House of Commons Hansard Debates for 25 Apr 1995

Mr. Cousins: I am grateful to the Minister, but I remind him of the news bulletins this morning. Adam Smith was probably rather cynical and pessimistic. Two or three might be thought to be a pessimistic view of a conspiracy, but seven or nine is clearly sufficient.

These are matters which cannot be overlooked. If the Minister is right that the bedrock concept behind the existing procedures and the new ones advanced in the Bill is the concept of "serious", a definition should be available to the House now and should form and guide part of the discussions on the Bill itself. The same request has been made by the hon. Member for Edgbaston and it goes to the heart of the matter.

I do not say that hon. Members are involved in a conspiracy, although presumably in other parts of our lives we can be, but unless the concept of "serious" is clarified for the Bill and for the existing concept of serious professional misconduct, we are no further forward in establishing the clarity, robustness and openness necessary to enable people to be clear about their rights, responsibilities and duties and for those rights, responsibilities and duties to be properly policed and enforced.

5.45 pm

Mr. Roger Sims (Chislehurst): I listened with interest to the hon. Member for Newcastle upon Tyne, Central (Mr. Cousins) who raised a number of points with which I have some sympathy. Indeed, in the past year, I have had some correspondence and discussions on minimal invasive surgery and the relationship between the General Medical Council and the royal colleges, but I am not sure how far those issues impinge on this relatively narrow Bill. No doubt we will have the opportunity to explore them on another occasion.

Before I go any further, I should declare an interest as a member of the General Medical Council. I thank my right hon. Friend the Secretary of State for her kind remarks earlier in the debate, but I must also declare an interest in the conventional House of Commons sense in that, as is recorded in the Register of Members' Interests, I receive an honorarium from the GMC in recognition of my work as a lay screener, to which I shall refer later.

I suspect that most of our constituents are pretty hazy as to exactly what the GMC is, what it does and what the difference is between the GMC and the British Medical

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Association. As recently as last Thursday in the privileges debate, a distinguished and senior hon. Member, while floating the idea of professional self-regulation among Members of Parliament, twice referred to the BMA and its control over doctors.

Of course, the BMA is a trade union of professional people, which doctors are free to join or not as they wish. It is not comparable with the GMC, which was, as we have heard, set up by statute. If I may just correct the figures that my hon. Friend the Minister for Health inadvertently gave a few moments ago, I think that I am correct in saying that, of its 102 members, 54 are elected by their fellow doctors, 35 are appointed by the royal colleges and universities and there are 13 nominated lay members.

As we have heard, there are proposals in the pipeline to increase the lay membership. Those lay members include the hon. and learned Member for Montgomery (Mr. Carlile), who was appointed with me to the GMC in 1989. I know that he would have wished to be here today if other commitments had not precluded that. At that time, no Labour Member was appointed, but we were pleased to be joined last autumn by the hon. Member for Gower (Mr. Wardell) who has already intervened in our debate.

The key to understanding the role of the GMC is that the person who in other organisations might be described as general secretary or chief executive bears the title of registrar, for the very good reason that he is responsible for the register. It is he who keeps it, and no doctor can practise unless his name appears on that register.

The General Medical Council lays down the curriculum for medical training and monitors the work of medical schools. It satisfies itself as to the quality of medical education and it accepts on its register only men and women with the appropriate qualifications. It also has other duties. It recognises--or refuses to recognise--medical training in some places overseas and decides whether doctors trained overseas can practise in Britain with or without conditions. Those are matters outside the Bill, but I can assure my hon. Friend the Member for Birmingham, Edgbaston (Dame J. Knight) that a test known as the PLAB--Professional and Linguistic Assessment Board--test would normally ensure that doctors from overseas have a reasonable command of the English language.

The GMC not only decides the established standards that doctors must reach before practising but is responsible for maintaining those standards. It has to deal with doctors who are brought to the council's attention because it appears that they may have fallen below the standards required.

Cases normally reach the GMC through three routes. First, if a doctor is convicted before the courts, it is virtually automatic that the GMC will be notified, regardless of whether the charge is a fairly simple one of being drunk and disorderly, whether it is shoplifting or a murder. The second route is through the findings of local medical services committees. A doctor who is found not to have kept to the terms of his contract will be reported to the GMC. It is important to understand the distinction between the relationship between a doctor and his local employing hospital or health authority and the relationship between a doctor and the General Medical Council. A doctor may have been found to have broken the terms of his contract and he will have been dealt with by a local medical

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services committee. Ultimately, when the decision has been confirmed by the Secretary of State, that doctor may suffer a withholding of his salary--in effect, a fine--but the circumstances in which he has broken his contract may or may not be relevant to his registration with the General Medical Council.

