Examination of witnesses (Questions 600
- 619)
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.
600. The use of that system seems to be somewhat
haphazard as to whether the trusts use it or not but certainly
some patients find it very helpful. Another means of advising
patients is the Association of Community Health Councils think
that it should become a statutory duty for them to help patients
who wish to complain but they need to be given the proper resources
to do this. Do you think they are a suitable vehicle?
(Mr Dobson) What I said to last year's annual conference
of the Association of Community Health Councils was that as a
large number of things have been done within the health service
now which impact upon the tasks that they have been carrying out
for want of anybody else to carry them out then I would like some
of the things that we are proposing to bed down for a bit and
see how they work and then sort out what tasks remain for the
Community Health Councils to carry out. That might be one of them,
but only "might".
Mr Gunnell: Thank you. It does seem to me that
it often is very helpful to patients to have someone who can guide
them through the complaints system and there are possible ways
of doing it.
Dr Stoate
601. As well you will be aware, if someone complains
about their GP they have to approach the GP practice in the first
instance to make their complaint. Some witnesses have told us
that might pose a problem, particularly as they feel they might
be disadvantaged or somehow removed from the GP's list if they
do. Do you believe there ought to be a separate mechanism for
those patients who are worried about that or do you think the
current system works well enough?
(Mr Dobson) It probably does not work well enough
in a few places but it is difficult to contemplate how you could
come up with an alternative that did not involve the person complaining
going to the GP practice complained of. It might be, again thinking
aloud really, even if it counts as thinking, that it is a role
that the primary care groups might take on or might consider taking
on whether in their particular locality they would say if you
feel you cannot go to your GP maybe we could make some arrangement
to try to act as some sort of mediator, that sort of thing.
Julia Drown
602. A number of witnesses have talked to us
about their view that a lot of the complaints process is not impartial
and that is partly because the trust non-executive directors who
are part of that process who work as convenors are not seen as
independent. If the complaints process really is going to work
and be seen as independent, is it possible to have those non-executive
directors involved in that process?
(Mr Dobson) Most people appear to be satisfied with
the complaints machinery—
Julia Drown: Not the ones we have seen.
Mr Amess: Oh dear, oh dear, oh dear!
Chairman
603. What makes you say that, Secretary of State?
I find that rather surprising from the evidence we have received.
(Mr Dobson) When the Ombudsman has been looking at
it and producing his reports for the Public Administration Committee,
unless my recollection is wrong, he does not report dissatisfaction
by a majority of the people who use the machinery. What I was
going on to say, if I may, is if you have got some complaints
machinery, and let's suppose for the sake of argument then that
most people who use the machinery are satisfied with it, then
you have got to try to deal with the problems of the people who
are not satisfied with it but that does not necessarily disqualify
the machinery for the rest. So we have got to try to make sure
that the complaints machinery is satisfactory for everybody, that
I agree, but you do not necessarily start off from the point of
looking at the people who are dissatisfied with it.
Dr Brand
604. Do you not think that it would be helpful
not to call it an "independent" review panel because
people really do object when they find out that the members of
the review panel are non-executives of that very same trust or
recently retired members of that very same trust. I have had cases
where all three members of the panel have been closely associated
with department complained against. That clearly cannot be independent.
I think it would be much better to have a trust review process
and then people would know there is still another independent
stage through the Health Commissioner.
(Mr Dobson) We have established an independent review
of the complaints machinery involving London Health Economics
Consortium, Public Attitude Surveys and the King's Fund and we
expect that to report by the end of this year. I would hope that
that would be able to produce figures which show levels of satisfaction
and dissatisfaction and so on. I am quite prepared to change the
system if they come up with conclusions that there are things
seriously wrong with it and come up with propositions for changing
it. It has been in place for about three years at the most and
we have already set up the inquiry into it and I think we have
got to await the outcome of that inquiry.
Julia Drown
605. I do recognise we are going to get the
cases where it does not work but I think the Committee would feel
that those cases have been so serious that the review that you
mentioned just now is definitely required. We have heard a lot
about variations in performance and the operation of the independent
review panels. Will that review be looking at this and perhaps
recommending or imposing more formalised structures on the systems
so they are seen as genuine appeals, particularly the timescales?
We have had some really awful cases of people not being told for
months after an adverse clinical incident what really happened.
A look at the timescales in particular would be very, very helpful.
