House of Commons Hansard Debates for 25 Apr 1995

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Mr. Deputy Speaker: Order. Whoever wants the hon. Gentleman to raise that matter, if it is outside the debate, he cannot raise it.

Mr. Evans: Thank you, Mr. Deputy Speaker.

There are other examples of good news about the national health service that do not make the newspapers. On Friday, I spent all day visiting district nurses in the Clitheroe practice. I also visited Lancashire Ambulance trust and saw some superb news going on there. In the evening, at an award ceremony in my constituency, I met more district nurses operating in my constituency.

I have also visited GPs in the Clitheroe practice and discussed the concerns that GPs have in Longbridge and Whalley. One cannot discount the fact that far more pressure is placed on GPs these days than was the case in the past. The expectations of patients are exerting more pressure on the GPs. GPs are now given more freedom to take more power to help their patients, to prevent them from going into or being referred to hospital. I believe that, in some cases, that pressure and the expectations of their patients lead some of the patients to believe that they are not receiving the due care and attention that they would wish to have. They wish to ensure that the highest standards are met, especially by GPs.

Millions of patients are treated by GPs every year. The vast majority of people who are treated by the 26,000 GPs receive excellent treatment. Not all of that practice will be consistently high, and I believe that that, in some cases, is where the Bill will come in and ensure that standards are raised. The Bill aims to meet that challenge.

That does not mean that, in every case when patients write letters, they have good cause to write. It is simply that the expectations are much greater. People are now given more information about how to complain about the service that they receive. People know how to complain and are doing so, which is good. Patients and customers of the national health service will also want to know that their concerns are being dealt with properly, and the Bill will help to ensure that.

Like other hon. Members who have spoken, I am not saying that the Bill is absolutely right in all its aspects. That is where the Standing Committee will play a role. As the hon. Member for Newcastle upon Tyne, East (Mr. Brown) said, amendments will be tabled, perhaps from both sides of the Committee, to ensure that the finished Bill will be far better than the original one. We shall see what happens in the Standing Committee. It is important to note that the system that is adopted may prevent the need for investigations and complaints in the first place. That would raise the standards of the general practitioners and of those who work in the national health service.

I am sure that we have all received letters from the BMA, which has welcomed the Bill. It has reservations, but in the main it welcomes the Bill. The measure will ensure that the professional standards of all those who work in the national health service are maintained and, in doing so, it will benefit the profession.

The BMA raises some points that need to be considered, including the subject of retraining. The assessment of doctors' knowledge, skills and attitudes in the practice and their retraining will ensure that they are kept up to the required standards. The profession is constantly changing. The BMA wants to know who will pick up the costs of retraining, which is a fair question. Now, nearly £40 billion is spent on the NHS and £800

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million a year is spent on training. Will the cost of retraining those GPs and others who work in the NHS come out of that £800 million, or will additional resources be made available for retraining? That is one question that must be answered.

How many people who work in the NHS are expected to need retraining? That is something that we need to consider. The profession is constantly changing; new technology is being introduced all the time, and new procedures such as keyhole surgery mean that patients stay in hospital for shorter periods. What will be the retraining costs for such procedures? Will they come within the confines of the Bill? We need to know the facts.

Many people examining our proceedings today will be surprised that we have waited so long for the Bill. Many people will have expected a procedure to have been set up to replace the current

everything-or-nothing system. It is clear that the current procedures would not be sufficient to meet the sort of complaints that many of us receive as Members of Parliament. I hope that the Bill will introduce procedures in which people have confidence, so that when they complain about deficiencies, their complaints will be dealt with. Complaints should not fall foul of a system where they are not serious enough to warrant the General Medical Council taking action to correct the problems. The Bill will be extremely welcome if it achieves that aim.

Other hon. Members have mentioned the audit and suggested that the Bill should not involve audit. I agree, but the audit within the medical profession has a role to play in ensuring that all those who work within the NHS and reach a high standard give a lead to others, so that they raise their standards and we ensure that money spent in the NHS is well spent. Such procedures will include referrals to hospital and the amount of prescriptions currently written by some GPs.

