Examination of witnesses (Questions 280 - 299)
THURSDAY 1 JULY 1999
PROFESSOR HILARY THOMAS, MISS ISABEL NISBET, MISS MANDIE LAVIN, DR CHRISTINE TOMKINS and DR STEPHEN GREEN
280. Other than the geographical split, there are not splits within the elections in terms of the number of GPs represented, the number of hospital consultants?
(Professor Thomas) No. At the present time, anybody can stand and anybody can be voted on. There is no regional variation or specialty allocation.
281. Miss Lavin, would you describe how your organisation is made up in terms of those who make the decisions?
(Miss Lavin) Thank you. Our committees are composed of both council members and lay members. The UKCC has 60 council members, two-thirds of that number are elected members from the professions, the remaining one-third are appointed by the Secretaries of State across the four countries of the United Kingdom. The lay membership of the Councilour current definition of "lay" is somebody not holding current registration with the UKCCis certainly lower in percentage terms than the GMC, however, we do have the flexibility in our preliminary stages and also at our final conduct stage to involve consumers who are not members of our Council. We have two panels, firstly a consumer panel and, secondly, a practitioner panel of nurses in practice on a daily basis who will support and supplement those committees. We have recently consulted on changing our legislation to involve consumer groups in our health procedures, and that legislation is currently going through at the moment.
282. So it would be fair to say that the majority of members of both organisations are current practitioners?
(Professor Thomas) Yes.
(Miss Lavin) Yes.
283. What I would put to you at the outset is that one of the areas we have had serious concern raised about is the issue of the self-governing status of bodies such as your own. I accept we have met people who have had particular difficulties and we may not have had a fair overall picture, but the witnesses we heard from, certainly last week, and the people we have met on visits, clearly indicate a fairly general degree of lack of confidence in the self-governing process. How would you counter that lack of confidence?
(Miss Nisbet) I think one point we would make, which has been an important development in the GMC, is that no complaint to the GMC can be screened out and turned away without the agreement of a lay member of the GMC. So it has to be seen by a lay screener before it can be screened out. The judgments on what to do about every case involve lay members and evenand I say "even" because some people are surprisedthe performance procedures which involve very, very detailed assessments of doctors' performance have three assessors, one of whom must be a lay assessor. So we have taken the lay involvement very seriously. I understand the point you make about appearances, and the GMC is continually thinking how to be even more open to public scrutiny of what it does and whether it could enhance the lay involvement in each of its processes. What Sir Donald has said in the past is that the advantages of the self-leading of the regulation are the sense of ownership by the profession and the feed into and out of professional ethics. The disadvantages are that it looks like doctors judging doctors and I think he has agreed with what the National Consumer Council said recently, that the key is to try to get the best of both worlds, by transparency and openness and lay involvement. If we can build even more on that, that is what the GMC would like to do.
284. Are there any current proposals to look at the balance between the medical and lay membership to alleviate the anxieties which clearly exist among the public that self-regulation is not working? The perception which was put on the record by one witness, as I recall, was "GMCgreat medical cover-up". Now he has particular grievances which are understandable, but there is certainly a perception abroad that the system is not working, that the system serves the interests of those whose practice, as opposed to the people on the receiving end of that practice. Are you looking at the relationship of balance between the two elements to address this issue with a view to possibly changing the relationship between lay and medical members?
(Miss Nisbet) What we are doing, as the president announced in 1995, is a thorough review of every part of the fitness to practice procedures. There are researchers who are looking at all the screening at the moment and beginning to look at the Preliminary Proceedings Committee , and there is a large policy report on the professional conduct committee which was considered by Council recently in May. There are no firm proposals which have come out of that yet about the numbers of lay members, but lay involvement and the transparency of the processes of each part are completely being overhauled, and it is proposed to come back to Council in November with some more fundamental issues about the fitness for purpose of each part of our procedures and how we can make them more publicly credible.
285. Miss Lavin, can I put the same points to you, because the same concerns were expressed in respect of the overall professional regulation within health? How do you feel about this lack of confidence in self-regulation? Do you recognise the need to address that lack of confidence within the UKCC?
