Select Committee on Health Minutes of Evidence


Examination of witnesses (Questions 580 - 599)

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.

  580. I think that would be very sound. On the other hand, it would be very helpful if we had a new system for investigating poor performance.
  (Mr Dobson) Yes.

  581. But there was a bit more clarity about who would deal with what because at the moment I think it is jeopardous for the professional and totally confusing for the patient in their care.
  (Mr Dobson) Yes, I quite agree.

Julia Drown

  582. Secretary of State, you mentioned recently whistle blowers and that you were trying to change the instructions to the health service so that people could report their colleagues. Do you agree that it is still ,in many NHS organisations, very difficult for professionals to blow the whistle and to report on poor performance? We have heard that often people still feel they might be victimised or that they are being disloyal to their particular trust or the NHS institution that they work for. Do you agree with that interpretation and how do you want to deal with that problem?
  (Mr Dobson) It should be partly dealt with by the Public Interest Disclosure Act. That applies to the National Health Service just as much as anywhere else. That should encourage a change of attitude. We have just got to get over to people that providing they go through the proper machinery then it is their duty, it is not just something they might think about doing on a good day but it is actually the duty of a fellow professional first of all to draw attention to their colleague about whose performance they have some doubts, but not do it behind their back and not necessarily seek publicity from it, and then to go on. As I understand it there is a requirement set out by the General Medical Council that it is professional misconduct for a doctor to withhold information about the poor performance of a colleague. As I said earlier, there is always this problem of people feeling loyal to colleagues and so on, which is a good human characteristic which we normally encourage, but people have got to recognise that there are limits to it. What I feel is if we can put in place the machinery for logging things that go wrong in a non-accusatory way then the prospects of a colleague saying "your figures really are a bit rough, you ought to do something about it" will be greater if we can get in place the sorts of things that Professor Donaldson's expert group are looking at at the moment.

Mr Amess

  583. I apologise at the outset because sometimes in these evidence sessions I drift in and out of consciousness, so if some of my questions have been asked I do apologise. Over the last two decades it seems to me that when things go wrong in the health service the media seize on them and the Government of the day is blamed, perhaps unfairly, and then the health service is seen to be failing. When your officials came and gave evidence on 17 June, it is there in the record page 31, I was just a little bit surprised by their relaxed approach to it all. It seemed to me at the end of the day that they did not really bring too much to our evidence session. The first thing I wanted to ask you is these are very, very difficult issues to deal with but is this a real priority for the Government?
  (Mr Dobson) Mr Amess, you were obviously asleep right at the beginning because I did say that the official evidence was intended to be purely factual. I thought it best that both myself and the Chief Medical Officer, who are perfectly entitled to express a point of view which officials are not really, that was the best way of dealing with it so that is what we want to do. We want to give very high priority to dealing with this matter because it is very harmful to the limited number of patients and their families who suffer, it is immensely damaging to the reputation of the medical and nursing professions, and it is damaging to the reputation of the Health Service. I think it is just silly to have a system whereby procedures are harming the Health Service and the profession. It cannot be good for anyone that at the end of some of these laborious processes where there have been four or five investigations into one set of events and neither the clinician complained about nor the person making the complaint is satisfied. That is just potty.

  584. Given all of that, you do recognise that your answer about professional self-regulation is going to disappoint a number of people in all sorts of ways but perhaps we will not dwell on that—
  (Mr Dobson) Can I just say I do not give answers because they may appoint or disappoint people, I give my honest view of things and if anybody can suggest a better way of regulating the clinical professions than one that is based on a sound form of self-regulation I would be prepared to listen but I have never heard of one.

  585. From my point of view one of the joys of being on the Select Committee is I am here to ask the questions and not actually to give the answers. We received a letter on 12 July from Jim Fowles, the Parliamentary Clerk, and he said: "We have not been able to identify any central guidance on handling of incidents which may require the recall of particular categories of patients." I wondered if you thought that was in order?
  (Mr Dobson) No I regard the whole set of arrangements as a bit of a shambles and in particular I think that the non-accusatory side of things virtually does not exist and so the whole of this matter is looked at in the accusatory, blame mode which is not very useful. It is useful from the point of view of sorting out wrong doers and it may be useful from the point of view of the person who has got a complaint and a very serious complaint but it is not very useful in terms of stopping things happening again and so the bed rock of activity, the fundamentalist activity that Professor Donaldson is looking at now in getting in place machinery that logs everything that goes wrong whether anybody complains or any patient notices, looks at that, gets the data together, analyses the data, makes it available to people and then in certain circumstances, as you are suggesting, leads the management to then approach a category of patients and say, "Can we talk to you again about this because on the evidence that we have got you may not have been treated quite properly."

