Examination of witnesses (Questions 553
- 559)
THURSDAY 15 JULY 1999
THE RT
HON FRANK
DOBSON, a Member of the House,
Secretary of State for Health, was further examined, and PROFESSOR
LIAM DONALDSON,
Chief Medical Officer, Department of Health, was examined.
Chairman
553. Colleagues, can I welcome you to this session
of the Committee and particularly welcome our witnesses. Secretary
of State, would you briefly introduce yourself and Professor Donaldson?
(Mr Dobson) I am Frank Dobson, Secretary of State
for Health, and this is the Chief Medical Officer, Professor Liam
Donaldson.
554. May I begin by thanking you once again
for the written evidence that has been submitted to this inquiry;
we are very grateful for your co-operation. Obviously we recognise
that the Health Service has a good record in terms of successfully
treating vast numbers of people every day and this inquiry is
concentrating on where things have gone wrong, so clearly evidence
has been skewed in the direction of where things in some instances
have gone very badly wrong. I think the first area I want to ask
you about is that it has not just been a matter of things going
wrong, but the problem has been compounded for many people by
their experience of the complaints system, the grievance system
where people feel very badly let down by the lack of appropriate
systems to deal with their grievances. The system to me appears
to be something of a mess. Would you concur with that and if so,
what thoughts do you have on what we can do to improve it?
(Mr Dobson) Can I say, first of all, that the written
evidence which was submitted was intended just to state the facts
of the present situation because I thought that it would be better
if Professor Donaldson and myself expressed our views on the existing
state of affairs directly in evidence to you rather than to put
it in writing. As you know, my general approach to the question
of things going wrong in the Health Service is that we have got
to do whatever we can to stop them happening in the first place
and so that is why we have put a very substantial amount of effort
into setting in train measures which we hope will help reduce
the number of things that go wrong, with the National Institute
for Clinical Excellence, introducing the duty of clinical governance
and so on. My own view is that that is putting into practice a
process of trying to identify best practice and spreading it.
There has not been that machinery in the Health Service up to
now and we are trying to put that in place, but equally there
is not in place any systematic arrangement for identifying everything
that goes wrong and logging that information and then analysing
it and making it available to those, either managers or clinicians,
who could learn from it. Therefore, I think that one of the things
that we have got to do is to put in place a system that identifies
not just the things that are complained about, but that whenever
there is any adverse clinical incident, the information is made
use of so that people do not have to make their own mistakes,
but they can learn from the mistakes of others and we do not have
to wait for something to go terribly wrong before it is noted.
This is in line, say, with the approach of the airline industry
which does not just note crashes, but it notes near misses and
their causes and then tries to take action to avoid near misses
between disasters, so although there is some machinery at present
for collecting some information on those lines, the regional untoward
incident reports, the Medical Devices Agency gets reports if equipment
has failed and harmed a patient and the Medicines Control Agency
gets things under the yellow card system if there are adverse
effects of drugs, but, by and large, the present system only takes
seriously accusations and I think that that is a major failure.
Therefore, the Chief Medical Officer at the moment has got together
this expert panel, including people from other industries, say,
people in the North Sea oil industry and the aircraft and airline
industry, to see whether we can put in place a system which picks
up all the things which go wrong and then tries to make sure that
everybody learns from all the things that go wrong, whether they
are complained about or not. My own view is that the present system
is a mess.
555. You have given a general outline of broadly
the direction the Government intends to go in. Have you any specific
ideas on the mechanics of a new system, taking account of the
points that you have made at this stage, how it would work in
practice?
(Mr Dobson) Well, one of the reasons why we have got
the Chief Medical Officer consulting these various experts, both
internal and external, is to get some ideas no doubt better than
any that I could think of, or at least I hope so, and he is also,
we expect, to produce a consultation document on how to deal with
cases of doctors who either temporarily or permanently are not
up to it, and that document should be published fairly shortly.
My own feeling looked at partly from the point of view of the
patient, but also partly from the point of view of the clinicians
who may be complained about is that the present system really
is a bit of a shambles and quite frequently there are several
inquiries into one incident and they are lengthy, they are frustrating
and at the end of it all none of the people concerned, neither
the person complained about, nor the patient, nor the patient's
relatives, is satisfied, and if you have got a long, protracted
and expensive process that satisfies nobody, there is clearly
something seriously wrong with it and I think overall that there
is.
556. Professor Donaldson, do you want to add
to that?
(Professor Donaldson) Yes, if I could briefly, Chairman.
I think I would like to draw a distinction between four aspects
of the problem and I think each has got different areas of weakness.
