Examination of Witnesses (Questions 188-199)
DR GINA
RADFORD
20 JUNE 2006
Chairman: We welcome Dr Radford of the
Department of Health. We are very glad to have your help.
Q188 Dr Whitehead: When the evidence
of the Department of Health was received by the Committee it was
not entirely clear how the Department was involved in the death
certification and investigation systems. Can you explain how the
Department is involved?
Dr Radford: I will do my best.
The Department of Health is not responsible for everything around
death certification by any means. As the Committee will know already,
the legislation by which doctors complete medical certificates
is the Registration of Births and Deaths Act. That is owned by
the General Register Office which is part of the Office for National
Statistics. That Department owns the legislation dealing with
death certificates and the legislation under which doctors complete
them. Doctors complete medical certificates of the cause of death
as a personal statutory duty. That is a personal role that they
play under the Act of 1953. Therefore, issues to do with their
conduct in respect of this are subject to regulation by the General
Medical Council. First, we have the ONS with responsibility for
death certification itself and the legislation concerned with
that. The GMC is concerned with ensuring that the conduct of those
doctors in completing certificates is satisfactory. Finally, in
terms of the Cremations Act, which accounts for up to 70% of disposals,
that is legislation for which DCA is responsible. As for the majority
of the statutory responsibility, it sits outwith the Department
of Health.
Q189 Dr Whitehead: But the Government
has apparently changed its view since it put forward its 2004
position paper. Is it fair to say that the Department of Health
and the DCA work together on death certification and how to move
it forward?
Dr Radford: We have always worked
together. When it was under the auspices of the Home Office we
worked very closely with that Department in terms of producing
the position paper which was then published. Since the responsibility
for coroners was taken over by DCA we have also worked closely
with DCA officials.
Q190 Chairman: Is that why the view
has changed?
Dr Radford: That the responsibility
should change to that of DCA? I cannot say. Clearly, the content
of the proposed Bill is subject to ministerial views, so that
is not something on which I can comment.
Q191 Dr Whitehead: But any change
in death certification was not included in the reforms put forward
in the draft Bill?
Dr Radford: Absolutely.
Q192 Dr Whitehead: Do you think that
may have something to do with the fact that nobody appears to
have, as it were, clear responsibility for what goes on?
Dr Radford: There are a number
of processes that contribute to the satisfactory completion of
a death certificate and a body being able to be released to be
either cremated or buried. We sit within the current regulatory
framework. At the moment there are different regulatory responsibilities
depending on the element that we are talking about, whether it
be the Cremation Act or regulation in terms of satisfactorily
completing the necessary paperwork so that bodies can be released
or the required detail on a death certificate and the processing
of that certificate.
Q193 Dr Whitehead: But, as you set
out very succinctly, there are what might be called a number of
different poles of responsibility, none of which trumps any other
one. Is that a fair assessment of the process that you describe?
Dr Radford: Yes. There are different
elements of the process.
Q194 Dr Whitehead: Can the fact that
there are no reforms in the draft Bill be construed as perhaps
a requirement for the resolution of those particular poles? Indeed,
the DCA has said hat it is doing further work on the question
of death certification and, therefore, reforms may be in the "too
hard" tray, as it were, for the time being?
Dr Radford: We are certainly working
with DCA to look at what other aspects, particularly around death
certification, may be necessary to strengthen death certification
in the light of the recommendations of both Shipman and Luce and
the comments that clearly we have received and the context within
which we are now operating. I can say that most definitely there
is other work in progress.
Q195 Chairman: Dame Janet said to
this Committee that she did not think the Government's proposals
as they then were—they have not changed in this particular
respect—went any way to stop another Shipman. You were given
the task of working on the Government's response to Shipman. Surely,
the Department would say that it had a major stake in making sure
this is put right. Is not the Department involved in the policy
lead here with the health aspects and the registration process?
From the way you describe the process everyone can conclude that
nobody is responsible.
