Select Committee on Health Minutes of Evidence


Examination of Witnesses (Questions 227 - 239)

THURSDAY 16 MARCH 2006

MS ANNA WALKER, PROFESSOR SIR GRAEME CATTO AND PROFESSOR PETER RUBIN

  Q227  Chairman: Could I welcome our next group of witnesses and ask you each to introduce yourselves and the organisations you are from.

  Professor Rubin: I am Peter Rubin. I am here as Chairman of the Postgraduate Medical Education and Training Board, but, for the record, I should also say that I chair the Education Committee at the GMC.

  Professor Sir Graeme Catto: I am Graeme Catto and I am President of the General Medical Council.

  Ms Walker: I am Anna Walker, the Chief Executive of the Healthcare Commission.

  Q228  Chairman: Could I declare my interest, that I am a lay member of the General Medical Council and have been since 1999. You may have heard or seen some of the issues which came out of our session last week, that the Royal College and other medical bodies were suggesting to us that clinical standards in independent sector treatment centres are inadequate. Do you have a view about that, whether they are or are not?

  Ms Walker: The first thing I would like to make clear is that the Healthcare Commission regulates all NHS and independent sector healthcare organisations. We do not have a view as a regulatory body on what type of organisations they should be; our job is to ensure that, when they are there, we regulate them effectively. We have a well-developed regulatory regime for the independent sector; it is more developed than that for the NHS in many ways and in that there are a series of regulations and standards which look to oversee clinical effectiveness. Ultimately, it must be for those actually running a particular organisation to be responsible for clinical effectiveness and clinical outcome and what the regulatory regime can do is to ensure that the key issues are encapsulated and overseen in regulatory terms.

  Q229  Chairman: Is there any comparison being made between the ISTCs and the National Health Service, from your perspective, in terms of clinical indicators?

  Ms Walker: No, not on a systematic basis. The origins of the regulatory regimes for the NHS and the independent sector and, therefore, for ISTCs are actually very different. That is one of the things that we are working on at the moment because the more a mixed economy comes into place—and we have actually had a mixed economy for a long time and the crucial issue is a mixed economy where the NHS patient is being treated in the independent sector—the more actually the patient, and it is the patient which is the focus of our activity, actually wants to know that they are being treated broadly comparably. As your previous discussion showed, in many ways there is more information available on clinical outcomes, particularly from independent treatment centres, because of contractual arrangements with the Department of Health than there is systematically available from the NHS. One point that did, however, strike me was that there is a big difference between information being available between the Department of Health as the contractor or us as the regulator and the independent treatment centres and what is available to the public and there is a gap in availability to the public, and that is perhaps an issue we can come back to.

  Q230  Chairman: Good data collected to make meaningful comparisons would be helpful, as far as you are concerned?

  Ms Walker: I absolutely think that is right and information which is about outcomes and in a format which is meaningful for somebody who is trying to decide, "Should I take up this offer or not?", I think that really is very important.

  Q231  Chairman: Could I go back to this issue about clinical standards and ISTCs. Do you have any views at all?

  Professor Sir Graeme Catto: Yes, the General Medical Council is responsible for regulating all doctors in the United Kingdom, including of course those who work within ISTCs. As the Committee has already heard, the doctors who work within ISTCs are predominantly senior doctors who are already trained and come from outwith the United Kingdom and again predominantly from the EEA. I should make it clear that the arrangements for regulating doctors, for admitting doctors into this country are quite different for doctors that come from within the EEA from those that come from the rest of the world, the so-called international medical graduates who come from any of the other countries outwith the United Kingdom and outwith the EEA. Before a doctor can be admitted on to the medical register, he or she must meet certain criteria; first of all, they have got to have their primary medical qualifications; secondly, they must have a certificate of good standing from the country of their origin and that needs to confirm the fitness and practice details that are relevant to that doctor, whether there have been any disciplinary hearings against them in their own country; and, finally, they need to make declarations to us about probity and health issues which might affect their ability to work in this country. I should make it clear at this point though that being on the medical register does not mean that a doctor is necessarily entirely competent to work in all environments or is necessarily able to work unsupervised or even able to practise all of the procedures within their given speciality. The GMC believes that there are at least four levels, four layers of regulation: first of all, there is the personal level where the doctor himself or herself must be aware of their limitations; secondly, the team in which they work need to be aware of what the doctor is required to do; thirdly, and perhaps most importantly, the employing organisation has a real responsibility both for induction and to make sure that the doctor is competent to perform the individual tasks required of him or her; and then, finally, of course the General Medical Council has got a real role in ensuring consistency and having a national overview, and we make no distinction between private sector, public sector or any of the four countries in the United Kingdom. Therefore, it is clear from what I have said already, I think, that there are some limitations to having your name on the medical register and it may be that the Committee at some point would like to explore some of our proposals for revalidation and for changes to the specialist register which would make more information available to the public.