The first is the clinical complaints procedure itself which I
know that you will have taken evidence on, that was revamped four
or five years ago and it is currently being evaluated again, but
there does not seem to be heavy dissatisfaction with that, although
people do have criticisms of it. The second is the ability of
the Health Service to detect untoward incidents, as the Secretary
of State has said, serious incidents where patients are harmed,
nearly harmed or sometimes die, and we have various systems of
data-recording that throw light on that problem, but none that
captures it systematically and helps us to learn lessons from
it, and we do see evidence of history repeating itself sometimes,
similar incidents recurring sometimes in the same place, sometimes
in different places, so there is a serious weakness there. That
is, as the Secretary of State has said, why I have been asked
to chair this panel, called "Learning From Experience",
and we are about half-way through our work and should report by
the end of the year. Thirdly, there is the question of poor practitioner
performance and that may or may not be the subject of a complaint,
but it is obviously the subject of a concern, and there have been
procedures in place, NHS disciplinary procedures, for some time
and there are, in my view, quite serious weaknesses with those,
and that is the purpose of the consultation paper, to produce
some new mechanisms to resolve all the problems there. Then, fourthly,
there is the more general question of services performing under
par over time in a way that is really only detectable by strengthening
the sort of data we have to monitor quality and make comparisons
between services. So those are the four areas as I see the problem
and if I could just add briefly, I think the solutions should
be built around prevention, early recognition of problems and
then fast, effective and fair ways of resolving problems when
they do occur. Then, finally, the one lesson I have learnt from
quite a long experience as a regional director and seeing the
sort of problems that cropped up in the region and now as Chief
Medical Officer is that most problems are a mixture of individual
error and what in the jargon is called "systems failure",
so when a junior doctor gives the wrong dose of a drug to a patient,
yes, there is an individual error there, but it occurs in an organisation
where perhaps there has not been proper training, there are not
proper protocols in place or there is not proper supervision.
I think in the past we have sometimes tried to look only at the
individual error factors and not sufficiently at the environment
which predisposes somebody to commit an error or make a mistake.
557. If I have understood your answer correctly,
you said that in terms of clinical investigations, there was not
a lot of dissatisfaction with the present scheme. I think I understood
what you said, but what I would say to you certainly from the
evidence we have got is that there is, I think, very grave concern
about the question of self-regulation and the concept of self-regulation,
and certainly grave doubts about whether it is appropriate for
the current system to continue and the perception, rightly or
wrongly, among many of the people we have talked to is that doctors
are covering up for doctors' mistakes and it is all a kind of
cover-up where people cover up for each other. Now, I am not saying
whether this is or is not correct, but it is certainly the perception
among many of the people we have had in front of the Committee
and met as a Committee that this is the case. Do you feel that
there is, and I put this question to both of you, a need to review
the current concept of self-regulation both in terms of the GMC
and the UKCC if there is a lack of public support, public confidence
in that concept of self-regulation?
(Professor Donaldson) Well, if I could just maybe
emphasise the point that I made earlier, I only commented other
than negatively on the clinical complaints procedure, not on the
process of investigating poor performance or concerns about doctors.
That was in my third category and I think there are serious weaknesses
in that, but, as you know, the complaints procedure per se
is governed by a lay convenor and a lay panel and it does not
have any professional self-regulation element, so I was saying
that that had been changed relatively recently and it still has
to be evaluated, and there have not been very serious criticisms
of that so far, although clearly it could be strengthened. However,
I think the other areas, particularly dealing with poor clinical
performance, I would agree with you that there is a need for major
reform there.
(Mr Dobson) I agree with what the Chief Medical Officer
has said, but I have to say we have got to have a system which
commands the support of two groups; it has got to command the
support of the professions concerned and the public. My own view,
for what it is worth, is that the basic concept of professional
self-regulation is right, providing it is carried out properly
and the machinery is effective and it can carry conviction, if
only because I cannot imagine any other way of regulating it without
a substantial element of involvement of the profession. If we
want to try and set some standards for heart transplants, then
I personally would wish to start from someone like Sir Magdi Yacoub
rather than the editor of The Guardian or someone from
the Consumers' Association. We need a lay element in there and
I think that the present procedures, the combination of the inadequacy
of the National Health Service's procedures and their almost sort
of geometric progression relationship with the GMC as well, which
is overloaded, mean that the present system is unsatisfactory,
but I do not think that the fundamental concept of self-regulation
involving a lay element is wrong, but there are lots and lots
of things wrong with the way it is working at present.
558. Do you think that the balance between the
lay element and the medical element or the nursing element on
those two bodies I have referred to is correct or might it be
looked at, might it be addressed differently in some way? Broadly
what you are saying is that you are satisfied with the concept
of self-regulation, but looking at the perception that we have
picked up, the lack of confidence in that, how do you feel perhaps
that lack of confidence might be addressed in relation to the
make-up of both of those two bodies?
(Mr Dobson) Well, I do not think it is entirely related
to the GMC and the UKCC. I think a lot of the dissatisfaction
starts at the place where the incident happened and the feeling
that there are people just sort of covering up for one another
and that sort of thing. Everything in this world is a matter of
judgment and some sort of loyalty to one's working colleagues
is generally regarded as an admirable characteristic in most places
of work and I think it should be within the National Health Service,
but there are boundaries to that and it is quite clear in some
cases that people have gone well beyond the boundaries in backing
up a colleague and there are cases where quite clearly a number
of people have been involved in covering up what has been going
on or averting their gaze from things that they are concerned
about. I think that most of the dissatisfaction, therefore, sort
of gets started at that level and once people feel that they cannot
trust the professional judgment of one group of doctors, they
are not likely to think that they can trust the judgment of another
group of doctors, or nurses for that matter.
559. So you are basically saying that the dissatisfaction
in terms of self-regulation arises from lower down the order effectively
rather than actually the functioning of the GMC or the UKCC?
(Mr Dobson) My feeling is that it is initiated at
a lower level and once it has been initiated, it is very difficult
to convince somebody who feels that either they or a relative
of theirs has suffered at the hands of a paid member of the medical
profession or the nursing profession and that they then have not
got straight answers from the person directly concerned or from
other people who are in the same profession in that same place
or from the management in that area. Once you have got to that
state of disbelief, then people would be super-human then to look
at the General Medical Council or the UKCC and think that they
were going to be a fair and independent body, so I think the rot
sets in there.
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