Dame Jill Knight: I am most grateful to my hon. Friend, because we have a unique opportunity to acquire a great deal of information that is not always easily available to us. My hon. Friend referred to language. He may not be aware that there are quite a lot of complaints about difficulties with language. From what I have just heard, if a patient feels that a doctor has not understood him correctly, that patient cannot complain to the GMC because it has already been decided that the doctor can speak perfectly adequate English.

Mr. Sims: The patient could go to the local family health services authority and say he or she is not happy with the doctor and wishes to change to a doctor with whom he or she would feel more comfortable. That would be the solution in that particular case. I said that there were three ways in which cases could come to the GMC--through a conviction, through the findings of a local medical services committee and through straightforward complaints from the public, from patients or their relatives. Virtually all the conviction cases and medical service committee cases and many of the complaints from the public are passed on for consideration to the preliminary proceedings committee--a committee of the council consisting of nine medical members and two lay members, of whom I am one. One of the two lay members must be present for any matters or cases to be considered.

We examine a range of cases, including those that involve sex and, therefore, hit the headlines, but they are a minority. An enormous range of cases comes before us. They include irresponsible prescribing, abuse of drugs, breach of confidence, inappropriate treatment and falsifying the outcome of clinical trials. It is a long list. Each case is considered most carefully by the preliminary proceedings committee. If hon. Members sometimes see me during a late sitting in the Library with a large pile of paperwork, they will know that a PPC is pending. I can assure hon. Members that great consideration is given to each case.

When we consider a case, we can decide that it calls for no action at all. If the matter that has been raised is admitted by the doctor, we can decide that a warning or a cautionary letter in appropriate terms is appropriate, but if there is a prima facie case of serious misconduct, it is passed to the professional conduct committee, a body whose proceedings, though of a civil nature, are very much akin to the criminal courts, with similar standards of proof required. Anyone appearing before that committee has been charged with serious professional misconduct. There have been several queries as to what exactly that means and attempts to define it. Quite a useful definition is conduct of such a nature as to call into question whether that doctor should be allowed to continue to practise without restriction. The professional conduct committee considers all the evidence and the parties involved appear before it and are examined or cross- examined. The process is

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similar to court procedures. The committee can decide to dismiss the case, that the doctor should be admonished or that the doctor should continue to practise subject to certain conditions. It can suspend the doctor for a specified period or it can erase his name from the register altogether so that he may no longer practise. When the preliminary proceedings committee is examining a case, it may consider that the account it has had of the events that led to that consideration brings into question the doctor's health. The doctor will then be subject to the health procedures to which reference has been made. Under those procedures, the doctor will be invited to undergo examination by other doctors who may suggest a course of treatment or certain restrictions on how he practises, the work he does, and so on. Only if he refuses those conditions or proposals will he then be subject to disciplinary procedures. Perhaps I could interpolate in my narrative of my work on the GMC a couple of comments. First, contrary to the general perception and the view expressed a few minutes ago, my experience is that almost without exception, doctors tend to be far harder on their own profession than I and my fellow lay members would be. Quite frequently, having examined a case, I have in mind a certain course of action and find that the doctors themselves want to take a stronger line; so it is certainly not a case of doctors protecting themselves.

Secondly, the House is often anxious to protect people against double jeopardy. It is a matter about which we are necessarily concerned. Hon. Members will realise from what I have said that doctors constantly face a double jeopardy situation. A doctor may have been convicted and sentenced by the courts or he may be brought before a medical committee which may then find that he has breached the terms of his contract and his salary is withheld. However, that is not the end of the matter for that doctor. His activities must then be considered by the General Medical Council and his livelihood could be at risk.

The weakness in the procedures which I have described, and of which I have been a part for the past five or six years, lies in the fact that, at the end of the day, the GMC can deal only with single incidents of serious professional misconduct. It is virtually powerless to deal with doctors who appear to be deficient in their knowledge of medicine or in their knowledge of the correct procedures for diagnosing and treating patients. The GMC cannot deal with doctors who show a lack of sensitivity or courtesy to their patients--that does not constitute serious professional misconduct. The Bill proposes that, when such deficiencies are revealed, there should not be formal disciplinary procedures but that steps should be taken to help to rehabilitate doctors so that, in due course, they may resume full medical practice. To that extent, the procedures proposed are akin to the health procedures which I explained briefly.

