Select Committee on Health Minutes of Evidence


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.


 
previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries

© Parliamentary copyright 1999
Prepared 9 August 1999