Examination of Witnesses (Questions 140-150)
CHRISTINE MILES,
STEPHEN MORRIS
AND DR
JOHN GRENVILLE
12 OCTOBER 2004
Q140 Dr Whitehead: Ms Miles, as far as
NHS hospitals are concerned, perhaps your hospital in particular,
how prepared do you think your hospital is for full implementation
by the starting date?
Ms Miles: I think I am cautiously
optimistic. We have obviously got our publication scheme on our
website which is populated and we have going to the Trust Board
next week an operational policy on how we are going to deal with
individual requests within the Trust and then doing another awareness
campaign across the Trust for staff because obviously enquiries
come from all parts into the Trust in all different ways. We have
had a project team going for about 18 months now on freedom of
information. We have not had any additional resources, but what
we have done is looked as to the most appropriate place for the
responsibilities to be held and, for my own Trust, that is going
to be with the Director of Governance who covers complaints and
also works closely with the communications adviser.
Q141 Dr Whitehead: A difficult question
I know, but how typical would you say your hospital was with the
NHS in general?
Ms Miles: Well, it is hard to
say from January onwards, but certainly during the first phase
of the project I was impressed with the amount of enthusiasm.
Every trust attended one of the regional workshops and went away
with a CD-rom with the information of the model publication scheme
and everyone achieved the deadline of 31 October. I think it needs
to be set into the context that over the past few years there
has been a lot of emphasis about making more open the decisions
made at the trust. For instance, trust boards are held in public.
A number of trusts have had quite active websites for a number
of years where minutes of trust board meetings are put on those
websites and trusts are used to dealing with the press and with
complaints from patients. I think the area that we all need to
focus on in trusts is about records management. Medical records
management has been a real focus, but general records management
is an area that I think we all need to work on in order to be
able to ensure that we can deliver the information that is requested.
Q142 Dr Whitehead: How concerned are
you about the extent to which there may be different practices
between different trusts and that, therefore, you may get, as
a result of that, people coming back, say, to your hospital and
saying, "Well, down the road they gave me this information
and this form and you haven't done that at all. Therefore, you
ought to do this"?
Ms Miles: There are two mechanisms
that will hopefully reduce that variation. One is that the questions
on the information governance toolkit are quite specific and you
have to answer them and give yourself a mark of one, two or three
against these questions. There are very clear definitions on how
you score a one, a two or a three, and that information is being
looked at by the strategic health authorities so that they can
see the individual performance of trusts and of trust boards as
well, looking at their individual performance. Also at strategic
health authorities, the responsibility for freedom of information
is with the head or director of corporate affairs and with other
projects they will be holding meetings with the designated leads
in trusts and getting that exchange of information. Also there
is the exchange of information through the website which is a
very active freedom of information website and I think we are
all going to be exchanging experiences over the first six months
and I am sure that the press will make sure that if there is a
variation between trusts, that is highlighted in the press as
well.
Mr Morris: I met at the end of
last month with the heads of corporate affairs of the 28 SHAs
to discuss where people felt this was at so as to get the local
knowledge in their discussions with their local trusts and PCTs
and yes, of course there will be some variations, but the use
of networks is well developed in seeking to understand where we
are with this, particularly between communications teams. What
we decided at that meeting as we run into 1 January is that we
put a little bit more resource at this point into the website
because that is used widely within the NHS and we associate that
with an e-based helpline so that people can actively have managed
issues which they are coming up with on a day-to-day basis and
we will continue that through into the early part of 2005 and
see what the level of activity actually looks like, so there will
be an additional piece of support which will enable people to
compare what is the actual experience. It is very difficult to
get a sense of how readily and quickly various users of FOI will
be doing this because a lot of NHS information is already available
in the public domain.
Q143 Mr Soley: Can I turn to an area
which I know you do not individually have detailed knowledge of,
but it is this area of mental health and behavioural problems
within the Health Service generally. I understand that in terms
of individual patients you are covered by patient confidentiality,
but where the behaviour is disturbed and potentially dangerous
or, alternatively, where you fear the onset of mental illness,
particularly certain types of mental illness, how would you communicate
this within your organisation if you felt it was necessary for
other people to know that information?
Dr Grenville: Within primary care
I think there are two elements here. One is what is required to
help that particular person. If a referral is being made to someone
else within the team, or indeed outside the team in the secondary
care system, then the referral must give as much information as
that person requires. It is in most practices' basic documentation
where we describe to people (in our practice handbook, for instance)
how information that we hold about you will be used that we say
that when you are being referred to someone else as much information
as that person requires in order to help you will be given to
that person unless you specifically object to something being
told to them. So to that extent, yes, if I were referring to a
community psychiatric nurse I would give all the details. If I
were referring to a psychiatrist, again, I would give all the
details. When it becomes a question of public safety, if I think
that someone may be so disturbed and they may be going to harm
someone else then I have to make a judgment about whether I can
breach that person's confidentiality or not. A particular instance
that I have had to face is a man who had been prevented by the
courts from having any contact at all with his children and who
sat in the surgery saying, "I am very angry, I want some
treatment for my anger, and if I do not get it I am going to kill
my wife and my children." He seemed fairly genuine about
that and the police were informed. One has to make that judgment.
The bottom line for a doctor in that situation is that he may
have to appear before the General Medical Council and justify
that decision.
