Examination of Witnesses (Questions 240
- 259)
THURSDAY 16 MARCH 2006
MS ANNA
WALKER, PROFESSOR
SIR GRAEME
CATTO AND
PROFESSOR PETER
RUBIN
Q240 Dr Taylor: So you then will
be in a position to compare, as it were?
Ms Walker: We will be in a position
to compare, and we will have people locally, so, if we have a
concern or if others have a concern, we can go and visit.
Q241 Dr Taylor: You did say also
that the Commission so far has only received one complaint against
an ISTC. Could you give us any rough idea about how many of our
NHSTCs there were?
Ms Walker: There was one formal
complaint about an ISCT. We receive about 9,000 complaints a year
about the NHS. Now, that is clearly not a comparative figure and
I am not suggesting for a moment it is a comparative figure. The
complaints process takes complaints in the first instance to the
provider of care in the independent sector and, if satisfaction
is not available there, actually somebody being treated in an
ISTC has two routes they can go: they can actually complain under
the NHS processes or the independent sector processes; and, if
they are not satisfied with their independent sector provider,
they can come to us.
Q242 Dr Taylor: We had a very impressive
submission from Care UK which runs some of the centres and they
said at one point, "An NHS-trained and experienced surgeon
is appointed as a lead clinician at each site and is responsible
for clinical governance and mentoring". Would you pick up
if that existed in other sites?
Ms Walker: Yes, in the sense that,
when we look at things, we are actually trying to ensure that
the basics are there. What you are describing looks like very
best practice. Now, actually our statutory role is to encourage
improvement, so we are concerned to pick up that best practice
and, as far as we can, suggest or incorporate it.
Q243 Dr Taylor: Any comments?
Professor Sir Graeme Catto: None
from me, sir.
Q244 Dr Stoate: This does actually
raise some extremely fundamental questions. Professor Catto, you
are saying effectively then that you have someone on the specialist
register from a European country and you have to accept them on
to the register. We have also heard from other witnesses that
some of them are trained not to the same level as an independent
consultant in this country, but more as a sort of consultant under
supervision, as it would be in another country, and you are saying
that, as far as you are concerned, you cannot differentiate between
the two. The question I want to ask is: were there to be a complaint
to the GMC about a consultant who perhaps had acted beyond his
competence because he was trained effectively as an understudy
to a consultant in the EU, how would you handle that because you
would have to accept that he was a consultant, you would have
to accept that he was on the register, but he may be in fact acting
beyond his actual personal competence in a particular field for
which a UK consultant may have no problems?
Professor Sir Graeme Catto: He
would be treated in exactly the same way as any other doctor performing
a task. The words sometimes get in the way. "Consultant"
may or may not be the appropriate word here. This doctor is clearly
taking a leading role in treating a patient and he or she must
perform that within his or her own level of competence. The situation
in Europe is that all doctors who have got to a speciality level
are deemed to have got this CCT arrangement, certificate of completion
of training, and, therefore, they should at that stage all be
equal. That does not mean that they are all equally competent
at any given task and it comes back again to ensuring that the
doctor is not just clinically fit as he reaches certain standards
in training, but is actually fit for the purpose for which he
happens to be employed at the time. There is a real onus of responsibility
on the employing organisation to ensure that, I think.
Q245 Dr Stoate: So who is to blame
then when a consultant perhaps does overstretch himself and is
asked by his boss to do a procedure which he may not be totally
qualified to do, even though he would be qualified to do the majority
of procedures? Who is to blame in that situation?
Professor Sir Graeme Catto: Well,
the onus of responsibility must predominantly lie with the individual
consultant or the individual doctor, it seems to me. If he or
she ends up working in circumstances that cause difficulties,
then the first port of call is for the doctor to put that right
himself or herself, but I think we should try and get away from
using terms like "specialist" or "consultant";
it is simply a doctor ensuring that he or she is competent for
the task in hand.
Q246 Chairman: Sir Graeme, has the
General Medical Council got any adverse patterns in terms of complaints
from ISTCs as opposed to other areas of NHS work?