The Bill's effect may be to raise the number of complaints referred to the General Medical Council. An increase in the number of complaints does not mean that standards are lowered--quite the opposite. It means that scrutiny is being improved, which has to be welcomed. The measure must be seen in the context of the pressures currently exerted on the NHS, the demands and expectations that we have of it and the vast amount of good work that is being carried out within it. One has only to talk to people from abroad to discover that they look at what goes on in this country and admire it. We have the best health service in the world. We have the world's favourite health service and we wish to see it maintained for the future. That is why I welcome the Bill.

7.54 pm

Mr. Piers Merchant (Beckenham): It gives me great pleasure to follow my hon. Friend the Member for Ribble Valley (Mr. Evans). I particularly endorse his last few remarks and associate myself most strongly with them. I listened with great interest to the earlier part of his speech. He was right to say that, these days, the spotlight of public attention is very much on health matters generally. Although the Bill deals with one specific and fairly narrow part of that subject--the conduct of doctors in the medical profession--that must be understood to be a matter of concern within a much broader picture. My hon. Friend was right to draw attention to that.

I listened to my right hon. Friend the Secretary of State when she opened the debate. She was right to mention the public's greater expectations. I should like to apologise to

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the House for missing a short part of the debate after that, but I was sitting on a Standing Committee, where I was required. I was sorry to miss the contribution of the hon. Member for Newcastle upon Tyne, East (Mr. Brown), not just because he is the Opposition spokesman on the subject but because I have listened to him on many occasions with great interest. I know him to have a well-measured approach to all matters debated in the House.

I also regret missing the contribution of my hon. Friend the Member for Chislehurst (Mr. Sims), particularly as he has given long service to the General Medical Council, of which he is a lay member. I also regret missing his contribution, because of his interest in, and knowledge of, health matters, which is considerably greater than mine.

I have for some time been critical of the existing complaints procedure and the disciplinary system within the medical profession. When I was first elected as Member of Parliament for Beckenham, I dealt with a case involving a doctor who could fairly be described as incompetent, but who was not so unreliable as to be considered guilty of professional misconduct. I was surprised to discover at the time that, although local remedies existed, there appeared to be no national remedy to deal with the problem--in terms either of discipline or of finding a way to overcome the problem by imposing, for example, retraining. It was that experience that first led me to realise that there was a deficiency in the procedure.

My views were brought into sharp relief by a case which I should like to go into in detail but cannot because I have guaranteed the privacy of the individuals involved, for understandable reasons. It is still outstanding. It has been running for two years and involves what I regard as dubious practice on behalf of a member of the medical profession. The treatment provided was dubious; the way in which it was carried out was certainly dubious.

I was further alarmed to discover while investigating the case that it was by no means the first example of that member of the medical profession behaving in that way. There had been a number of examples and I believe that there have been more since--it is a continuing problem. I took the matter up with the GMC as I believed that that was a way of, if not obtaining a remedy, at least preventing such things from continuing.

Although I have to compliment the GMC on recognising that there was a problem and on being prepared to look into it immediately, at the end of the day it was not able to offer a solution because in its judgment--a judgment that I have to respect--this case did not come within its rules. The GMC suggested that I take the matter to the Department of Health, which I did. I was advised that, sadly, there was no scope for action there because nothing illegal was being done--it might be dubious, but it was not illegal.

I found that, as a Member of Parliament, there was effectively nothing that I could do to prevent what was happening. I could offer only sympathy to the people involved, which was certainly not sufficient. They decided, quite rightly, to pursue a legal remedy and went so far as to get counsel's opinion, but found that in this country, unlike in many others, there was no remedy via the courts and the legal system. I was left with the impression that complaints and disciplinary action relating to the conduct of doctors was, at least in that case, inadequate. I doubt that the changes introduced by the Bill

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and the regulations that will follow will be sufficient to deal with such cases, but the Bill is at least a step in the right direction.

I have begun by criticising two members of the medical profession, but I have had considerable experience of dealing at many levels with members of the profession and I want to make it clear that I have encountered many who are of the highest quality and offer the highest standards of care, service and expertise. I do not want my remarks to be taken to mean that I am casting aspersions on the profession in general.