  Q232  Dr Taylor: I really want to go on on that sort of theme because it has been pointed out to us or alleged to us by various people in some of the specialist fields that accreditation on the Continent, for example, is not accreditation to work unsupervised, but accreditation to work under a particular chief, and then people have alleged that they come then to this country and are accepted by you as fully qualified to work unsupervised. Is that correct or is that not correct?

  Professor Sir Graeme Catto: Well, under the European legislation, we have no option but to accept these doctors in at the speciality level, so they come to us if they have already been accredited specialists within their own country and we would have to have a reason for deciding not to take them on to the specialist register.

  Q233  Dr Taylor: But you would agree that that level of accreditation is perhaps slightly lower than ours?

  Professor Sir Graeme Catto: It may be different in a practical sense, but, from a legal point of view, once the agreement within Europe was signed on 1 May 2004, there was a general acceptance that doctors who had reached the speciality grade would be able to move from one country to another without hindrance, so we accept them on to the specialist register and we would have to have a reason for not doing so.

  Q234  Dr Taylor: So this is a very, very important point and the professionals who have talked to us do have a point?

  Professor Rubin: Perhaps it would be helpful if I explained to the Committee the three main routes on to the specialist register because it is relevant to this discussion, and the word "overseas" has been used a couple of times this morning. There are three main routes on to the specialist register. For UK graduates, they go through a rigorous and quality-assured undergraduate medical programme. They then work for a couple of years in a managed environment, showing that they can put in the practice, the knowledge and the skills required of students. Then they go through a rigorous and quality-assured postgraduate training programme and there are assessments all the way through from the first day as a student through to the end of the postgraduate programme. That is what UK doctors do to get on to the specialist register. For doctors outside the EEA, international medical graduates, they too have to go through a robust procedure for which my organisation, PMETB, is responsible in which they have to produce documentary evidence in terms of certificates and references and other things to show that their training and experience is equivalent to that of a doctor working as a consultant in the NHS, so that is IMGs. As Graeme was saying, in the case of the EEA, neither the PMETB nor the GMC has discretion in the matter, but we have to accept the equivalence of training, so at both the undergraduate and postgraduate level we have no discretion.

  Q235  Dr Taylor: So is there any obvious recommendation which we should be making from that?

  Professor Rubin: To repeat what Graeme said, and this is a message that I try to give whenever I have the opportunity to do so, it is for employers to look very carefully at what a doctor has done and, for the reasons that Graeme is saying, whatever the EU says about the equivalence, there may not be equivalence in terms of the culture in which a doctor worked and all sorts of differences may exist, so it is for the employer to look very carefully at what every individual doctor has done in their country of origin.

  Professor Sir Graeme Catto: The same caveat applies to language. The regulator is not able to assess language competence of doctors coming from the EEA, but they can of international medical graduates and again it would be up to employers themselves to ensure that the doctor was able to communicate with patients adequately.

  Q236  Dr Taylor: Sir Graeme, you said there were four strands, the personal one, then working with the team. Are you happy that in these independent sector treatment centres there are teams that would hold the boss of the team, the chap doing the operation, to account?

  Professor Sir Graeme Catto: I have no knowledge of that and it is beyond my competence to answer that question. It just seems important to the General Medical Council that there are sufficiently robust induction processes to ensure that people coming to work in this country are able actually to perform the tasks expected of them.

  Q237  Dr Taylor: So we go to the Healthcare Commission.

  Ms Walker: What I wanted to add, which I hope might be helpful here, is that the regulatory regime for the independent sector and, therefore, for the ISTCs as well does put emphasis on the management of a healthcare organisation to satisfy themselves of those that they are employing for clinical purposes. In other words, there is a regulatory arm to this which can help. Now, there may need to be a debate about whether we have phrased that in the right way and there is also obviously a question about then the rigorous follow-up which we try and ensure that there is in relation to our inspection. My point is that I think there is something here in the regulatory system that can help as well.

  Q238  Dr Taylor: So you would be able to pick up on your visits from members of the team, for example, if they were not happy about what was going on?

  Ms Walker: Yes, to some extent we could. I could not claim that we could do it in all circumstances, but procedures in place, recognising the importance of this, the very fact of that standard makes a difference and then the checking of the standard also helps.

  Q239  Dr Taylor: I think you said it is a specialist team that does the ISTCs, so it is a different team that inspects NHS treatment centres and ISTCs, is it?

  Ms Walker: No, we are actually increasingly integrating our staff across the piece because we feel that is the best thing going forward. What we have had is a small team in the centre because we have had to think through the regulatory issues, especially in relation to ISTCs. As they become established, the team will remain in the centre, but our regions, because we are regionalising the organisation so that we can be in touch on the ground with local organisations, will take over the regular relationship.


 
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