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.
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