It is surely in the profession's interest that its complaints system operates in such a way as to inspire public confidence in the profession generally and ensures that action can be taken when conduct has not been of the highest standard. No profession is immune from having within its ranks people who are not up to the required level of competence, who are not entirely honest or who do not behave as their position requires. Such problems are inevitable because professions consist of human beings. The House should ensure that, as far as possible, there is a way to protect the medical profession's good name against the few bad cases and that public confidence can be retained. I believe that the Bill will succeed in doing that. My right hon. Friend the Secretary of State said that public expectations are much higher these days. That is undoubtedly true. She also said that doctors are no longer regarded as paragons. Indeed, people are much more critical now than they would have been even 10 years ago and they require a system that enables them to have their complaints about inadequacy dealt with so that standards are improved.

I am delighted that the GMC has made it clear that it supports the thrust of the changes because, of course, it is far better to reform the profession if the profession is prepared to endorse change rather than having it imposed on it. I pay tribute to the hon. Member for Newham, South (Mr. Spearing), who for many years waged a campaign to change the profession's disciplinary system. To an extent, the Bill is the fruit of his efforts, although I know that he would have liked to go further.

Given the need for swift reform, it is absolutely right that it should be carried out under the present regime of self-regulation. However, were we starting ab initio, I should not feel especially well disposed to having such a heavily self-regulatory system. I speak with some experience of self -regulation, having worked for a while in the advertising industry which operates a system of self-regulation. Although it operates well, it was clear to me that it could not provide all the answers that the public had come to expect. The system was deficient. I was also involved in the setting up of self-regulation for the direct mail industry and came to the same conclusion in that instance.

We need to ask whether self-regulation is sufficient for the medical profession. The hon. Member for Strathkelvin and Bearsden (Mr. Galbraith) spoke effectively on that point. He said that he did not believe that there was a conspiracy among professionals to cover up. I accept that judgment, but I still believe that self-regulation is open to potential criticism. Although I would not accept that there is any conspiracy or whitewash among professionals--indeed, they have reason to aspire to the highest

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standards--there is clearly a danger that the profession will indulge in self-protection and use the Bill and existing legislation to be cautious, if I may put it like that, when dealing with complaints and criticism. The profession is naturally resistant to change. It does not want any further requirements placed on it in respect of discipline and standards of conduct unless absolutely necessary.

If the public are to be sure that a system is operating properly, they have to believe that everything is above board. If the public think that everything is not above board, even when it is, there is a deficiency in the system. I therefore have some doubts about self-regulation, especially in respect of the national health service, whose professionals are required to obtain higher standards than in, for example, commerce.

Mr. Malone: Before my hon. Friend leaves that point, I hope that he will bear in mind that the GMC has a substantial lay element, so it is not quite a closed shop. I am sure that he will concede that the Government are not imposing something on the profession. The GMC fought for the Bill for some time and the Government are glad to be able to support it.

Mr. Merchant: I am grateful to my hon. Friend. I said a few minutes ago that the GMC clearly supports the Bill. I was going to stress that, in any event, there is not a system of pure self-regulation in the medical profession. There is a lay element in the Acts of Parliament which gives backbone to the system and which means that the profession is not entirely self-regulating. It is self-regulation built on a statutory framework. It owes its origin to the Medical Act 1858, to which the Bill is related.

We must bear it in mind that that Act was passed at what was perhaps the peak of laissez-faire, so the system is, in essence, Victorian. I do not say that in a critical sense but simply as an explanation. The Act provided a structure in tune with health provision of the time, but times have changed considerably. The public's demands have changed, which is why the Bill is needed to update the system.

I regard the Bill as part of a continuing process. I predict that further changes will be needed in future to take account of yet more changing attitudes. I do not share the somewhat apocalyptic vision of the hon. Member for Cannock and Burntwood (Dr. Wright), who went a little far in talking about the dangers posed by problems in the medical profession. Although I understand his concerns, the Bill is pretty narrow in terms of the changes that it introduces. There will come a time when a broader framework will be required to cover not just those who the Bill covers-- registered medical practitioners--but many quasi-medical professionals whose numbers are multiplying and who offer medical services that are now accepted by the national health service. Some of them are regulated by legislation, such the Osteopaths Act 1993 and the Chiropractors Act 1994, which I was delighted to support, but many other mushrooming activities in alternative health care should also be included in the legislation.

