Select Committee on Health Minutes of Evidence



Examination of witnesses (Questions 420 - 431)

THURSDAY 1 JULY 1999

PROFESSOR HILARY THOMAS, MISS ISABEL NISBET, MISS MANDIE LAVIN, DR CHRISTINE TOMKINS and DR STEPHEN GREEN

  420. Does that mean that you frequently do if there has been a concern about, say, a unit?
  (Miss Lavin) Certainly on an informal basis the UKCC would approach the GMC just to make sure that we act as a safety net that the doctor has reached the GMC. Quite often we find people who think we are the GMC and we redirect them to the GMC. We do have very good working relationships. I would also say that extends not just between the GMC and the UKCC. I have certainly had a situation recently where I have had concerns about a pharmacist and approached the Royal Pharmaceutical Society. We have got very well developed links with the Health Service Commissioner's Office because clearly there are matters that fall into the jurisdiction of the Ombudsman that we also scrutinise. It does operate well. That is not to say that there is not room for some further work in terms of consolidating some of the lessons that can be learned from all of our cases.

Mr Amess

  421. Would you tell the Committee how the NHS and regulatory bodies work together when lapses have occurred and disciplinary action has actually had to be taken?
  (Miss Nisbet) When an event has occurred which leads to a judgment that the doctor could be a danger to patients then the NHS manager or doctor who has made that judgment has a duty to inform the GMC. The question which has been partly touched on but raised in a slightly different form is whether that is foolproof and the answer is it is not. We and the Government are in discussion about how to make sure that any gaps are plugged. The Chief Medical Officer is particularly concerned to pull together the various threads of what happens when things go wrong to make it more effective. The GMC is fully in support of that exercise.
  (Miss Lavin) I think the situation is that it can be quite hard to make sure it always happens but we do try to inform the NHS about how we operate as a regulatory body. I think I have stated in evidence on behalf of the UKCC that many members of the public perhaps believe that when there has been local disciplinary action there is some automatic mechanism that operates that means we will get every case and that is not the situation. Fifty per cent of all of our cases are coming from NHS managers. That is not to say we are getting everything we should be getting but overall the NHS is becoming far more responsive to its responsibilities. We have noticed a shift in terms of availability of information and responsiveness to the regulatory body. That is not universal. I can think of a trust I have written to recently on behalf of the Preliminary Proceedings Committee about which we have got serious concerns about systems failures. I wrote a letter to the chief executive outlining the concerns of the committee and asking for an assurance that these had been scrutinised and that there had been some remedial action taken. I received a letter back saying he was expressing surprise that the UKCC should have such an interest in the day to day activities within his NHS trust. I wrote back to him and invited him to come to the professional conduct committee and sent him some of our standards leaflets and the code of professional conduct. I have yet to hear from him again but I may go and pay a visit very shortly to his trust for a seminar with his practitioners. That identifies that perhaps the culture of collaborative working with the regulatory body may not exist in all parts of the NHS.

Dr Stoate

  422. Could I just ask the Medical Defence Union, what do you think about the present disciplinary procedures, both with regard to nurses and doctors? Do you think they currently work properly? Are they good? Are they bad? If you could change them, in what way would you change them?
  (Dr Tomkins) Our experience is largely with the disciplinary procedures as they affect doctors and as they affect hospital doctors although we do have some cases of disciplinary procedures involving general practitioners. As they affect hospital doctors we find that trusts do not always follow the same procedures, there are local variations on HC(90)9. The ways in which procedures are followed are patchy and the question of what is professional conduct, professional competence, and the question of what is personal conduct can be confused.We also find that the use of the informal suspension without adequate explanation of what the allegations are is something which some trusts resort to and that the time limits which are applied are not adhered to. What we would like to see is a fair, transparent, disciplinary procedure which is applied consistently across the NHS and which sets clear timetables which are properly adhered to and which provide the doctor with details of the allegations which he must answer early in the procedure.

  423. Do you want fundamental change or do you just want the current regulations tightened up and made more uniform?
  (Dr Tomkins) The current regulations under HC(99, when they are properly applied, work reasonably well.

  424. So you are happy with the arrangements as they are but you would like to see them more uniformly applied?
  (Dr Tomkins) Yes.

  Chairman: Any other questions?

Audrey Wise

  425. Yes. Dr Green mentioned that he thought the new complaints procedures had been a "success". Can you tell the Committee whether that is from the point of view of the patients or from the point of view of doctors and why you think they are a success?
  (Dr Green) I think it is from both points of view actually. I think the primary reason for introducing the new procedure was that the old one was seen to be unsatisfactory and did not provide patients with explanations, it was slow and bureaucratic. The new procedure, which has been in place for three years now, does seem to work more swiftly. It has enabled patients to get explanations and to understand what has gone wrong. Our own studies of the numbers of cases that come to us are that 90 per cent, and that is both in general practice and in the hospital sector, are resolved at local resolution. Very small numbers actually go on to the independent review panel stage.