Dr Radford: Certainly, the whole
process of death certification needs to be seen in the context
of a much broader reform agenda that Shipman and Dame Janet highlighted
in terms of issues to do with improving overall quality—quality
of care and health care—and clearly death certification
is one element of those. We have been working across the broad
front of health care reform for a considerable time, as you will
know, and quite significant changes have been made in terms of
quality and patient safety improvements that have been made in
the health care sector. Clearly, as to death certification we
are working on issues with DCA in terms of what else can be done
outwith the draft Bill to take account of some of the concerns
raised by Dame Janet and others.
Q196 Dr Whitehead: In your view,
would that involve further legislation or simply a reshuffling
of how things are done?
Dr Radford: One of the issues
on which we are in discussion with DCA is whether this will require
further legislation or we have satisfactory legislation in place
which will allow us to improve the system in a way we would wish
to.
Q197 Chairman: I find myself quite
uneasy. This is a fairly serious matter which involves a major
initiative on the part of the Department for Constitutional Affairs
but it seems just to pass the buck to you by saying that death
certification is for health, not DCA, and so it is not doing too
much to incorporate it. Am I misinterpreting what is happening
here?
Dr Radford: That is perhaps an
unfair summation of its position. Clearly, its draft Bill does
not cover death certification as it is set out at the moment,
but that does not mean there is not work ongoing in terms of what
else can be done to improve the process of death certification
to address some of those issues. But at the moment that is not,
as you rightly point out, within the draft Bill that is before
you.
Q198 Chairman: One matter for which
the Department is responsible is the training of doctors. Earlier
this afternoon we had quite a good deal of discussion about that.
This is looking at it from the other angle, not Shipman; that
is, all the other problems which arise for those who have to go
through the coroner and inquest systems. Do you think that training
may develop in a way which means, as indicated earlier, that we
could have fewer reports to coroners because doctors are more
confident about what they are doing?
Dr Radford: We are very much aware
that to make sure people are appropriately trained is and has
been for some time an issue, but we need to realise that training
comes at different stages of a medical career. First, there is
the undergraduate training which goes on in medical schools to
make sure that before they qualify as doctors people have an understanding
of death certification. The content of that training is the responsibility
of the medical schools. A recent survey by the Council of Heads
of Medical Schools showed that at all the medical schools which
replied to that survey medical students are being trained in death
certification, so medical students are receiving training in terms
of how to fill in a death certificates, what the statistics are
used for, the reason we need to have accurate death certificates
and so on at that stage. But clearly that is not sufficient of
itself. We then talk about postgraduate medical education. That
is under the control of the Postgraduate Medical and Education
Training Board set up in September of last year. Training for
doctors in issuing death certificates is now a requirement of
postgraduate training. There is a requirement in postgraduate
training to ensure that doctors are competent because the training
is based on competence, not just "tick box" ability,
to issue death certificates. Finally, there is continuing professional
development which is lifelong in terms of making sure that practitioners
throughout their medical careers are competent and up to date
in terms of things like death certificates. As you may be aware,
last year ONS published some renewed guidance to all doctors,
which also accompanied the CMO's newsletter, reminding them how
to fill in death certificates, setting it in the context of how
the information from death certificates is used. But you are absolutely
right that there is an ongoing need to ensure that people who
fill in death certificates are competent to do so. Clearly, one
of the issues is that some doctors do not fill in death certificates
necessarily very often. Some do and some do not. To keep that
competence up to date and fresh is important. Clearly, that is
an ongoing issue, not a new one. How does one keep competence
in a task that perhaps is not performed on a daily, weekly or
monthly basis up to date and to an appropriate standard?
Q199 Chairman: Post-Shipman did the
Department consider a random check of death certificates to see
from the results whether competence was being maintained generally?
I am not talking of an individual doctor but across the system.
Dr Radford: Yes. You will remember
from the Home Office position paper that one of the issues was
to do with scrutinising all death certificates, because we are
aware of the importance of devising systems that will encourage
good practice, rather than just leave it to individuals, and looking
at what systems we can put in place to improve the quality of
death certification. Clearly, that line will not be pursued in
terms of the Home Office position paper and, therefore, we are
looking with DCA and others at how we may address the need to
improve the quality, and also quality assurance, of death certification
in an achievable and appropriate way.
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