(Miss Lavin) Indeed we do, and the UKCC is in no way complacent about its duties in respect of justifying public trust and confidence. I share many of the observations my colleague from the GMC has made with regard to openness and scrutiny. We are here to discharge a public duty and if the public do not feel happy with it, then that is an important issue for us. It was precisely for that reason that we decided we needed to extend consumer involvement in our processes because, as I said earlier, consumers had been excluded from our health procedures. To some extent the Government has rather beaten us to it in that we have had a review of our statutory functions and there are proposals for a far smaller, strategic council, supported by panellists who would be drawn from a whole range of consumer groups and consumer organisations. So I believe we already have the future mapped out, although we are in the very early stages. That does not mean to say that we have to wait until that is fully implemented, there are steps we are taking at the UKCC to ensure the public are better informed of our processes. We have a very large register, 640,000, and the registrants themselves also express concern to us sometimes about the way in which we discharge our duties on their behalf. We will not allow a professional conduct committee to sit without having consumer involvement and, unlike the GMC, we do not have a screening stage before our complaints go to the full committee. Therefore we do have consumers in the process but there is a lot more we need to be doing. We have had initiatives. We have launched specific leaflets geared to the public, putting them in places like CHC offices, Citizens Advice Bureaux, so that people know we are there to complain to, but there is still more that needs to be done.
286. Could I ask a specific, question to our witnesses from the MDU? Is it possible to give a rough break-down from the figures you gave in your evidence as to how the work you do splits into the different members you represent? Clearly you do not just represent doctors but other professional groups. In the evidence you gave us you gave a number of cases but how does it break down on a percentage basis on a national basis?
(Dr Tomkins) The vast majority of our activities are for our doctor members.
287. The percentage?
(Dr Tomkins) Well over 90 per cent.
288. Before I bring my colleagues in, can I ask a couple of specific questions to the GMC particularly on the issue of referral to the GMC? One of the concerns I have relates to your different procedures, the three chunks of your procedures, which you outline as the conduct procedures, the performance procedures and health procedures. I am sure there is a clear explanation for this but I was not clear why the performance procedures did not relate to a person being struck off, you had to go through conduct procedures for that. Could you explain the distinction here because I think the public is as baffled as I am as to why when a doctor's professional performance is deficient, that cannot lead to that doctor being removed from the register?
(Miss Nisbet) I fully understand that and I asked exactly the same question when I arrived at the GMC. What the performance procedures can do is decide to suspend a doctor. He can be suspended for 12 months and then after another 12 months, if it is thought he should still be suspended, he can be suspended indefinitely, and that means he has to undergo a full performance assessment before he can come back. So that is a very, very severe penalty. Perversely, there are those who would say that suspension, particularly indefinite suspension, is a tougher fate than erasure. The difference is a philosophical one, I am told, that erasure is saying in the conduct procedures that that doctor did that thing in the past and it was so bad it means his name should be taken off the register, but in fact he can then apply for restoration after that. I would suggest to you that the two cases which have hitherto come to the Committee on Professional Performance, in both of which the doctors have been suspended for 12 months and reconsideration of that will be coming round, those are very, very severe events for those doctors indeed.
289. What I do not fully understand is the distinction between your performance procedures and what may happen in any event to, say, a hospital doctor who is suspended within his or her own employment with possibly some element of retraining there, some help given. What are the distinctions between what may happen internally within the employment of the doctor when that doctor is suspended or given garden leave, as it is described on occasions, and what you do within your performance procedures?
(Professor Thomas) If the doctor is suspended by their trust, that does not restrict them working in the private sector or working as a locum elsewhere or having other medical employment. If their registration with the General Medical Council is suspended, then legally they are not entitled to work as a doctor at all.
290. Which it would be if they were subject to the performance procedures?
(Professor Thomas) Yes. If they were suspended under performance procedures, they would not be allowed to work. In reality, doctors who have had very severe lapses in their performances have come through the performance procedures, probably for not having satisfied the criteria for serious professional misconduct, but nevertheless we know they are not a safe doctor, and the chances of them coming back on to the medical register and being rehabilitated if they really are seriously under-performing are relatively slim. If they are not allowed to practise medicine, it is going to be quite difficult for them to be rehabilitated, but clearly we have to leave that possibility open if the doctor is capable of being reformed, which is really the aim behind the performance procedures. But I do not think that the public should have any great concerns over that distinction, because those doctors who are seriously deficient in their performance are very likely never to practise again.