  426. I am interested because of course it is at this stage, after the new procedure has been in being for three years, that this Select Committee has felt it necessary to do an inquiry. Have any of our other witnesses any views on the new complaints procedures? Does it impinge on your work in any way?
  (Miss Nisbet) Yes. The GMC does receive references which result from a complaint, either from a complainant or from the trust or the health authority. What we would say is if better local resolution can mean that matters get sorted out sooner then that is to everybody's advantage. The GMC has agreed that. If you asked us how we felt the procedure was looking from our vantage point, which is a very particular one, it is quite early days to say. There do appear to be slightly more worries about local resolution in general practice than in the hospital sector. There is the whole question of the independent review process which is a question mark, not quite as independent as it purports to be. Also, I would say from the GMC's point of view that sometimes we do get information after a local inquiry of some kind, whether it is a complaint or some other ad hoc inquiry, where the inquiry has been so informal and so quick that it in fact has not followed any kind of fair processes at all, our solicitors have advised us that we cannot use it because it would be destroyed if we tried to sue, so we have had to start again and that is a pity. I do think there is an issue about fairness and reasonable due process at the earlier stages if we are going to be able to use the material from it.

Chairman

  427. Miss Lavin?
  (Miss Lavin) Just to say, in summary, in the cases that we do see I think it is fair to say that there are occasions when people do have a frustration with some of the time factors. I think the limits that are imposed may sometimes be ambitious and when they are not met people feel disappointed. It is not a requirement of referral to us that somebody has necessarily gone through the NHS complaints system.

  I would also say some of the reports of the independent review panels that I have seen have been of very poor quality, some have been very fine and have assisted greatly and others have almost frustrated our cases.

  428. We have had evidence from people who instituted inquiries that they felt badly done to in the arrangements, so I am not surprised at what you have said. I was going to follow up about GPs. There is a piece of evidence that has come in to us from a user organisation which mentions GPs and it says about the change that GP practices are now supposed to deal with their own complaints whereas previously it was managed through the health authority: "In our experience and in the experience of many community health councils, complainants are appalled that in the first instance they are supposed to take their complaint to the practice itself". It goes on to say that the fact that it is dealt with inhouse has important implications for quality of care in that the health authority is no longer the central collecting point for the complaints and therefore does not necessarily know what complaints are building up, it lacks the knowledge base that it used to have. Would you have any comments on that kind of point?
  (Miss Nisbet) There are occasions when people come to the GMC because they are reluctant to go to their GP because they are wanting to continue an ongoing relationship and you are going right back to the person who you want to complain about whereas with a hospital it is a slightly bigger organisation and less personal. Also some of the experience I had working with the Ombudsman did back up some of these concerns. There are some effective mechanisms for trying to help that through particularly the use of conciliators which probably started in general practice and where they have been called in at a very early stage that has often worked quite well, the earlier the better. There have been some positive lessons there.
  (Professor Thomas) We do get referrals from the CHCs in some situations, such as the one you have described. The second point to make is that in the time that the complaints procedures have been in place the number of complaints to the General Medical Council has risen quite significantly and it is going up regularly approximately every six months in the year and continuing to rise.
  (Miss Nisbet) There are over 100,000 complaints in the NHS in England in the year and 3,000 in the GMC.

  429. Obviously it is nobody's wish to disturb people's confidence in the health professionals because that would not be to anyone's advantage. Clearly we are dealing with a minority of problems. For myself I think that it is greatly to the advantage of the professionals if the complaints procedures and all the procedures when things go wrong are as good as possible, that is the best way to maintain confidence. One problem with GPs is that at the first hint of any disquiet on the part of the patient, when the complaint is a twinkle in the patient's eye, as it were, the patient may well find that he or she and their whole family are immediately struck off and GPs can do that without giving an explanation. Do you think that is a fair balance of power between doctors and patients, particularly in view of the fact that for the doctor a patient more or less or a family more or less is not of a lot of consequence whereas it might be the only medical practice within reach? Do you have any views on how GPs should take an attitude to this?
  (Professor Thomas) We have not. We have written guidance about the approach that doctors should take. If the relationship between the doctor and the patient, or the patient's family, has broken down to such an extent that it is irretrievable we may well take the view that it is in both parties' interests. The doctor has an obligation to ensure that alternative care is available to the patient, so they are not in a position to remove people from their list if they are in a remote part of the country where there is no alternative care available. In the case of doctors where they have viewed the entire family where they have taken quite a dim view, whether that would satisfy the criteria of serious professional misconduct or not is questionable. If you have a pattern of behaviour on the part of a general practitioner who was removing all the extended family of an individual patient we are likely to refer a situation such as that beyond the screening stage certainly.

  430. Thank you.
  (Miss Nisbet) Can I add, Chairman, that in its recent edition of Good Medical Practice the General Medical Council emphasised that normally a doctor should explain to a patient why he has judged that the doctor/patient relationship should end because that confronts straight on the other aspects of the events which Mrs Wise was referring to when traditionally under the terms of service GPs had no requirement to explain why. It is set here. That actually has made a big difference because, as the Deputy Ombudsman, we often came across GPs who said they were not members of the Royal College or the BMA, so why should they be interested in that kind of guidance. They cannot duck the guidance from the GMC. That was really quite an important change which came in in 1998.

  431. 1998?
  (Miss Nisbet) Yes.

  Chairman: Anybody any further questions? Are there any further points any of our witnesses wish to make or clarification? Can I therefore thank you for your co-operation, once again for your written evidence and your willingness to go on with the session today, it has been most useful.



 
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