The Bill's provisions will offer an opportunity for the doctor to consider and analyse his shortcomings and to discuss and agree with fellow professionals and a lay person a course of action that he could take to remedy those deficiencies. In most cases, he would wish to take such action in his own interests and those of his patients. The question of sanctions would arise only if the doctor concerned refused to take the steps proposed.

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I have no doubt that those powers are needed. Cases have come before the preliminary proceedings committee that do not involve serious professional misconduct but suggest that the doctor is below standard. For example, in 1993 the GMC received information from a hospital expressing concern about Dr. N's level of clinical competence. The concerns were such that the hospital decided to dismiss the doctor in question, but, in the event, he tendered his resignation and sought employment elsewhere.

The GMC requested further information about the specific incidents that had caused doubts about the doctor's competence. Although the inquiries revealed a disturbing pattern of clinical deficiencies on the part of the doctor, no specific incident was considered to amount to serious professional misconduct. Similar inquiries were made about an earlier appointment held by the doctor and about the circumstances in which he had left that post. Here, too, there was evidence of a pattern of poor performance as well as evidence that the doctor lacked insight into his deficiencies. Again, however, there was no specific evidence of behaviour by the doctor which amounted to serious professional misconduct, so the GMC was unable to intervene. In another case, the council received details in March 1993 of a medical service committee report involving Dr. S, who was a general practitioner. He had made a diagnosis over the telephone and he did not visit the patient at home. The patient's condition subsequently deteriorated and he was admitted to hospital where he underwent an operation for an ulcer. The medical services committee considered that the doctor had not placed himself in a position to diagnose the patient's condition properly and to treat him appropriately. The case was then passed to the GMC because it raised questions as to whether the doctor had been guilty of serious professional misconduct. On the basis of the evidence before it--the GMC bases its decisions only on such evidence--it was decided that it would be sufficient to send the doctor a letter of warning and advice regarding the standard of medical care which patients are entitled to expect.

Mr. Cousins: The hon. Gentleman's example brings us to the heart of the matter: why was it not decided that serious professional misconduct had occurred in that instance? If the case was serious enough to warrant sending a warning letter, why was it not sufficiently serious to be regarded as professional misconduct?

Mr. Sims: I do not have all the details of the case before me, but I have explained that serious professional misconduct involves the question of whether a doctor should continue to practise. In that case it was felt that, although he had fallen short of the standards that could be reasonably expected, the question of suspending him or removing him from the register did not arise.

Mr. Cousins: I do not wish to pursue the hon. Gentleman on this point, and I am grateful to him for giving way a second time. Does he not see that that means that the evaluation of the case was determined not according to the nature of events but by the severity of the sanction? That is precisely the kind of institutionalised self-regulation that is so dangerous in such matters.

Mr. Sims: I do not accept that view. The case was considered carefully in the way that I have suggested and

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that was the decision reached in that case. But the narrative continues, because shortly after that incident there was another medical service inquiry about the doctor's surgery hours and his provision of services to patients. In that instance, it was found that he had not complied with his contractual responsibilities but that was not serious professional misconduct.

Shortly after that, the family health services authority wrote to the council expressing general concern about the standards of service provided by the doctor. It referred to the disorganised running of his practice and it mentioned his bad record keeping. The FHSA expressed particular concern about those matters because the doctor had persistently resisted the authority's attempts to improve his performance and to rectify his deficiencies.

The difficulty for the council is that its disciplinary procedures are designed to deal principally with specific allegations that a doctor has behaved towards patients in a manner that may amount to serious professional misconduct. Therefore, it was not able to pursue the case. I accept that, if it had taken a different course in the first instance, things may have been different. However, the doctor's pattern of performance certainly justified intervention by the GMC, but it did not have the power to do so.

Mr. David Congdon (Croydon, North-East): I think that I understand my hon. Friend's point about the new powers in the legislation and how they will enable the council to investigate a doctor's pattern of performance and behaviour. I wonder whether he can help me on another point. When a single act is committed which falls short of serious professional misconduct but which nevertheless deserves some form of sanction, will the new powers in the Bill enable it to be investigated?

Mr. Sims: I understand that they will not because the Bill is specifically intended to deal with cases where there has been a pattern of performance. That is the whole point of the legislation.

Mr. Malone: Let me clarify the matter. If one specific incident showed a deficiency--it would be unlikely to be isolated, as it is more likely to be part of a pattern--it would be possible in certain circumstances for it to come within the procedures that are proposed in the Bill.