Q144 Mr Soley: If it was a situation
where you feared the onset of paranoid psychosis or something
of that nature, which is often very difficult to tell in a person,
what would you do in that situation, particularly if you wanted
a second or third opinion?
Dr Grenville: There are people
whom you think are at risk of developing a psychotic illness for
various reasons and one talks to those people and tries to explain
what the problems are. Some people are receptive; some people
are not. However, the actual onset of a psychotic episode is usually
fairly clear-cut and at that stage if a patient agrees to treatment
that is fine, if he does not you have to consider the use of the
Mental Health Act. In terms of someone who is at risk of developing
a psychotic illness of whatever sort, there is very little that
one can do in advance. They are not ill, they are not a present
danger to anyone, it is really just a question of trying to build
up some sort of a rapport with them so that if and when they feel
that they are getting into difficulties they will come to you
or if, as often happens, when the illness finally appears, they
have no insight, when other people start coming to you, at least
you can go to them and they know who you are.
Q145 Mr Soley: I understand that but
you are talking about treatment there or building up to treatment
and what I am asking about is what you would record about such
a person and how you would communicate that within the National
Health Service?
Dr Grenville: I would record that
I had concerns very often about young people. I would record in
their personal notes that they had a very flat affect or that
their thought processes were slightly odd and that I was concerned
that this person may in the fullness of time develop schizophrenia.
I would not actually communicate that to anybody else unless and
until I felt I needed help in the management of that patient unless
I thought that that patient presented a danger to other people.
If, for instance, I thought that someone presented a danger to
another member of my team, perhaps the practice nurse, but that
they did not have a formal diagnosis of a psychotic illness, I
might just say to the nurse if she was seeing the person say for
a dressing, "You need to be careful about this chap, he is
slightly odd." It probably would not go any further than
that.
Mr Soley: Could I ask all three of you
on a general area—
Chairman: —We are running very
short of time.
Q146 Mr Soley: I am sorry, if I could
have a quick answer to this. It is a difficult area but it is
one we need to tackle. On this whole area of behavioural mental
health, without going into details, do you think it does cause
particular problems for the Health Service?
Mr Morris: I think the simple
answer to that is yes because these are judgments which are having
to be made. I think we have certainly in the area of mental
health significantly improved the communications and the protocols
and policies for communications, particularly between agencies
such as mental health trusts, the police, probation and social
services, and I think the experience of the FOI project in terms
of discussing this with a wide range of NHS bodies across England
was to focus attention as much on the importance of patient confidentiality
and data protection as it was on freedom of information and to
reinforce the arrangements such as the Caldecott guidelines or
the Caldecott Report in improving those, but it is a very difficult
area.
Q147 Mr Soley: Do you think we ought
to re-visit this?
Mr Morris: In talking with professionals
who are directly involved with secondary mental health services,
I think that the honest answer to that would be at the moment
they feel, from my discussions with them, the breadth of decision-making
which is left to professional judgment is very wide. Having said
that, and then in discussing that with the Information Commissioner,
how to legislate that does not look at all easy.
Q148 Peter Bottomley: My personal view
is that I have very much more confidence in the way that health
services are going to deal with data protection and freedom of
information through having the publication thing in. If my doctor
thinks I should not be driving and writes to Swansea and says,
"You ought to check on this person", that is data protection
if I asked for the information, quite clearly. If I asked my GP
practice how many times they had written to Swansea in the last
year saying one of their patients ought not to be driving, do
you think that is clearly freedom of information and is it the
sort of thing that could require a practice to search through
all of their records?
Mr Morris: I think I would take
it in stages. Is the data readily available? Does the practice
collect the data on a regular basis? If it does not I do not think—correct
me if I am wrong—the Act requires them to analyse their
own data further, so that would in a sense be the simplest response.
If for whatever reason they were collecting that data, maybe they
were doing research or something, then I think they would need
to weigh whether the disclosure of that information would be prejudicial
in terms of leading back to the identity of those patients who
were involved. I do not think we have to make these things necessarily
more complicated and we were very keen in the project to avoid
this defensive "reach for your lawyers" response. In
fact, doctors have been doing this kind of stuff a lot for many
years.
Dr Grenville: I would agree with
that response. As a GP I would probably say giving you the actual
answer to that question is very difficult but the real answer
is about once in five or 10 years. However, I would be much more
careful if it was a newspaper reporter asking me the day after
the front page had said "Epileptic man kills little girl
on road".
Q149 Ross Cranston: I just wanted to
get a very brief view of your perception of the DCA. Dr Grenville
did not know the DCA was involved so he can be excluded, but how
do you think the DCA has gone about implementing this? Have you
had very close relations? I think you, Mrs Miles, were on the
Advisory Group?
Ms Miles: My understanding is
that the DCA did get involved in our regional workshops and when
we asked them to attend they always sent somebody and they were
very supportive and certainly it was useful on the committee to
actually hear what other sectors were doing. However, I must admit
we did get funding from the Department of Health for the central
project and so our focus was on that and we were learning from
each other within the sector.
Q150 Ross Cranston: We heard about the
turnover of staff. Was that a problem in terms of contact?
Ms Miles: I personally did not
find it, no, but there was continuity within our own project and
so it did not really matter. As I say, they were very supportive
of the regional workshops that we ran.
Chairman: I am reluctant to draw this
part of the evidence to a close but we need to because we have
got some more witnesses. We are very grateful for your help, thank
you.
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