Examination of Witnesses (Questions 60
- 79)
THURSDAY 2 MARCH 2000
PROFESSOR GRAEME
CATTO, MR
FINLAY SCOTT
AND MS
SUE LEGGATE
60. Have you come across this, Mr Scott?
(Mr Scott) I am aware of a complaint against a plastic
surgeon, in fact a series of complaints that we are currently
investigating where it is alleged—and I would like to emphasise
we have not investigated this—that out-of-court settlements
invariably include a gagging clause.[1]
Chairman: Thank you. John Gunnell?
Mr Gunnell
61. A change of topic. In our report on adverse
clinical outcomes we also made recommendations about improving
the GMC's international links because there was a case, which
I am sure you will recall, where a clinician who was suspended
from the register in Canada was subsequently employed in the United
Kingdom without his previous record seeming to have been followed
up. What I wonder is what action you have taken to improve your
international links since that time.
(Professor Catto) We very much share your disquiet
but there are practical aspects to this which I think Finlay may
wish to address.
(Mr Scott) There are three dimensions here. One is
we have been very active internationally in working with other
regulatory authorities in terms of the policies and procedures
they have been developing so we can share best practice. If we
move beyond that I think there are practical implications in two
different ways. One is what information is available to us when
we register a doctor in the United Kingdom for the first time.
There are real practical difficulties surrounding that but our
Registration Committee in April this year in just over a month
will be looking at proposals from us at how we might address some
of the practical issues and secure a greater confidence when we
register a doctor from overseas that there is nothing we should
know about. It has to be stressed that the great majority of overseas
qualified doctors who come here do an absolutely excellent job
and without them the National Health Service would be in serious
difficulty. However, we have to be confident in registering a
doctor that we know enough about them. I think the third dimension,
which is related to the point you made, is the flow of information
from other regulatory bodies to us when they have taken action.
I am aware of the great disquiet that surrounds the particular
case you have in mind. I would like to emphasise that if those
circumstances arose today we would act quite differently. In fact,
since that particular case arose on the basis of information from
Canada we have taken separate, independent action against five
doctors subsequently, so our current approach is quite different
today. We enjoy very good relations with a number of overseas
administrations. Canada is an example. But even within Europe,
Chairman, there are difficulties with the flow of information.
The Medical Directive in Europe says that regulatory bodies may
exchange information but does not impose a duty upon them. That
has caused it to be difficult to secure information. I have particularly
in mind here Germany where the regulatory authorities there believe
they face legal impediments. Nevertheless, we have ,unusually
for Britain in the European context, played a leading role in
establishing bilateral relations with all other countries under
which we now exchange information. I think I would like to distinguish
between our commitment and practicality. We play a leading role
internationally but, as Professor Catto says, I do not think we
should ignore the very practical realities of life. Securing information
from some parts of the world, particularly those where there is
political turmoil, is extremely difficult. We have to be careful
that we do not inadvertently disadvantage the very doctors who
have come to this country because of the political turmoil that
they faced.
62. I understand that. At any rate you can be
quite sure that the incident which brought this to our attention
before would not occur again without the necessary flow of information
taking place?
(Mr Scott) That is correct.
63. I have got a further question. This one
is not based on concrete evidence we have received but what we
want to know is what action you take to counter the possibility
of racial discrimination in your procedures. I do not think we
have received any direct accusation from any witness who has claimed
racial discrimination but there are sometimes reports which suggest
that is the case.
(Professor Catto) It is an issue we take extremely
seriously. We deal with that at a number of different levels.
Sue, do you want to pick up on this.
(Ms Leggate) I think it is better for Mt Scott to
describe first.
(Mr Scott) I will try to be fairly brief. At the end
of 1993 the British Medical Journal carried a letter from
two doctors pointing out that of the cases before the Professional
Conduct Committee some 60 per cent concerned ethnic minority doctors
and yet overseas qualified doctors make up only 25 per cent of
the NHS workforce. In response to that letter the then President
of the GMC, now Lord Kilpatrick, set up immediately a racial quality
group chaired by a lay member of the Council, Rani Atma. That
group undertook work in the course of 1994/1995. That included
commissioning a completely independent study from Professor Isobel
Allen of the Policy Studies Institute. She and her colleagues
were given unrestricted access to all our records and reported
in 1996 that they had not found any evidence of overt discrimination
or bias. Nevertheless, they were unable to explain the phenomenon
,which left us extremely uncomfortable. We commissioned, therefore,
a further independent study from Professor Allen, again with unrestricted
access to our files, but this time with the advantage that she
was able to design the study in advance of the data whereas previously
she had been using retrospective data. Her interim report was
available to us in May of last year, and again she was able to
report that she had found no evidence of racial discrimination
or bias. Her next report will be taken by the Council in May of
this year and I do not know what that will say but I believe that
Professor Allen, at that stage, will be able to indicate some
of the alternative possible explanations to racial bias or discrimination.