Mr. Sims: I am obliged to my hon. Friend.

I shall quote one further case, as it is a graphic example. Two years ago, a surgeon in Yorkshire made errors in his surgical practice that were so extensive that the complaints about him were subject to inquiry by the regional health authority. In its report, that RHA categorised faults, and described a minor fault as being an error which

"although falling foul of the Bolam test is readily understandable, in the context of a busy surgical practice, and which is unlikely to be repeated."

It went on to describe an intermediate fault as being an error "of serious proportions, which warrants disciplinary action, or appropriate retraining but which is not sufficient to call into question the fitness of the surgeon to continue in surgical practice, in that appropriate retraining is likely to eliminate the risk of repetition."

It referred to a major fault as being an error

"of such substantial proportions as to cast doubt upon the fitness of the surgeon to continue in surgical practice."

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In that particular inquiry, the report found intermediate fault in the case of five patients and minor fault in four, but in none of the nine did it find major fault. The case was reported to the GMC, but it was unable to act because, in the light of that classification and the report following a detailed inquiry, there was no single incident of serious professional misconduct. Quite clearly, that surgeon should not have continued to operate. In fact, he retained his position after giving an undertaking to his employers to undergo retraining and to work for a time under supervision. But he could have chosen to leave and go elsewhere--if not practising in the NHS, then privately, without any hindrance whatever. The GMC would have been helpless. He seems to me to be a perfect candidate for the performance review procedures that we are discussing.

Not all the complaints that come to the GMC go before the preliminary proceedings committee. Indeed, if they did, we would be overwhelmed. There is, as we have heard, a screening procedure. A medical screener--one of the doctor members of the council--considers each complaint and whether action should be called for, or whether the complaint should go forward to the preliminary proceedings committee for consideration, or he can decide that it calls for no action. Until a few years ago, a letter in those terms was then sent out.

The president of the GMC, to whom my right hon. Friend the Secretary of State quite rightly paid tribute for the energetic and dedicated manner in which he has led the GMC for a number of years, felt that, if people were to receive a letter telling them that the GMC was taking no action over their complaint, that decision should be not only taken by a medical member but endorsed by a lay member. He asked me, therefore, whether I would accept the office of lay screener, with the task of looking at all the cases on which the council said that it was taking no action. That I did, and I looked at some 40 cases a month. Indeed, after a year or two, the president, realising the burden, appointed a second lay screener. Hon. Members who have noticed the size of their postbags in the past few years may not be surprised to hear that, although there are two of us, I still deal with some 40 cases a month.

Of course, some of the complaints are trivial and, inevitably, some of the letters are from people who--perhaps one could kindly refer to them as such --are eccentric. There are matters that the GMC cannot deal with. People write in to complain that their doctor has knocked them off the list. He is perfectly entitled to do that, just as--as I explained earlier to my hon. Friend the Member for Edgbaston--one can knock oneself off the doctor's list. People write in to complain that the man next door is throwing rubbish over the fence. They say, "He's a doctor. I want you to do something about it." I am afraid that that is outside the GMC's purview, as are arguments between patients and doctors about fees for private medicine.

But some of the cases that I have seen on which the GMC cannot act--I have to agree that it cannot act--leave me uneasy, and they are about doctors who are not up to the standard that patients should reasonably expect. Misdiagnosis is one area. It is easy to misdiagnose symptoms. Doctors are human. They can make mistakes. Medicine is not an exact science. Various symptoms can be interpreted in a number of different ways. Misdiagnosis

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is not serious professional misconduct. But if one finds several similar cases of misdiagnosis on the part of the same doctor, perhaps that suggests that he has fallen behind with keeping up to date with medical knowledge, and that the GMC should be able to act. I have to agree to a letter saying, "We are sorry, but the GMC cannot act." I see complaints about a doctor's attitude. The classic one, sometimes quoted by the president of the GMC, is of the patient who walked into the doctor's surgery, to find him bending over his desk, writing, completely ignoring the patient. As she got nearer, she realised that he was writing out invitations to a drinks party, or whatever. After an interval, without looking up, he said, "Yes." That is not really quite the way in which one expects to be received by a doctor.

I recently saw a complaint from a 20-year-old girl who, with her mother, went to consult her doctor. He sent the mother out of the room, with no explanation, and asked the daughter to undress. He stood watching while she did so. His subsequent treatment of her, the way in which he sought to find out what was the matter, asked questions, touched her in various parts of her anatomy, was generally insensitive. Far from being reassured, that young lady left the surgery in distress. That is clearly not a case of serious professional misconduct. Restricting the way in which that doctor can practise may not be the answer. In fact he may be a rather good doctor, medically, but he needs to be pulled up about his attitude to patients.