Professor Sir Graeme Catto: I
looked into that before I came to the Committee today and the
answer is no. That may of course be because the ISTCs have been
in business for a relatively short period of time. We have got
some doctors about whom complaints have been brought to the GMC,
though none has gone through our processes completely yet, and
we have got no reason to think there is a disproportionate number
coming our way.
Q247 Mr Amess: How should appointment
procedures be improved?
Ms Walker: Graeme actually talked
about the onus being on the doctor. There must be a very significant
onus on the employer, the management of the ISTC, to ensure that
the doctor is qualified to look after the patients going through
their care. Over and above that, I think the regulatory regime
can help and it can help by holding management to account in the
right way. We cannot take the responsibility from them, but we
can ensure that in our regulatory regime the emphasis we put on
our management ensuring themselves that they have got the right
doctors doing the right things has sufficient emphasis.
Professor Sir Graeme Catto: Perhaps
I could just build on that because I think that is absolutely
right. I myself worked in the United States for some time and
it was very helpful to have a period of induction where I got
used to the way in which that particular organisation worked,
the facilities that were there and the equipment that was used,
so, although my clinical skills were transferable, the way in
which they were actually applied had to vary and had to be adapted
to meet the local circumstances, so I think it is not just the
interview process or the appointment process, but it is the induction
process thereafter, I think, that is critically important in giving
these individuals time to accommodate to a different situation.
Professor Rubin: I do not have
anything to add to those two answers.
Q248 Mr Amess: Has the additionality
principle which applied to Phase 1 contracts led to an over-reliance
on overseas doctors and should it apply to Phase 2?
Ms Walker: I can understand the
reason why the Department of Health in Phase 1 wanted the additionality
clause there. There is real concern that there could be otherwise
some very adverse consequences for the NHS, whereas actually this
programme was clearly about ensuring that the NHS could in one
way or another cope with some of the peaks of demand. I think
that moving towards a situation where the additionality is not
removed, but relaxed where that can be borne by the local health
economy is the really crucial issue.
Q249 Mr Amess: Beautifully put!
Professor Sir Graeme Catto: I
thought the Committee might just be interested in some of the
numbers associated with this because, with all I can tell you
about the numbers of doctors who come on to the medical register,
I cannot actually tell you where they are working or even if they
are working. Some people may choose to be registered and not actually
come to this country for some time. It is quite interesting that,
if we look at international medical graduates, that is not UK
graduates nor graduates from within the EEA, then in 2004 there
were 104 that got on to the specialist register and in 2005 there
were 36. If you look at doctors from the EEA, then in 2004 there
were 1,329 and in 2005 there were 1,788, so there is a very small
number coming from countries beyond Europe on to the specialist
register, but apparently substantial numbers from within Europe
coming on to the specialist register, though I cannot tell you
where these colleagues are currently working.
Q250 Charlotte Atkins: One of the
issues which has been arising in our evidence sessions is about
the follow-up treatment for patients treated in independent sector
treatment centres. Have you got any evidence that it is inadequate?
Ms Walker: No, we have not got
evidence that it is inadequate, but it is one of the issues that
in the early stages of the ISTCs has been raised with us in a
number of ways. When it has been raised, what we have done, what
our normal practice is, is to go into those particular centres,
try and establish what is happening and find a way forward that
is positive. In each case, we have been satisfied that there are
appropriate new arrangements being made to ensure that that happens,
so I think actually it was an issue which was not thought through
clearly enough and that came back to us in terms of complaints
and concerns. I think a lot of progress has been made on it.
Q251 Charlotte Atkins: So are you
saying that you now think that there is not a problem with follow-up
treatment?
Ms Walker: I could not say that
I did not think there was in all circumstances, but I think two
things have happened. Where there has clearly been a problem,
then there has been a dialogue on putting it right and that has
been generally taken as learning across the piece both by those
of our staff who regulate and by the centres themselves and, I
am sure, by the Department of Health.
Q252 Charlotte Atkins: How many times
have you had to go in and have a look at the situation?
Ms Walker: Not that frequently.
Again, in preparing for today, you can imagine that one of the
questions which I asked was: what is the pattern of complaint
or actually the thing which is reported to us, what is called
in regulatory terms, a `serious untoward incident'? The answer
is that it has been broadly of a norm.