Dr. Spink: Does my hon. Friend share my concern that the public might be disappointed with what the Bill delivers? It will not be a panacea and resolve every small complaint. People may be looking for rather more. The

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Bill is a move forward, but there is further distance for us to cover, particularly in improving the way in which FHSAs deal with complaints.

Mr. Merchant: I agree with my hon. Friend. He is absolutely right. It is a stage that will be welcomed, but it is a step behind public expectations. His latter point about FHSAs is also absolutely right. The Bill's major deficiency is that it widens or deepens the authority provided by existing measures only slightly and it does not provide a comprehensive system to cover the complaints procedure via the national health service, to which my hon. Friend was referring, or the quasi or alternative medical professions.

My principal feeling is that the Bill is useful and important because it covers a surprising gap in the present powers. The average member of the public would assume that the current disciplinary system or complaints procedure covered adequacy or inadequacy among the medical professions, incompetence, constant poor performance and faulty judgment. Most people would imagine that any doctor who demonstrated incompetence would immediately be caught by the provisions of his own profession's standards and disciplinary systems. That is not the case. There is a gaping hole in provision. The present legislation allows for what was described by the rather quaint phrase "infamous conduct in a professional respect". What, indeed, is infamy? It was defined in 1894 by Lord Justice Lopes who said that it was conduct

"regarded as disgraceful or dishonourable by the professional brethren of good repute and competency" .

That is a very persuasive description, but it is not sufficient to cover poor, simple incompetence and inadequacy and, in that sense, a gap existed.

The GMC's "Proposals for new Performance Procedures: A consultation paper" went straight to the heart of that. It defines

"`seriously deficient'--in other words, so blatantly poor that patients are potentially at risk".

Surely it is necessary to include in the statutory framework behind the disciplinary system that the GMC operates full scope for that to be covered. The Bill does that, and not before time.

The Bill covers the need to protect the public from deficient performance, but it proposes to do so in a way that is supportive and remedial. The first objective is to protect the public. The second objective is to try to deal with the problem positively by finding a means to raise the individual doctor's standards. Given the potential expertise, the training that doctors have to undergo and the cost, it is surely right that, if possible, a means should be found of rescuing the doctor and putting him back on the straight and narrow. The GMC is perfectly right to do that. It recommends putting in place a procedure that will be fully covered by regulations under the Bill when it becomes an Act, local assessment and a complex system of ensuring that justice is done, even if the complaint is relatively minor.

The GMC has produced an exceptionally complicated flow chart which, when one follows it through, as I have done, is logical and ensures not only that complaints are properly screened and dealt with in the right way, at the right level and with the right degree of proportionality but

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that the doctor is given adequate care and attention at each stage to solve the problem, from the point of view not simply of the complainant but of the doctor.

I do not believe that the Bill solves all the problems, but it represents an important step forward. However, I hope that my hon. Friend the Minister can reassure me on one point. It is a contradiction between the judgment of Jean Robinson, vice-president of the Patients Association, and that of the GMC.

Mrs. Robinson was quoted in The Independent as criticising the proposals for not going far enough. She said that the procedures "would involve only cases judged on poorly defined criteria to be `serious', would operate entirely in private and would provide none of the rights to be represented or to seek a judicial review which are enjoyed by patients bringing complaints of misconduct." Referring to the changes, the GMC document said:

"They will not form a lower form of the conduct procedures. They are not aimed to attract a new category of complaint to the GMC, rather they will provide a way of dealing with many existing complaints concerning failures in professional performance." I am somewhat puzzled by that. I hope that the Bill addresses the concerns expressed by Mrs. Jean Robinson and does not entirely reflect the GMC document.

If the Bill does nothing more than underline what is already occurring, it does not go far enough. If it goes a step further, as I understand it does, the GMC description is not entirely accurate when applied to the Bill. There is a need for a lower tier of conduct procedures. There is a need for complaints that are not caught by the existing procedures to be addressed. If the Bill operates as it should and if the regulations that follow it are sufficiently tough, that is precisely what will happen. The two new committees that the Bill sets up will do that, but I hope that my hon. Friend the Minister can give us some reassurances to that effect.