Chairman, if I could take the opportunity to identify another
area where we feel some considerable discomfort. Each year we
register about 10,500 new doctors in the United Kingdom. About
4,500 to 5,000 of them are UK trained, that is less than 50 per
cent, the rest come from other parts of the world, including a
very large number, about 4,000 to 4,500, who come mainly from
the Indian sub-continent and other areas. Unfortunately, because
of the way the legislation is framed, we are required by law as
it stands to distinguish those doctors into two groups, a group
whose qualifications we accept immediately for full registration
and a group whose qualifications lead to something called limited
registration. We are exceedingly uncomfortable with this two tier
system. I think it is since 1992 or 1993 that we have been seeking
a change in the law so that we can operate a single system of
registration for overseas qualified doctors. So far we have not
been successful in having the law changed. The effect of this
two tier system is that it makes us appear to be racist because,
as it happens, the category granted full registration immediately
are Australia, New Zealand, South Africa and other countries where
it appears that there may be a relationship based not upon clinical
knowledge and skills but on racial overtones. That is not the
case, it is an accident of history. We want it changed quickly
and we would welcome a change in the law.
64. To get that change in the law you would
need the Department of Health presumably to look at the quality
of the validation, the original validation, of the doctor in his
home country and to be satisfied that academically his training
is at a satisfactory level?
(Mr Scott) What we need, Chairman, is to move away
from a system that distinguishes people on the basis of their
primary qualification. We think it is no longer satisfactory to
assume that because you went to a medical school in one country
rather than another country you are necessarily acceptable for
practice in this country. The Council's preferred policy, and
it has been our policy now for some years, is to assess the knowledge
and skills of the individual doctor at the point of entry. That
is what we do with the majority of doctors coming to this country
now, but unfortunately because of the law we cannot do it with
the separate group. There is a separate issue around Europe on
which I am sure we could spend all day but that is not the immediate
concern.
Chairman
65. I am trying to recall the specific test
that is required.
(Professor Catto) PLAB.
66. I said PLAN, not too far out. I had a constituent
who came up against that and he went through that on a number
of occasions and was concerned. Would it be your intention to
look at this issue?
(Professor Catto) There are two issues there. First
of all, the PLAB test itself has been very substantially revised
over the course of the last year.
67. Has it?
(Professor Catto) The new system being brought into
play for the written component this summer. The clinical exam
was revised about 18 months ago. There has been a very substantial
change in that examination. I think what Finlay is talking about
is using that as the yardstick for doctors coming into Britain.
We need to make the link though that it is the same degree of
clinical competence that we would expect of our own students as
they graduate and proceed into the SHO posts. We need to ensure
that the standards expected of UK medical schools are compatible
to the standards expected of PLAB.
Dr Brand
68. Can I just tease this out a little bit further.
I have got a constituent who qualified at an Italian university
and my understanding is that any European Community citizen who
qualifies in a European Community university automatically can
practise in this country but this girl was born in India and although
she is an Italian graduate is being discriminated against. That
strikes me as being totally ridiculous.
(Professor Catto) It is a stepping stone argument
that if you are a non-EC national but happen to be in another
European country practising medicine, that does not give you an
automatic right to move to another European country and practise
there.
69. No, but the point I am making is this lady
worked very hard and got her degree, a number of her fellow students
are working in this country with exactly the same degree that
she has got but she cannot work in this country without taking
further tests.
(Professor Catto) Yes.
70. Because she happens to have been born in
the Indian sub-continent.
(Professor Catto) My understanding is this is not
a GMC issue, this is simply the law of the land at the present
time.
Dr Brand: It is a registration issue because
the GMC will not register her because she is a foreign national.
Chairman: This is a very complex area.
Dr Brand: I think it is discrimination, Chairman.
Chairman: I think there is a law issue and we
could spend all afternoon on this. I blame John Gunnell for taking
us down this road. It is a very important area. I think it would
be very helpful if you could give us a brief note after the session
on where you are on this point.
Dr Brand: And what you would like to see changed.
Chairman: That is right.
Dr Brand: I think we all recognise that this
is discriminatory, that the Department of Health is hiding behind
rules, you are saying there are rules. For goodness sake, let
us change some of those rules.
Chairman: If you could drop us a line we would
be very grateful.