(Mr Dobson) It is a no-holds barred look at every
aspect of the complaints machinery.
(Professor Donaldson) I was involved for 12 years
at regional level with the complaints procedure and it did undergo
a fairly fundamental change three years ago. Before that time
the Ombudsman could not look at clinical complaints; he can now.
Before that time there were not lay members leading panels; they
can now. Before that time the patient did not receive the actual
report of the complaint, only a letter from the trust chief executive.
So there were a lot of changes introduced and I do think it would
be valuable to review it again. I am sure the Ombudsman if he
felt that the current system was a complete disaster would have
said so in his reports to Parliament. He has made a number of
constructive criticisms of individual complaints and I am sure
that when this review looks at these matters it will look at the
Ombudsman's reports over the last three years but I hope it will
be able to build on the changes that have been made and we will
not slip back to the position where for example the Ombudsman
could no longer look at clinical complaints because I think that
has been a very valuable improvement to the system.
Julia Drown: Not all the cases that have come
here have gone that far so perhaps we need to feed into that review
some of the cases that have come here.
Audrey Wise
606. What data do you publish on adverse clinical
incidents and outcome?
(Professor Donaldson) The data systems I have mentioned,
the regional systems, the yellow card reporting system and the
Medical Devices Agency system for faulty equipment. The Medical
Devices Agency and the yellow card information is publicised.
The Medical Devices Agency information is publicised both in annual
reports and also in alert bulletins that are put out after specific
incidents and the regional information is published when there
were investigations into the incidents. They are usually made
public.
607. Are you satisfied with the yellow card
scheme?
(Professor Donaldson) It is said to be the best system
in the world. Very few countries have a system for post-marketing
surveillance of drugs. That is the first thing to say about it.
It has received something like 350,000 reports since it was instituted
in 1964. The weaknesses of the system are that it is based on
voluntary reporting so probably seriously under-estimates the
true nature of the problem but it plugs in pretty rapidly to the
Committee on the Safety of Medicines so if there is a cluster
of reports about a particular drug it is drawn very quickly to
the attention of the Committee on the Safety of Medicines and
they are able to make an intervention. Undoubtedly the system
could be improved, but it would depend on getting data on drug
side effects which was not totally reliant on reporting by doctors
and nurses and pharmacists.
608. Like patients perhaps? Is that one way
that the data could be improved?
(Professor Donaldson) Certainly, yes.
609. The Medical Defence Union felt that the
data published by the NHS was not adequate, but I do not think
they gave us any steer as to how to improve it. Is it something
that you are looking at now or you intend to look at or you do
look at?
(Mr Dobson) It is not just that the data that is published
is inadequate, the data that is collected is not adequate, which
is why we are contemplating very large changes in the system,
so that there is more adequate data. Subject to anonymity I would
expect most of it to be published.
610. That is very helpful. While I am on the
Medical Defence Union, doctors have a professional code of practice
which requires them to report concerns that they have about colleagues
whose performance is under par, but it is clear from the evidence
we have received from the Medical Defence Union that, in fact,
doctors employed by the defence organisation exempt themselves
from that duty. Do you think that is right?
(Mr Dobson) It is my understanding that the General
Medical Council has said that it is a requirement for people to
report professional shortcomings and if it is then they would
be in breach of their professional duty, as I understand it, for
not doing so.
(Professor Donaldson) Could I just make the distinction
between doctors who are in practice and covered by the Defence
Union through insurance and doctors who are actually working in
a legal capacity within the Defence Union. The duty to report
is placed by the GMC on all doctors in practice. I could not say
how it would be interpreted for the small number of doctors who
are actually employed in a legal capacity within a defence organisation
responsible for providing legal advice to doctors, that would
be something that we would have to write to you on.
611. Can I suggest that you examine that because
it may be a small number of doctors who are in this capacity but
they do have access to more information than most other doctors
would have. I am referring to doctors who are on the medical register,
I am not referring to doctors who have taken themselves off the
register, they are registered doctors. I think the Committee would
like to know whether the Department and the GMC, but you can only
answer for the Department, feels that they are exempted from the
general professional requirement?
(Mr Dobson) I do not think that the Department's opinion
is that significant but I am certainly prepared to pursue the
matter with the General Medical Council.
612. Thank you. Do you think there should be
a duty on trusts and health authorities to refer cases to the
GMC if an Independent Review Panel report raises questions about
professional competency?