We are talking about doctors who have fallen foul of the GMC. Let us be quite clear that most doctors, be they GPs or hospital doctors, are competent, conscientious and caring. But there are some who are simply incompetent. There is a particular problem with locums, who work for a short time, either in general practice or a hospital. Before very long, their shortcomings begin to come to light. By that time, nobody can do anything about it--the locum may be nearing the end of his stay, he may have already moved on or he may been rumbled and resigned. Neither the family health services authority nor the hospital, whichever employed the locum, can take any action because it is no longer that doctor's employer. Often, the hospital or doctor's practice is glad to see the back of that locum and so will do nothing about the problem. However, sometimes the GMC receives an account of the series of incidents that have caused concern about the locum. However, as no one incident could be described as serious professional misconduct, the GMC can do nothing.

I hope that I have clearly shown that in such cases the GMC should be able to act. It needs the powers in the Bill to do the job that Parliament and the nation expect it to do. I hope that the Bill will make rapid passage through both Houses.

Before I resume my seat, I want to refer to the motion on the Order Paper that the Bill be committed to a Special Standing Committee. I have always been an advocate of Special Standing Committees. Indeed, I have sat on one or two of the relatively few such Committees that there have been. I do not think that the procedure is used enough. Hon. Members will be aware that it is a cross between a Standing Committee and a Select Committee. As the hon. Member for Newcastle upon Tyne, East (Mr. Brown) said, it provides an opportunity for people affected by a Bill or with views on it to express those views directly to the Committee, without the need to find

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a sympathetic Member of Parliament to do so on their behalf. It is also useful when there has been little opportunity for consultation before a Bill is published.

However, none of that applies in this case. The proposals were first published two years ago and very wide consultation has taken place. At the back of the original proposals are two pages listing all the organisations and individuals that have been consulted. The president of the GMC spent a great deal of time meeting a wide range of organisations and individuals, seeking views that he then took into account in the formulation of the Bill, which has wide support. Therefore, I have to say that whatever the merits of the Special Standing Committee procedure, it is not appropriate or necessary for this Bill. Indeed, it would simply delay our proceedings. I urge support of the Bill, but ask the House to reject the committal motion.

6.23 pm

Mrs. Diana Maddock (Christchurch): Few subjects are capable of stirring up such anger and emotion as complaints against doctors. Those whom we tend to regard as saintly while all is going well are too easily cast in the role of devil when treatment begins to go wrong. Of course, most doctors are well trained, careful and competent. To sustain that high standard can be very difficult, which is why we need a comprehensive and thorough system of complaint investigation--to ensure not only that those who fall below acceptable standards can be identified, but that they are brought to account, retrained where appropriate and disciplined where necessary. The GMC is an historic body, but despite its long history it is often misunderstood. Examples of that have been cited this afternoon. It is not a trade union for doctors, although some of our correspondents seem to think that it is. It does not even deal with breaches of contract by doctors; that is the role of doctors' employers. Its statutory and historic role is to deal with the registration of doctors. That means that it has a duty to register doctors who have reached the requisite level of qualification. It also has the duty to affect a doctor's registration by attaching conditions to it or by the ultimate sanction of erasure from the register if the protection of the public so requires.

During recent years the GMC has changed a great deal. We have already heard that under the leadership of its current president, Sir Robert Kilpatrick, it has modernised itself and is moving towards simplification of some of its registration procedures. It is determined to increase the proportion of lay membership to ensure that the non-medic has a full role in its deliberations. I believe that the measures that we are discussing today would not be before us had it not been for the energetic efforts of many of those lay members, including the hon. Members for Chislehurst (Mr. Sims) and for Gower (Mr. Wardell) and my hon. and learned Friend the Member for Montgomery (Mr. Carlile). My hon. and learned Friend very much regrets that he is unavoidably unable to be present for today's debate. He strongly supports the Bill, as do I and my other colleagues. I believe that increasing lay membership is of great importance for the future credibility of the GMC.

Until now, apart from special procedures to deal with sick doctors, which have already been mentioned, the GMC has been able to affect the registration only of

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doctors found guilty of serious professional misconduct, something that we have discussed at length today. Despite the apparent relaxation of the standard of proof permitted by the Privy Council as a result of the McAllister case, the standard of proof remains high and the quality of misconduct amounting to "serious" is unsatisfactorily limited.