Audrey Wise
71. A rather different aspect of the same point
but something that has come to me through constituency work and
I think may come more and more. An area like mine with a high
number of people from minority ethnic groups includes a good number
of doctors who have now been here for a long time and who have
families. It is my observation in any case that my Asian constituents
are very keen on encouraging their offspring towards medicine
and the law for professions, they are frequently quite ambitious
for their children. Obviously if there is medicine in the family
it often happens that the new generation also wants to be a doctor.
What has been raised with me is there is a feeling, and I am trying
to explore separately whether there are grounds for this, that
it is harder to get into medical school if you are of minority
ethnic origin even though you are British born. It is hard to
get into medical school anyway and undoubtedly the place will
be littered with people who feel they would be marvellous doctors
and they could not get on the first step on the ladder. The same
sort of thing happens in cases where people suspect sex discrimination,
it is really quite hard. I am trying to find out on the basis
of proportion and likelihood so far, and what the medical schools
themselves think, whether they have any attitudes one way or the
other, whether they say they are colour blind or whether they
say "yes, we monitor it and here is the proportion".
I wonder if this is anything that has been raised with you. Obviously
doctors cannot get towards being registered if they cannot get
towards being trained. This could be something which was a discrimination
at an earlier stage. I wonder if you, with all your contacts and
knowledge, have any views about this is something that you think
may be happening, just may be happening, or is it something you
are quite convinced does not happen, or what?
(Professor Catto) Let me try to answer that one first.
It is an area of enormous interest to us. We do not have direct
control over admission to medical school, but because people coming
into medical school do eventually end up on the register clearly
it is a matter of some interest to us. There have been suggestions
that the intake to medical schools of some groups is less than
might have been anticipated. The medical schools themselves, a
bit like the GMC in the past discussion, have opened up the books
and invited academics and others to come in and see precisely
the process that is being undertaken there. I have no doubt there
is a degree of openness, there is a concern that has been raised
that has not yet been fully resolved. There is a second issue
that in a sense nestles behind that, and that is there is a need,
I think, perceived by many of us in the profession, and in the
public at large, that we seek to widen access to medicine. It
does not actually follow that because dad was a doctor and mum
was a doctor that you should be and widening that access may mean
that you seek the capabilities and individuals that are separate
from purely academic capabilities. If you ask applicants for medical
schools not only to demonstrate that they have got good passes
in GCSE and so on but they also undertake work in the community
or different aspects of social interest, that may in itself, quite
inadvertently, put some groups at difficulty. There may be a cultural
element in this which allows some groups to participate more readily
in that kind of activity than others. We have to be very careful
in this area that we do look at all the aspects of this and guard
against any kind of inadvertent discrimination. The one point
I would make on finishing is I am quite sure if there is any—and
there is no evidence that there is it is entirely inadvertent
for the technical reasons I have said and not because there is
an overt discrimination.
Chairman
72. My experience of this area is there tends
to be no discrimination against Scots, Professor Catto. There
are many Scottish doctors.
(Professor Catto) It is certainly true of my life,
Chairman.
Mr Amess: I was very encouraged and interested
in Mr Scott's earlier remarks about registration, that was very
worthwhile. Now, without upsetting any of my colleagues—
Dr Brand: You do it so well.
Mr Amess
73. Right, well I will upset someone. It is
my firm view that some Members of Parliament are crazy. Now they
are crazy when they are elected and they get re-elected. There
are some who are perfectly ordinary and because of all the strains
here they go crazy and the electorate decide to sling them out,
but what I am saying is we are subject to the most rigorous test
imaginable. Doctors up until fairly recently have been seen as
Gods, no-one would have thought there was this sort of cloud of
mystery behind doctors and everyone had such faith in them and
no-one would have dared challenge anything. Well, if we are going
to find an asset from the media perhaps certain elements where
there have been publicity have dissolved all of that. The point
that I am coming to is that in 1998 you came up with your revalidation
proposals and I wonder if you could give us a little detail—which
I do not think you have yet—about the timetable. I think
there are three elements to the revalidation process, perhaps
if you might spell them out and the Committee might be able to
challenge them.
(Professor Catto) Yes. The timescale as we envisage
it at the moment is that we go out to consultation on our proposals
this May. We are going to take proposals to the Council in May
and thereafter we will go out to very widespread consultation,
to the public, to anyone who is interested in telling us their
views on those proposals.
(Mr Scott) On the timetable—I am sure Sue Leggate
has a lot to say about revalidation from her heavy involvement
in the preparation—the fixed date is a decision on the fully
worked up model for revalidation by February 2001, so just a year
from now.