(Mr Dobson) Generally yes. I cannot envisage any but
there might be some odd circumstances in which it would not be
appropriate. Generally speaking there ought to be a presumption
in favour of doing that, yes.
613. Finally, the Department has very helpfully
supplied us with some extra evidence about procedures and it includes
procedures into the Clinical Negligence Scheme for trusts. I was
very interested to see that there are standards for clinical risk
management which have been developed by the Department and member
trusts are assessed annually against these standards and they
can have discounts from this pooling of charges if they meet the
standards. The aim is to steadily improve the quality of clinical
risk management across the NHS and to give some financial incentives
to those who do it well which seems very sensible. However, your
evidence goes on to tell us that it is not compulsory and by no
means all member trusts have yet attained the level one standard
nor is it compulsory that they should attempt to do so. Not attaining
is one thing. Not needing to attempt to do seems to me to be another.
Have you looked at that or have you any comments about it?
(Mr Dobson) There are two or three aspects of the
way we want that dealt with. When you talk about risk management
what you are talking about is reducing the risks by stopping getting
so many things wrong.
614. Of course.
(Mr Dobson) Which is the object of the exercise, so
placing the duty of clinical governance on the trusts will have
a favourable impact on reducing the number of adverse incidents
and also a detailed procedure is being developed by the NHS litigation
authority with a view to reducing the risks as well and I hope
that the combined pincer movement there will help. Again, it is
all part of a general overall effort to spread good practice and
to identify bad practice and allow people to learn from it. So
again, the work that the Chief Medical Officer is doing at the
moment will augment and supplement both what we are doing through
clinical governance and indeed in some senses some of the basic
statistics he wants to gather will be almost a necessity if clinical
governance is going to work properly but it will also augment
what the litigation authority is trying to do as well.
Dr Stoate
615. Secretary of State, a doctor's clinical
practice may fall well below the standard required and he may
be suspended from the GMC register pending retraining. If a doctor
is suspended from the register obviously he or she cannot carry
on their employment. Who therefore should be funding the retraining
of that doctor to bring them up to the standard required to get
them back on the register?
(Mr Dobson) I think broadly speaking them.
616. How can they do that if they are not able
to work because they are suspended, they have not got a job and
they cannot practise in general practice and they cannot carry
working for the trust. They need to get retrained to get back
on the register. Some of these doctors may at heart be good doctors,
it is just that they may need a period of re-training. How are
they able to fund their training if they are not able to work?
(Mr Dobson) Supposing someone has recognised themselves
or their colleagues have brought home to them that they are not
up to snuff and they ought to improve themselves, then it might
well be that their employer having a clear interest in them improving
themselves would find the necessary help and advice and keep paying
them while they are getting it. Quite frankly, if someone is struck
off by the General Medical Council because they are not up to
it and if they are capable of making themselves up to it again,
I think they owe it to the rest of us to finance their own improvement
if they have been struck off. You have to be pretty far down the
road of not being professionally up to it to get struck off.
617. The point you made about employers keeping
them on the books would certainly apply to a trust if they were
a hospital doctor. It certainly would not apply to general practitioners
who are self-employed and are not employed by anybody. Do you
think there is a distinction or do you think the same rule should
apply?
(Mr Dobson) In some cases it might be again appropriate
for the health authority to give them some help or their own partnership
to give them some help or perhaps the primary care group to give
them some help. There might be some circumstances in which it
is only proper that they have got themselves in the cart and it
is up to them to get themselves out.
Dr Brand
618. Secretary of State, can I briefly go back
to the discussion you had with Mrs Wise. In those cases where
the defence organisations settle out of court, or in court indeed
because a case cannot be defended, there does not seem to be an
obligation on them to report that to the General Medical Council
whereas if a doctor has a conviction for a criminal case which
may have nothing to do with his medical practice it is automatically
reported to the GMC. Do you think there is an inconsistency here
that at least a settlement, and they can be enormous settlements,
should warrant someone having a look and asking some questions?
(Mr Dobson) Yes, and I think that will form part of
what we are looking at at the moment.
619. I am glad to hear it.
(Mr Dobson) We have got to make sure that where information
is available the various authorities, be they the employer or
the professional body, are kept informed.
Chairman: If there are no further burning questions
from my colleagues, are there any final points that our witnesses
want to add? If not, can I thank you for your co-operation, we
are most grateful. We look forward to seeing you again hopefully
next week.
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