Many cases of sheer bad doctoring have slipped through the net. There is a clear need to provide a procedure to deal with the doctor who is sloppy, who is rude, who is persistently inefficient or who is the source of constant complaint from patients, without any particular incident that could be described as serious misconduct. Unfortunately, some doctors are an accident waiting to happen. The procedures introduced by the Bill will enable the GMC to deal with such circumstances. I believe that the intention is not to introduce a new punitive procedure; the emphasis will be on advice and retraining, although the ultimate sanction of erasure will be available for those whose deficiency of performance cannot, in the end, be remedied.

The cost of remedial training has been estimated at £530,000, according to the Bill's financial memorandum. That may be an underestimate, especially if the introduction of the new procedures brings forward a flurry of cases. I hope that the Minister will confirm that should the cost be greater, public interest demands that it should be met in full, save in so far as it is reasonable for the cost to be met by the doctor himself.

The Bill represents a step forward in the consumer's interests and I hope that the House will support it.

6.28 pm

Mr. Anthony Coombs (Wyre Forest): Like a number of hon. Members who have spoken, particularly the hon. Member for Newcastle upon Tyne, Central (Mr. Cousins), I support the principle of the Bill, which can only be good for patients and for the reputation of doctors. At the same time, however, I have some reservations about how exactly it will work out in practice, and about whether the definitions of seriously deficient performance will allow the public's aroused expectation--I am sure that it will be aroused as a result of Bill--to be met in practice.

A danger exists in the Bill. The public will feel that, in relation to a range of performance, if they are not satisfied on a local basis, they will be able to report their doctors to the General Medical Council. When they find that it is not prepared to entertain such complaints, I am concerned that they will be disappointed and that, therefore, we will not have taken any steps forward in improving credibility in or the quality of the medical profession's care for patients.

In the medical service, not just in Britain, but in the rest of the western and industrialised world, the power of the consumer is far greater than it used to be, through both the patients charter and league performance tables, which have been suggested by hon. Members on both sides of the House at various times. The population's deference for doctors has fallen. Previously, doctor always used to be right; now doctor is someone whose judgment can often be questioned. Given that sociological or even emotional change in attitudes to the medical profession in the past few years, it is inevitable that people will demand not only higher standards from doctors, but more specific accountability from them.

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The hon. Member for Newcastle upon Tyne, Central quoted Adam Smith in putting forward his ideas about a committee.

Mr. Cousins: I thought that the hon. Gentleman would like that.

Mr. Coombs: Very good. I shall quote an article in The Sunday Telegraph which appeared at the end of last year by Dr. James Le Fanu. He quoted Robert Louis Stevenson talking about some of the virtues that people expected from doctors, apart from professional competence. They included generosity, discretion, tact, heraclean--whatever that is--cheerfulness and courage, which, the article states, brings

"air and cheer into the sick room and often enough, though not as often as he wishes, brings healing."

Dr. Le Fanu went on to talk about the seven sins of medicine as described by the late and distinguished Sir Richard Asher. They are obscurity, cruelty--both physical and mental--bad manners, over-specialisation, love of the rare, common stupidity and sloth. I do not know whether many of those points would come within the definition of seriously deficient performance as set out in the Bill, but I am sure that a significant number of members of the public will expect that they will be able to report any of their doctors who do not exhibit those virtues and who consistently or otherwise exhibit some of the deadly sins to the GMC, and that, as a result of this new consumer-friendly Bill, which we all so avidly welcome today, those doctors should be able to be brought to account. That is dangerous. The public's perception and that of the GMC, which, as our excellent brief from the Library states, anticipates only about 100 to 150 cases per year, may be considerably out of kilter in relation to the credibility problems that I have described.

I have a particular interest in the matter, as, I am sure, every hon. Member does. It so happened that Dr. Carol Starkie, who is quoted as being one of the doctors who could be assisted by the new procedures involving the committee on professional performance, was a constituent of mine-- certainly her parents were, and she grew up in my constituency. Hon. Members may recall that, a couple of years ago, she was a consultant based at the Royal Orthopaedic hospital in Selly Oak, Birmingham, and that she was found to have misdiagnosed no less than 42 potentially cancerous tissue samples.