74. Right.
(Mr Scott) The implementation timetable has not yet
been decided and that is not because we are lacking in any enthusiasm
for the idea but it is a fundamental objective of revalidation
that it should not be turned into an additional level of bureaucracy,
but should as far as possible be fully interwoven with the Government's
plans for clinical governance and other developments. Also, going
back to the Chief Medical Officer for England's paper, it should
be firmly linked with the plans for appraisal for doctors. Because
those proposals have not fully been worked through, nor do they
yet have their own timetable, we are unable to say what our timetable
would be. There is no lack of drive and enthusiasm, as I think
Sue Leggate may very well confirm.
(Ms Leggate) Absolutely not. I think it is one of
those processes, certainly the consultation period I am really
glad is going to happen in two months' time because I think it
is important and I think all of you with your constituents, it
needs to be made that everybody takes part in it.
75. I hope it will not be one of these rushed
consultations.
(Ms Leggate) No.
76. It is all done when everyone is on holiday
or you get the thing delayed in the post, is it going to be a
real meaningful consultation? In other words, I hope it is not
going to be something where we have already decided the way it
wants to go and everything has to fit around it? I hope it will
be meaningful.
(Professor Catto) Can I give you an absolute reassurance
on that. There is absolutely nothing in it for the GMC to do that.
It is critically important that we get this right, that we have
got the public behind us, that we have got the profession with
us and that we go forward on that basis. To rush this through
in a quick under the counter way is absolutely not in our interest,
it is not in anyone's interest.
(Ms Leggate) We are engaging with people who can then
get to local communities, with the CHCs, with the health authorities,
who again have their own mechanisms because they have a duty to
consult in any case and so have ways of getting into a local community.
So we are consulting both public and the profession, Government
and yourselves, and these kinds of people on the proposals. You
asked what it was?
77. Yes, how it will work?
(Ms Leggate) Because I am a lay person—
78. That is excellent.
(Ms Leggate) It is going to be the Ladybird book guide
to revalidation I am afraid. It is going to be about a very open
demonstration that doctors are carrying out their practice in
line with the standards of good medical practice, which is the
guidance that doctors are expected to work to, which covers a
whole range of issues. It covers a lot of things that I would
call the clinical and technical, that will be monitored and judged
in one way, it covers a whole lot of what we will call perhaps
the softer issues about the doctors, the way they communicate
with their patients, the way they deal with the patients, the
satisfaction that the patients have with them, right through the
period. At the moment it is envisaged that revalidation itself
should be a five yearly process but it will tie in with the local
process that is being set up by the NHS around, for instance,
appraisal and clinical governance. The details are not fixed because
they are out for consultation, but the idea is that the doctor
should maintain what is going to be a personal folder or record
which will contain demonstrations of all the things that the doctor
is involved in, whether it is in the NHS practice or private practice
because the doctor will have to be revalidated for everything
they are doing, not just for the section they do, for instance,
within the NHS. It should contain records of complaints against
that doctor, it should contain details of all that doctor's work,
all the things that are generated, for instance, within a hospital
trust. It should contain information done on a patient survey
and there are various ways of getting at patients' information
that would allow that to be fed in. That is not just going to
be looked at once every five years but when it is looked at for
revalidation purposes it will be done, say, by a group of people
who will include both clinical people, probably people who are
managerial in relation to that doctor and lay people who will
make the judgment on whether this doctor has demonstrated satisfactorily
that he or she is working to the standards of good medical practice.
That would be awful if it only happened every five years. Within
the appraisal process and within what we envisage is that there
will be probably be annually or 18 monthly or whatever, for instance,
the NHS might decide, dips in to that doctor's career and folder
and anything else that is coming out. We are not just going to
get a rush of doctors who are being sent down to the GMC five
years on because the folders or information about them or their
audit or their patient satisfaction has been found deficient,
but at any time doctors can be referred out of that process either
for remedial education at a local level, which the Department
of Health paper is envisaging, or if it is something much more
fundamental than that, directly to the GMC and into the fitness
to practise procedures. The flavour of it should be that one ought
to have a view on where a doctor is at, what he is doing, whether
her performance is good from audit, from patient information,
from peer review, all the way along the line. It is like having
a log book in a way.
79. It sounds marvellous and I am greatly reassured
that it is not going to be every five years because that would
be a complete waste of space, some of us change every month. This
is going to cost megabucks, who is funding all this? This is a
huge resource requirement. It is a great wish list.
(Ms Leggate) Yes, it is a great wish list. One of
the important principles—and I will pass over to Finlay
then—is that it should use existing processes as much as
possible. Those are the existing processes that are being set
up in the Protecting Patients Supporting Doctors guidance.
1 Note by witness: We are seeking powers from the
government to put us on a par with the power the Ombudsman has
to require documents and evidence to be produced. Back
|
