed to be taken, and that example shows how the NCAA went through the process, observed that patients were at risk and worked with the employer to deal with the situation satisfactorily.

In the second case study, a referring body contacted the NCAA because it had been led to believe that a doctor working for it had a criminal record and that the nature of the alleged criminal activities might jeopardise patient safety. However, it had no way of substantiating the concern. The NCAA, working with the referring body and using its contacts with the police and others, was able to establish robustly and within three days that the allegations were unfounded, completely clearing the doctor's name. In that way, the NCAA was able to prevent the injustice that would have occurred had the doctor been suspended.

There are examples of how other NAO recommendations have been reflected in the framework that we have been discussing. They include a requirement for strategic health authorities to scrutinise the length and cost of exclusions; ensuring that exclusion is used only if there is a threat to patient safety; considering, as alternatives to suspension, restrictions on practice and retraining; and ensuring that trust boards are kept in touch with the duration and costs of exclusion and that they review progress. For the first time, the new exclusion framework will provide for an initial immediate exclusion of no more than two weeks; formal exclusion for up to four weeks; notification of the NCAA before formal exclusion; active review to decide renewal or cessation of each exclusion; a right to return to work, if a review is not carried out; and, significantly, a maximum period of exclusion of six months, except for cases involving a criminal investigation.

It is clear that exclusion or suspension should be used in only the most exceptional circumstances and that the NCAA is fully integrated into the system. It has been fully consulted on the work of drawing up the framework, and it has key roles to play at different stages of the process.

I understand the views of those who say that it has taken far too long to get to this stage. It has been due to a number of things. It has taken time to accept the need for a fundamental shift in thinking about the way in which poor performance is managed in the medical profession. The work was led by the work of the Chief Medical Officer in his consultation document Supporting Doctors—Protecting Patients, which was published in 1999. It was here that the NCAA was conceived. However, such fundamental changes take time for professions to accept. The hearts and minds of the profession and its leaders had to be gained. I am glad to be able to say that the integrated approach of support and assessment that the NCAA has established is, I am reliably informed, a world leader and, to an increasing extent, accepted by the medical profession.

The noble Lord, Lord Clement-Jones, asked whether the NCAA was right in this context. He knows that there is a review of arm's-length bodies, and this review includes the NCAA. There is no more significance in my remarks than that.

At the same time, lengthy negotiations have continued with the profession to reform the investigation of cases and to replace the guidance on suspension. This is now in place. There is still the disciplinary strand of the framework to complete. Future progress requires co- operation from the profession, and I hope that we will be able to complete the package in the near future, but it takes two to tango.

The noble Baroness referred to the story in the Daily Mail about a brain surgeon allegedly suspended for consuming a bowl of soup—with or without croûtons, I am not altogether sure, but without paying. I am not sure that I share her confidence that the report was quite as full as she suggests. I do not recall it, for example, mentioning anything about actions caught on CCTV. This is, of course, a matter for the Nottingham University Hospital NHS Trust. The NCAA is not a disciplinary body. It may be helpful if I tell the House that the NCAA has offered its help, but it is of course for the trust to decide whether it wishes to accept.

The NAO has produced an important report. It highlights serious issues facing not only individual clinicians, for whom suspension can cause great difficulties, both professionally and personally—here I agree with the noble Baroness, Lady Knight—but also the NHS as a whole and, of course, patients.

The new framework which, I am pleased to say, embodies many of the recommendations contained in the NAO report, has its focus on helping doctors and dentists to keep up to date and practise safely and not to punish them for any problems arising from clinical performance.

I am confident that the innovative work of the National Clinical Assessment Authority, underpinned by the new framework document, will help the NHS to manage poor performance more constructively, and see an end to the suspension culture of the past. But I am sure we can rely on the noble Baroness to keep us on our toes on this issue.

Baroness Knight of Collingtree

My Lords, before the Minister sits down, I ask him very seriously not to brush aside the case that was reported today and to imagine that there has been a misreporting. As I explained, I took the trouble to ring the BMA—as did others, as we have heard—which confirmed that every word of that report was true. Surely we cannot regard lightly such a case, which has denied some very needy people some very expert care, at least for the time being.

Lord Warner

My Lords, on that last point, I am reliably informed that there will be no detriment to patients because the work that that doctor was due to perform will be covered by his colleagues. On that particular point, I can set the noble Baroness's mind at rest.

I was not trying to brush this aside, but the employer of this doctor is neither the Department of Health nor me—it is the local trust. It is the trust's responsibility to deal with this issue and, as I have said, I know that the NCAA has offered its help to the trust. I have also made it clear that it is for the trust to decide whether to accept that help.

Lord Skelmersdale

My Lords, before the Minister finally sits down, I asked him a question arising from something he said about the percentage of the number of cases referred to the NCAA where it did not recommend suspension. Will he be good enough to write to me, telling me in how many cases—I mean actual numbers rather than percentages—was the NCAA's advice ignored?

Lord Warner

My Lords, I will certainly let the noble Lord know, if we have the information, in how many cases the NCAA's advice was accepted, and ignored.

Baroness Farrington of Ribbleton

My Lords, I beg to move that the House do now adjourn during pleasure.

Moved accordingly, and, on Question, Motion agreed to.

[The Sitting was suspended from 8.18 to 8.31 p.m.]