  586. So your answer would be the same to his third point where he says: "There has been no central guidance issued specifically on the NHS's responsibilities in terms of supporting and providing information to patients following an adverse incident"?
  (Mr Dobson) I would not be sure about that.

  587. I was surprised when I read it but, there you are, it has come from the Department on 12 July.
  (Mr Dobson) I am quite prepared to believe it because the situation is generally unsatisfactory.

  588. Right. You said something earlier that problems start at a lower level and you felt that that was endemic and again that puzzled me really. Again, okay, you have inferred I was asleep at the start, perhaps I have been asleep throughout the whole thing, but were you implying that if someone comes in and they see a ward orderly and they are a bit off-hand or there is not somewhere available that they go away with the impression that things are not too good and then it builds up because it does not quite make sense that when the consultant has got the thing wrong or the doctor has got the thing wrong? Do you mind enlarging a little bit on what you meant by problems starting at a lower level.
  (Mr Dobson) I think we were talking about people having trust and confidence in the General Medical Council and the UKCC and my view was that it would be a pretty hopeless task to try to convince somebody that they could have faith in this collection of doctors or that collection of nurses, although there are lay people on both bodies, if they had already encountered a cover-up approach by the clinician who had been complained about and they had the feeling that the other clinicians locally and the management locally were also covering up. It would not be human nature really for them to then develop a trusting attitude to another collection of doctors or another collection of nurses. That is why I think not all but most of the doubts which people have about the General Medical Council or the UKCC as a fair and independent bodies springs from their poor experience of what has already happened to them.

  589. What role do the regional offices have in developing good practice in complaints procedures or what plans do you have to enlarge this role?
  (Mr Dobson) Rather against, as I understand it, the views of the official Opposition we want to strengthen the role of the regional offices of the National Health Service Executive in almost every way and certainly I would expect that if the independent review of the complaints system suggests that further action needs to be taken to improve the complaints system, then I would expect that the regional offices would have some supervisory and monitoring function to make sure that the trusts and health authorities and so on in their area do that and, similarly, with any changes that follow from what Professor Donaldson is doing I would expect them to have a monitoring role there as well.
  (Professor Donaldson) If I could add briefly. I do not think we have had the opportunity to be absolutely explicit about this untoward incident aspect. The complaints, as I have said, are one thing; the disciplinary procedures for doctors are another thing. The subject of untoward incidents, which I think was a reference to the 1950s, was looked at again when Sir Cecil Clothier undertook the inquiry into the nurse Beverley Allett and he recommended at that time that regions should receive reports from trusts and health authorities of untoward incidents. That was at the time of the NHS reforms when responsibilities and accountability within the Health Service was changing and regions were no longer responsible for overseeing trusts so the system was slow to come in but each region does have an untoward incident reporting system and in my old region, the Northern and Yorkshire region, we received about 200 every year. About 50 per cent of them were mental health related and the other 50 per cent were other areas of medical services, hospitals, acute and primary care, and so on. The expert group that I am leading will be commenting on that system. Already we think it is not adequate because it does not have sufficient analysis in it. It is not comprehensive enough but those incidents do come through. In my old region it was 200 a year, there are eight regions, so we are talking about 2,000 incidents. On top of that the Secretary of State said that there is going to be the yellow card system for adverse reports of drugs and there are the Medical Devices Agency reports of harm results from faulty equipment or misuse of equipment, and there are several thousand of those every year. So there are systems in place, it is just that they probably do not really do the job that they should do. We do have some information and that is where the regional element of it fits in.

Mr Gunnell

  590. Professor Donaldson, a bit earlier you talk about the need, if possible, to prevent some of these untoward incidents occurring in the first place and you talked about the level of scrutiny of those who practise overseas when they come to this country. Is that a general concern that you have? Are people appointed without the proper scrutiny when they come on the basis of their overseas' practice?
  (Professor Donaldson) I did not actually comment on the position of overseas' doctors. I was really thinking of two instances in my personal experience and some of the cases I have looked at in my own region. I actually wrote 50 cases up in the British Medical Journal in 1994 of poor clinical performance and I saw many more cases of a more minor nature and advised trusts on how to deal with them. There were a number of cases where, for example, somebody had been appointed to a consultant post where there were weaknesses in their practice when they were trainees but the appointments committee was keen to get them off the training programme and was willing to cast aside any reservations they had in order for them to be appointed as a consultant. Those cases are not common and hopefully now our new training scrutiny procedures cover that but in the past it has undoubtedly been the case that some of the problem doctors we have encountered should never have been appointed to consultant posts in the first place. I think there is a separate narrower issue about the position of the doctor who may have had problems in another country, been struck off the register in another country, who then comes to the United Kingdom and is appointed. In the past the General Medical Council has not always had reciprocal arrangements for dealing with such a case so they have been entitled to practise in this country where they have been struck off in another country. I know that the Secretary of State has looked at this matter recently and he has asked that all NHS appointments procedures should ask for the candidates to make a declaration, just as they have to do about any criminal offences, as to whether they have been the subject of any investigation by a licensing authority in another country. If they sign such a declaration and then are subsequently found to have covered up they would be sacked.
  (Mr Dobson) They would also be prosecuted under the Theft Act for obtaining financial advantage by deception.