The Bill is an excellent measure and I strongly support it. I hope that it passes into law soon. I hope that the regulations that follow will be adequate and will enable doctors and medical practitioners to continue to enjoy their excellent reputation by assuring the public that there are proper procedures to deal with those who do not come up to standard and to ensure that those doctors are brought up to standard, for the benefit not just of their careers and future and those of their fellow professionals but of all the people in Britain who seek and expect the best standard of care from health service practitioners.

Mr. Nicholas Brown: On a point of order, Mr. Deputy Speaker. The excellent House of Commons Library briefing note on the Bill has so far been read to the House four times tonight. There is a rule against tedious repetition. How often do we have to hear it read to us from the Conservative Benches?

Mr. Deputy Speaker: I am well aware of that particular rule and I have been taking note. The hon. Gentleman can rest assured of that. 8.19 pm

Dr. Robert Spink (Castle Point): It is a great pleasure to follow my hon. Friend the Member for Beckenham (Mr. Merchant), who always makes an interesting speech. As I expected, he demonstrated a wealth of knowledge about the subject in the course of his very cogent remarks. It is also a great pleasure to speak in support of the Second

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Reading of the Medical (Professional Performance) Bill. However, my contribution will be short because, as we heard a moment ago, much has already been said.

Mr. James Pawsey (Rugby and Kenilworth): But it will not stop my hon. Friend saying it again.

Dr. Spink: I am indebted to my hon. Friend. The Bill takes an extremely small but significant step forward in driving up standards of patient care.

Mr. Pawsey: I thank my hon. Friend for giving way. Does he find it as extraordinary as I do that there is only one Liberal Member, two Labour Members and not a single Back-Bench member of the Labour party--

Mr. Deputy Speaker: Order. Let us return to the Bill.

Dr. Spink: I am indebted to you, Mr. Deputy Speaker. The Bill received all-party support, so it seems absolutely incredible and outrageous that the Opposition Benches are empty, as my hon. Friend has correctly pointed out.

Mr. Nicholas Brown: As we support the principle of the Bill--which is what should be discussed during the Second Reading--the Opposition parties are trying to make progress while Government Back Benchers seem to be filibustering unduly. I cannot understand why they are doing so, but that is clearly what is going on.

Dr. Spink: Mr. Deputy Speaker, you have been listening to the debate very carefully and you will be aware that hon. Members have raised a number of very proper questions which will be dealt with during the Committee stage of the Bill. That is why the debate has proved so interesting and useful. The Minister is taking great notice of it and he is making copious notes. I look forward to hearing his speech.

Both the General Medical Council and the British Medical Association have given their blessing to the Bill. The GMC press notice of 16 March 1995--a significant document which I have taken from the Library research paper and which I do not believe has been read to the House--states:

"We identified a gap in our powers and I am pleased that Parliament has been asked to fill this gap to enable us to do our job more effectively".

That is what we are about tonight.

Mr. Congdon: I agree with my hon. Friend and we are all aware that the GMC was behind the Bill; it identified a gap in its powers. However, should we not ask whether there are other gaps that are not addressed by the Bill? There is a danger that we will pass the legislation and, in five years' time, realise that such gaps exist.

Dr. Spink: My hon. Friend the Member for Croydon, North-East makes a telling point that has been referred to before and that I will come to in a moment.

In talking about the support that the Bill has received, I must mention the important patient groups and associations which have indicated their support for the general thrust of the legislation, although they also expressed some reservations. Those reservations have been aired tonight, but in deference to the hon. Member for Newcastle upon Tyne, East I will not rehearse them again.

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In welcoming the Bill, I accept that there are some difficulties in the national health service and that mistakes sometimes occur. The NHS treats millions of patients each year and it would be incredible if occasional misjudgments or even gross errors of judgment did not occur. Thankfully, such events are rare and I pay tribute to the doctors, nurses and even the health service managers, all of whom enable the health service to function properly and provide an improved service to our constituents.

Southend-on-Sea trust hospital is improving the service it provides to my constituents. It treated 17,140 more patients last year and it has treated an additional 700 patients this year.

Mr. Deputy Speaker: Order. It seems as though my remarks have fallen on deaf ears. It is very interesting to learn what is happening in the hon. Gentleman's hospital, but we are dealing with the Medical (Professional Performance) Bill. I ask the hon. Member for Castle Point (Dr Spink) to address his remarks to it because we are nearing the point of tedious repetition.

