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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