  591. Thank you. I think it is likely that in this account you wrote you probably referred to one of the cases that we encountered where we met a group of patients whose complaint bitterly was against the trust in question employing the doctor they were complaining about because they said he had been struck off previously in two Canadian Provinces and, therefore, they felt he should have been scrutinised more carefully before he was appointed to his present post. I presume that you would take the same view that these patients took?
  (Professor Donaldson) Yes. That was not included in my article because it presented relatively recently, after I had written up the case series. In my view, and I have knowledge of that particular case, the regional health authority at the time, which was the Yorkshire Regional Health Authority, when it discovered that the doctor had been struck off the register in another country should have acted at that stage.

  592. They should have intervened on the trust's appointing procedures, should they?
  (Professor Donaldson) In that particular case at the time it was in the era when the consultant contracts were held by regional health authorities, so at the time the doctor was an employee of the authority to whose notice it came that he had been struck off in another country, so they had the powers to act on that. They also had the powers to take the view that he had concealed that information at the time of his appointment and that it was improper for him to have concealed that.

  593. Therefore, in a sense you would be giving advice now that if such a person were recommended for appointment their previous record would have to be known and would have to be followed through?
  (Professor Donaldson) As I have said, the Secretary of State is placing a requirement on the health service that doctors have to make a declaration about any interference or any investigation with their licence to practise in another country when they are applying for an NHS post, just as they have to declare any criminal offences.
  (Mr Dobson) I am glad to be able to say that someone came to my advice service to complain that they had been refused an appointment on the grounds that they had some dodgy record abroad, so I am glad that the system is working.

  594. Is there sufficient co-operation between the registration bodies? Would the GMC automatically receive notice of suspensions from registers overseas?
  (Professor Donaldson) No, they have not in the past and that has been a problem in cases such as the one you have referred to. That particular case has been referred to the GMC and I, on behalf of the Secretary of State, have drawn the attention of the GMC to this problem and that it is a loophole in procedures. Hopefully the belt and braces of placing a requirement in the application form is a solution.

  595. Hopefully there will be co-operation between the GMC here and equivalent bodies in other European and Commonwealth countries?
  (Professor Donaldson) Yes.

Mr Burns

  596. Can I just very briefly ask, do all countries in the rest of the world have procedures like the GMC or is there a potential loophole in some countries that may not have such a sophisticated system of administration? Where they do not have that sort of system they would not have to fill in a form saying they had been struck off because they would not have been struck off because there was not that sort of system.
  (Mr Dobson) There would not be anybody to strike them off.

  597. Yes.
  (Mr Dobson) My understanding is that most countries in the developed world have some similar system.

  598. What about in the developing world?
  (Mr Dobson) And some in the developing world will do as well and will do it very vigorously but I believe that there are places where that does not apply.
  (Professor Donaldson) They would still have to be licensed to practise in this country anyway, so it would not be that a doctor who was not licensed properly in his own country could come into this country without being licensed by the GMC to practise here. You would only be looking at a situation where the doctor was licensed to practise here, had been struck off in another country and we did not have knowledge that he had been struck off.

  Chairman: Secretary of State, I know you have to be away by six o'clock and we have a number of questions still to pursue. Can I ask colleagues to be very precise and sharp in their questions and perhaps we can have brief answers from our witnesses.

Mr Gunnell

  599. We have heard during the evidence of the practice of having patients' advocates which some trusts employ but many trusts do not. Do you have any intention to evaluate and judge whether the appointment of patients' advocates is something that you would recommend?
  (Mr Dobson) All of them should have a complaints manager, that is a requirement on all the trusts. Some of them are trying out other various forms of carrying out that activity. I am very happy to look at how the patients' advocate concept is working because there are so many things wrong with the present system that anyone who is trying to improve it needs to be taken seriously. We need to look seriously at any propositions that come up. We need to look at them rigorously as well because they may not work, they could make the situation worse, adding a complicating factor unless it is done carefully.


 
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