That aroused enormous public concern, including, obviously, among the people directly affected and their families. Five years ago, a family in my constituency--I have not asked whether I may quote them today, although they have been upfront in their complaints--lost a son aged 18 as a result of what they believed to be the professional incompetence of a locum and a local general practitioner. The boy was diagnosed as having a temperature for about four days. It gradually went up from 102 to 104 to 105 deg F. On the Thursday evening, a doctor insisted that he merely had flu symptoms, that the windows should be opened, and that he should be allowed to cool down. The next day, the boy was admitted to Kidderminster general hospital, where he died the same day. One can understand the devastating effect that that episode has had

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on my constituents' lives, and how concerned they are to ensure, not that the people involved should be compensated, but that such incidents should not happen to other people, and that those responsible should be brought to book--not necessarily in the court but through an effective General Medical Council--as being guilty of seriously deficient performance.

As I said, I happen to agree with the principles of the Bill. It would be difficult to do otherwise. Obviously, it is right that the purview of the GMC should be extended from merely considering professional conduct and health to wider terms of professional performance. I can understand the arguments, again very well put in the research paper that we have, that the proposals should apply to every sort of doctor, whether he works in a private practice or hospital, or whether he is a locum.

Nowadays, given the fact that medical practice is changing at an exponential rate as a result of new technology and new techniques, it is all the more important that some grip is kept on professional standards. Like my hon. Friend the Member for Birmingham, Edgbaston (Dame J. Knight), and the hon. Member for Newcastle upon Tyne, Central, who ably set out his case, I have some serious concerns about the definition of seriously deficient performance. I have considered part 2 of the GMC's regulations. It refers to conduct and talks about convictions and forms of professional misconduct that may lead to disciplinary procedures. It mentions

"neglect or disregard by doctors of professional responsibilities to patients for their care and treatment"

and

"responsibility for standards of medical care".

Paragraph 36 states:

"The public are entitled to expect that a registered medical practitioner will afford and maintain a good standard"--

not the best standard--

"of medical care. This includes: conscientious assessment of the history, symptoms and signs of a patient's condition; sufficiently thorough professional attention, examination and, where necessary, diagnostic investigation; competent and considerate professional management".

All those would appear to be related to medical duties. They are not related to misconduct whereby one is doing unmentionable things to one's female patients. They are directly related to the standard of one's medical duties. If we are saying that the new committee on professional performance can consider only seriously deficient standards of medical performance, we should take account of the fact that such standards are already accounted for in the conditions on conduct laid down by the GMC.

Therefore, if we are genuinely to extend the purview of the GMC to medical competence, we should do so not just for the most serious cases but for cases further down the scale. That was what the hon. Member for Newham, South (Mr. Spearing) wanted to do when he introduced his Bill. As my hon. Friend the Member for Edgbaston said, he has attempted to introduce such a Bill several times in the past six years.

My difficulty is that, although we had the word of the Minister when he intervened in the speech of my hon. Friend the Member for Chislehurst (Mr. Sims), we do not have anything in the Bill. It is significant that the schedule says several times:

"The General Council may make rules".

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It also says:

"The Committee on Professional Performance shall be constituted as provided by the General Council by rules under this paragraph." I am worried not so much about what we see in the Bill as about what is unseen and what will be decided by the GMC and determined in regulations.

The Library briefing says that the General Medical Council, when proposing a third jurisdiction, emphasised that

"there should be an `equivalence of gravity' between this offence and those of serious professional misconduct and fitness to practice being seriously impaired by ill health."

It said that they should be judged on the same standard. Either the Bill duplicates what is available at present, as I demonstrated a few moments ago, or it does not deal precisely with the type of problems further down the scale that many of our constituents would expect it to deal with, if competence and the GMC's ability to examine it was genuinely being extended.

Nor does the Bill tell us--it is left to the schedule--how cumbersome in practice the proceedings under the Bill will be; how quickly, for example, the concerns of someone who makes a reference to the GMC which goes to the committee on professional performance will be met. Justice delayed is justice denied. My constituents to whom I referred a few moments ago have been trying for eight years to find a reason why their son died and who was responsible. They still have not been able to do so under the existing procedures. If there is to be a significant improvement and if the system is to be effective, there has to be more speed.

Equally, I hope that access will be easier than it is under the professional conduct proceedings. When I investigated my constituents' case I found that only 9.5 per cent. of complaints ever got anywhere near the professional conduct committee, even though in many cases people had been through the gamut of complaints procedures at local and regional level. I have some worries, which the Minister cannot answer now, about exactly how the Bill will work out in practice. Those matters will be left to representations to the GMC on how it interprets its responsibilities under the schedule. I believe that the Bill will arouse the expectations of the public as to their ability to make effective complaints against what they see as deficient procedures and standards on the part of their doctors. Indeed, it is happening already. Action for Victims of Medical Accidents, which is the leading voluntary body in examining medical negligence cases, tells me that up to last year it had 14,000 cases on its books. I would suspect that it is very much more now. The patients charter, in emphasising patients' rights rather than patients' responsibilities, is all the time pushing people into a position in which their expectations are rising and, therefore, their potentially litigious feelings are being aroused.