Dr. Spink: I am indebted to you, Mr. Deputy Speaker. The Government have raised public awareness that taxpayers should expect good, timely and courteous service from all areas of the public sector, including the national health service. The Bill addresses that point very directly. The Conservative Government have raised patient expectations. The hon. Member for Cannock and Burntwood (Dr. Wright) outlined many of the ways in which patients have received more information and more rights, so I will not repeat those points. The citizens charter movement was initially scorned by Opposition Members, but it is now being studied and copied across the world, for example, in the United States. Tonight hon. Members have referred to a number of alarming cases involving serious neglect in the health area. The Bill should swing the balance of health care in favour of the patient while dealing with problems that occur from time to time in the health service. It will provide patients, the BMA and the GMC with another weapon in their armouries. The hon. and learned Member for Montgomery (Mr. Carlile) referred to that point in welcoming the legislation during debate about the Queen's Speech.

My hon. Friend the Member for Wyre Forest (Mr. Coombs) said eloquently that patients have responsibilities as well as rights and he referred to patients' increasing tendency to abuse those rights. People are making more night calls and they are constantly referring matters of little significance to their doctors. That is placing a burden on the system, doctors are being placed under greater pressure and that is leading to an increase in the number of mistakes that they make. I hope that we will look carefully at ways of inhibiting that development.

A story appeared on the news tonight about a doctor who worked 110 hours. He successfully sued his local health authority and received about £5,000 compensation because he said that he had been put under undue pressure and was therefore at risk of making a mistake in treating patients. If he had made a mistake which had amounted to gross incompetence, the Bill would have swung into effect and enabled him to receive additional training so that he could provide his patients with better care. That is one of the reasons why I support the legislation. We

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accept that patients have needs and rights and that they should receive the best possible protection from incompetent doctors.

Mr. Pawsey: I thank my hon. Friend for giving way and I apologise for interrupting the flow of his speech. He is making an extremely eloquent speech which I know will be noted carefully by all those hon. Members who are in the Chamber and by those who will read Hansard in due course. Does he find it surprising that there is no reference in the Bill to the work of the health service commissioner? My hon. Friend assiduously attends debates in the House and he studies such matters with the utmost care. Therefore, is he surprised that the Bill does not mention the work of the health service commissioner and the way in which he may hear complaints relating to general practitioners?

Mr. Deputy Speaker: Order. That was a mini speech, not an intervention.

Dr. Spink: I am indebted to you, Mr. Deputy Speaker. Although it was a rather long intervention, it was an interesting and important one. Of course, the health service commissioner plays a pivotal role in these matters, and I look forward to hearing what my hon. Friend the Minister has to say about that when he replies.

Whatever the reason why a doctor might be incompetent--the hon. Member for Strathkelvin and Bearsden (Mr. Galbraith), himself a distinguished medical man, gave a very illuminating account of the various reasons, so I shall not rehearse them--he or she should be given the opportunity to recover and repair. The Bill allows time for that process to take place. The Bill leads the way, therefore, to improving standards of doctoring by allowing time for doctors to retrain. It gives them one or two years--perhaps more--to retrain and represent and be relicensed, so that they can continue their profession. That is absolutely right. The Bill is not just about discipline and punishment. It is focused on driving up the standard of care that patients can expect to receive from their doctors. That is the way it should be.

On a technical note, my hon. Friend the Member for Ribble Valley (Mr. Evans), who made a most interesting and cogent speech, referred to the costs of retraining and asked whether they would come from the general NHS budget or from any other hypothecated budget. The explanatory and financial memorandum to the Bill said that the cost to the NHS of retraining doctors, as a result of the Bill's measures, would amount to about £530,000 each year. I do not think that we should consider that cost as unacceptable or, indeed, that it is an unacceptable demand on the health service budget, as sound benefits will flow from that relatively small expenditure.

Mr. Peter Atkinson (Hexham): I am grateful to my hon. Friend for giving way. What happens if the doctor involved is not a practising doctor but simply works as a locum and moves around the country? What happens, for instance, if that doctor was in private practice? Which section of the NHS does my hon. Friend think would have to cover that cost? Would the local family health service practitioners committee have to foot that bill, even though the doctor was in no way attached to it? There is a problem there.