Q253 Charlotte Atkins: So what sort
of numbers are we talking about?
Ms Walker: For serious untoward
incidents, about 90. Now, in terms of comparisons, I am making
those comparisons across the independent sector because we do
not actually receive systematic information about serious untoward
incidents in the NHS because that will tend to go to the strategic
health authorities, so this is one of those areas where, because
of the different backgrounds of the NHS and the independent sector,
it may be that some thought needs to be given to getting a database,
whoever is holding it, which is actually equal across both.
Q254 Charlotte Atkins: What about
across NHS treatment centres?
Ms Walker: I do not know the answer
to that.
Q255 Charlotte Atkins: When you are
talking about these 90 cases, was there a pattern whereby particular
firms or particular companies were receiving more complaints than
others?
Ms Walker: There are two of the
independent treatment centres which show higher serious untoward
incidents than others. In each case, those statistics are not
regularly published and they are not, as I say, for the NHS either.
There is actually a debate of really some quite national significance
over this, this question of wanting to ensure that that incident
is reported so that the right action is taken compared with whether
all of that is made publicly available. Anyway, the position at
the moment is that that information is not publicly available.
What we do, where there is a serious untoward incident, is we
go into that particular treatment centre or organisation to satisfy
ourselves that the appropriate follow-up action is being taken.
If we have either a pattern of concerns or the particular concern
is very significant, then we will actually insist on a root-cause
analysis and satisfy ourselves that it is being followed up in
that fundamental way.
Q256 Charlotte Atkins: Did you do
that in these cases?
Ms Walker: Yes.
Q257 Charlotte Atkins: Could you
name those treatment centres?
Ms Walker: No, I cannot, for obvious
reasons.
Mr Amess: What a pity!
Charlotte Atkins: Absolutely.
Q258 Mr Campbell: I just have a question
on training and the ISTCs. Basically, do you foresee any problems
with the training in these centres?
Professor Rubin: I think, as with
any new development, there are opportunities and there are risks.
The opportunities come from a new provider coming up with new
ideas and I do not think we should ignore that. There could well
be innovative approaches to education and training coming out
of the ISTCs and, as you have heard from previous witnesses this
morning, in the first phase we are not required, or expected,
to get into education and training because they had a task in
hand which was to get through the large numbers of procedures.
With respect to the next wave of ISTCs, there is a risk with respect
to education and training, and the risk is that there will be
a lack of clarity about what is expected by those who are commissioning
the education and training and those in the ISTCs who are going
to be providing it. Going back to the reasons of the ISTC: speed
has been one of the reasons, to get through a reasonable number
of procedures and to cut waiting lists. Once you start to train
people, you would reduce the number of procedures you can do because
you are taking time to show somebody else how to do that. For
example, if you are doing cataracts, as a ball-park figure you
might get through eight cataract procedures or so if you have
a specialist who is doing the cataracts and not training; you
might get through four or five if that specialist is training
somebody else to do them. That is fine, as long as everyone goes
into the arrangement, with respect to what is expected of the
ISTC, understanding all the issues. It is not fine if the ISTC
signed up to the same throughput as before while agreeing to take
on training, unless that was explicitly acknowledged in some way
in the contract. So there is a risk to the next phase of ISTCs
and how they will handle the education and training aspect.
Q259 Mr Campbell: Who would have
to bear the cost? Do you have to bear the cost?
Professor Rubin: The costs for
undergraduate and postgraduate medical education are handled slightly
differently. In the case of undergraduate medical education, there
is more flexibility, in that there is something called SIFT which
reflects the additional costs of education and training. In the
case of postgraduate medical education, it is the salaries of
the trainees that are held by postgraduate deans who are held
responsible for postgraduate training. That is not the whole answer.
Paying for the trainee is fine, but the trainee is being trained
and you are still reducing the throughput while the trainee is
being trained, so there has to be time to work through. What does
it really mean to have educational training going on in ISTC?
Those negotiations have to be intelligent and informed so that
everybody goes into the arrangement with their eyes wide open.
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