We have performance indicators for different consultants or GPs. GPs are in a more competitive position through fundholding or total purchasing and are providing more and more services to their patients. So I should have thought that expectations would be aroused and that the number of complaints which will potentially go through the system outlined in the Bill will significantly increase--certainly way beyond the 100 or

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150 mentioned by the GMC. That raises concerns about how complaints in the health service are dealt with before they ever reach the GMC. It is likely that a complaint to the GMC will be at the top end of people's aspirations. Complaint to the GMC will be their ultimate deterrent when they find that the performance of their doctor is not what they would like it to be. I know that the Government have examined the existing plethora of complaints avenues. The Wilson committee has written a document called "Being Heard" which referred precisely to the plethora of complaints procedures--what AVMA called a labyrinth of complaints procedures available to the public. Although complaints procedures may be available, if there is a labyrinth, one cannot get through it quickly. If people think that there is a labyrinth, they do not go into it in the first place. Therefore, some people who would like to make a complaint--probably a legitimate one--about their doctor may be deterred from doing so. Existing complaints procedures include formal and informal procedures for family health services authorities, hospital administrative review, the hospital clinical complaints procedure and the health services commissioner. Only then does one get through to the civil courts. So there is a variety of complaints procedures. It is no wonder that AVMA has become more and more popular with patients. They need someone to guide them through the labyrinth. The Government have produced a document called "Acting on Complaints" only within the last month, in response to the Wilson committee document. It proposes that, where possible, the resolution of disputes in the health service should be local, speedy and far more easily accessible and streamlined than the present procedures. If that comes about, it could have one of two effects. Either there will be more satisfied complainants at the lower end who will not go to the GMC or, as I suspect, there will be more complainants and, as a result, potentially more people will complain to the GMC. So if the system outlined in the Bill is to work effectively and not weigh down the GMC in a huge maelstrom of complaints, the Government must get local level complaint resolution procedures absolutely right. When one talks about quality in the health service and avoiding problems of defensive medicine--matters which AVMA referred to recently--the more one emphasises quality-led outcomes and the more there is the opportunity for subjectivity about what is an acceptable quality-led outcome. Therefore, there is more potential for making a complaint against a particular doctor who does not come up to that quality-led criterion.

It is not merely a question now of saying, "I had my operation. I was in and out and I got better eventually." People consider what treatment they received before going into hospital, how long they had to wait, what their post-hospital treatment was like, whether they went into the appropriate nursing home or whether they had the appropriate home treatment. All those quality-led outcomes, which are rightly demanded by the public, will lead to greater opportunity for people to complain about doctors, whom they believe should manage their treatment in a particular way.

I was somewhat surprised to read in the briefing paper compiled by the Library that the GMC did not see the new powers as in any way directly related to medical audit procedures in the NHS. The powers may not be directly

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linked to medical audit procedures in the national health service, but I cannot see how they can be anything but indirectly linked with medical audit. After all, medical audit is about the quality of outcomes and assessing that quality. As I said, if we raise people's expectations of the quality of outcomes and those outcomes are not effectively delivered in every case, people will be more likely to complain about the conduct of their doctors.

In the main I support the Bill, but I am very concerned that the devil, as they say, is in the detail and that what the GMC puts into place, when it looks at the schedules, may not meet the kind of expectations that have been aroused in patients. The problem about arousing--legitimately-- expectations of improved service in patients and giving them more rights in the health service is that for every right there is a responsibility. The health service has a responsibility to come up with a particular level of service. Equally, the public have a responsibility to ensure that they treat their health service appropriately. It is not appropriate--my local doctors have told me of such behaviour--to turn up at the surgery to have a plaster put on, or to ask for a prescription for a medicine which is perfectly easily and cheaply available over the counter, or to ask for advice about nettle rash. Patients should have some cognisance of such activity when they consider their responsibilities to the health service.

Although the Bill rightly makes people aware of their rights and the improved quality of the health service--indeed, they are getting that improved quality from our national health service, which is operating more effectively than ever before--it equally diverts their attention in the long term from their responsibilities in the health service. Only by emphasising people's responsibilities in the health service will we in the long term be able to manage demand for health services which the taxpayer can afford.

6.51 pm

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