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Dr. Spink: These are all extremely interesting and important questions which my hon. Friends on the Front Bench will be addressing--

Mr. Malone indicated assent .

Dr. Spink: I have seen the nod of the head. I, like my hon. Friend, look forward very much to receiving the explanation about that and perhaps to reading the deliberations of the Committee, which, no doubt, will go into this with a fine-toothed comb.

Mr. Pawsey: Once more I apologise to my hon. Friend for interrupting his speech. I draw his attention to clauses 5 and 6. He will be aware, because quite clearly he has studied the Bill in considerable depth, that clause 5 provides that an

"Order in Council may bring different parts of the Bill into effect at different times."

Yet clause 6 says that the Bill

"will extend to the whole of the United Kingdom."

Does my hon. Friend agree that perhaps there is an argument for some form of pilot scheme to be introduced, perhaps, for example, into Scotland, to see how the Bill operates and to sort out any teething troubles? I would welcome his advice on that point.

Dr. Spink: My hon. Friend has clearly assiduously read the Bill, has taken in all its clauses carefully and is considering them. I believe that it is such a good Bill--it takes an important step forward in its contribution to improve patient care and helps doctors who are having problems to recover from those problems in an honest and honourable way-- that it should be brought in without a pilot, as soon as possible. No doubt those items can be deliberated on at length in Committee.

I was talking about whether the £530,000 cost of retraining doctors is acceptable or whether it would be an unacceptable burden on the health service, and that benefits would flow from that expenditure and that it was relatively low. The increased effectiveness of doctors as a result of the expenditure on their retraining, and the better diagnoses that they would make, would deliver massive benefits that would far outweigh the very small cost. I do not think that the cost is of any great significance. I believe that it would be money extremely well spent.

I agree with other hon. Members, particularly my hon. Friend the Member for Croydon, North-East (Mr. Congdon), that we need better systems to deal with chronically poor doctors--those who make small mistakes from time to time, who need a small amount of help--rather than the very serious bad performance and outrageously bad professional conduct, which, in a way, are easier to deal with. The Bill addresses those more directly. We cannot avoid the problem of the chronically poor performance, and we must find systems and improved ways of dealing with that.

Mr. David Lidington (Aylesbury): Has my hon. Friend studied the precedent set by the Osteopaths Act 1993 and, dare I say it, the Chiropractors Act 1994, which provide for penalties in respect of conduct by a practitioner that falls short of the standard required of either a registered chiropractor or osteopath respectively? Does my hon. Friend believe that those might serve as useful precedents

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that the Government might study with a view to introducing something not dissimilar with regard to the orthodox medical profession?

Dr. Spink: My hon. Friend makes an important and interesting point, which no doubt will be considered carefully. He comes to the House with a lot of knowledge and has done a great service to society at large through his work with the Chiropractors Act. We pay tribute to him now.

I shall give a specific example of a chronically poor performance. It has not been covered before. You will not be aware of it, Mr. Deputy Speaker, but there has been a lot of repetition tonight, and I deplore that. Indeed, I am trying to avoid it. The example is one of a doctor who falls out with a patient--perhaps there is a personalty clash, or whatever--and decides to remove that patient from his list, but refuses to give a good reason, or any reason, for so doing. The GMC will not take any notice. It is not terribly interested. I have tried to interest it in a difficult case in my constituency, but it has not shown any willingness to become involved. The FHSA sometimes finds that it cannot be of much help. Doctors in the area talk to one another. Other doctors are reluctant to take on the patient. As a result, the patient, who herself was damaged as a result of the medical profession making a bad decision in the first place, may well be causing a nuisance to the doctor.

But that is the nature of it. Many of our constituents cause what might be considered a nuisance to us. They have every right to do that. That is what we are paid for, and we must accept that and deal with it in a proper and professional way. We cannot turn our backs on our constituents, and we do not. Doctors should not turn their backs on their patients, but some of them do. I doubt whether the Bill would deal with that. The committee on professional performance, which is mooted in clause 1 of the Bill, would not be able to deal with that. It would not consider it to be any great professional misconduct issue that it should deal with. Gross misconduct or serious deficiency in performance would not cover the removal of patients from a list. So we have--

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