291. Could you, from the GMC point of view, explain your understanding of the referral procedures where a problem may have occurred, say, within a trust? Would it be at the end of the day the medical director who would refer the individual case to the GMC? Who would be responsible? The chief executive within the trust? How would the procedures happen? What is the normal practice for referral to you, where we are talking about a hospital doctor?
(Miss Nisbet) First of all, a lot of complaints come to the GMC from members of the public, not from the hospital managers at all, in fact about 70 per cent of the complaints come from members of the public.
292. I am concerned specifically about referrals from hospitals.
(Miss Nisbet) About 20 per cent is from referrals from hospitals or NHS management or the police or some other public body. What would normally happen is that the medical director in many cases of a trust would either write or contact the GMC to say they were concerned about Dr So-and-So, either about a particular set of events or about the pattern of the doctor's performance, and they might be concerned he might be appropriate for performance procedures. Then the judgment is, is it time to come to the GMC or might there still be scope to do something locally to put it right? We have a help line which gets about 50 calls a month which doctors and medical directors can use to discuss that, and we give them a chance to talk it through in confidence with an experienced medical member of the Council. But the key, which is in our booklet called Maintaining Good Medical Practice, is that if they feel there is a pattern in the doctor's performance which suggests that patients are at risk now, then they should come to the GMC now. It is the patient risk which is the trigger point.
293. So the medical director is the key individual within a trust where it is a hospital doctor. One of the concerns I have had expressed to me is that the relationship between the senior consultants and the medical director is quite often a fairly cosy relationship. Are you satisfied that the medical director is sufficiently independent in such circumstances to initiate the procedures which you expect?
(Professor Thomas) It is not invariably the medical director, chief executives can make them as well.
294. I appreciate that.
(Professor Thomas) Our advice to trusts through the help line or through other mechanisms, is that often when we find out about a doctor and we uncover a cosy relationship where we find that the people concerned are not prepared to take the steps, we now take a much firmer line. We will often point out that once we know the facts, as Sir Donald will say, we cannot un-know them. We can also advise individual doctors who are concerned about other people, perhaps the whistle-blower scenario, who they might wish to go to with their evidence or with their examples to ensure it does see the light of day and is not suppressed locally. So I think the days when the medical director was in a position to suppress things are dwindling and probably shortly to be over.
295. In your evidence you referred to the fact that you would occasionally receive referrals from coroners directly from an inquest. That is correct, is it?
(Miss Nisbet) Yes.
296. Would there be any verdicts at an inquest which would automatically result in referral? You would expect a particular verdict to automatically result in a referral to you?
(Miss Nisbet) What I am going to do is say what I think now and then reflect further on it.
297. I appreciate that. If it is a difficult question, please reflect on it and come back to us.
(Miss Nisbet) The question would be if the coroner felt that because of what he had learnt about the doctor he was worried about that doctor continuing to practise. Whether there is any one thing that a doctor might have done which would automatically trigger that judgment, I find it difficult to say.
298. If the coroner established that the death was wholly avoidable as a result of what had gone wrong within the treatment process, would you expect there to be a referral by the coroner concerned to you?
(Professor Thomas) Yes, if the coroner had concerns. At the present time we are undertaking a major overhaul of many of our procedures and we have already arrived at the situation in certain clinical circumstances where we are describing screened cases as serious professional misconduct by definition, for example, dishonesty. There are already various categories and those categories are being broadened. We have not arrived at the point yet where there are certain criteria in a coroner's referral which would automatically result in referral, but from my own experience as a medical screener the vast majority of coroner referrals would go to the first stage, the Preliminary Proceedings Committee , and they would not under any circumstances be screened-out by the medical screener.
Mr Austin
299. If a trust, in the case of a hospital, or a health authority, in the case of a practitioner, was to take some disciplinary action on the grounds of conduct or performance, by suspension or whatever, would that automatically be referred to the GMC?
(Miss Nisbet) Not automatically. We are encouraging the management of the NHS to report these events much more quickly to us than they do. Many medical directors will do, not all do, and we think more should.
|