[Relevant documents: Eighth Report from the Constitutional Affairs Committee, Session 2005-06, HC 902, and the Governments response thereto, Cm 6943. Uncorrected minutes of evidence of 8 May 2007follow-up, HC 515-i.]
The Minister of State, Department of Health (Andy Burnham): I am pleased that we have been able to secure time this afternoon to debate the findings of the Shipman inquiry, which dealt with a matter of huge significance that has far-reaching ramifications for several Government Departments and which raised matters of great horror for the families who were affected and for the communities that still, to this day, remember the consequences.
To begin, let us remind ourselves of the facts. In January 2000, Harold Shipman, a sole-practice general practitioner in Hyde, Greater Manchester, was convicted at Preston Crown court of murdering 15 of his patients. He committed those murders by injecting his patients with lethal doses of diamorphine, a strong painkiller that is related to heroin. It has legitimate and widespread use in the treatment of the terminal stages of cancer and of other medical conditions. As further information came out during and after the trial, including the results of an audit of Shipmans mortality data that was commissioned by the Department of Health, it became apparent that those crimes were not isolated but were merely a small sample of an horrific series of murders committed over a period as long as 25 years and spanning virtually the whole of Shipmans professional life.
The Shipman inquiry was set up in January 2001 and was tasked with investigating the extent of Shipmans unlawful activities, inquiring into the activities of the statutory authorities and other organisations that were involved, and making recommendations on the steps needed to protect patients in the future.
The inquiry published a total of six reports. The first report addressed the extent of Shipmans criminal activities as a GP. The second report covered the 1998 investigation by the Greater Manchester police. The third report covered the system of death certification and the coroners system. The fourth report covered the systems for ensuring the safe and appropriate use of controlled drugs. The fifth report covered the arrangements for monitoring and disciplining GPs, including arrangements for the handling of complaints in the national health service, and the sixth report addressed the extent of Shipmans criminal activities in the early part of his career as a junior hospital doctor. I wish to put on record the conclusion of Dame Janet Smith, now Lady Justice Smith, in paragraph 28 of the summary to the sixth report. It states:
My overall conclusion, therefore, is that Shipman killed about 250 patients between 1971 and 1998, of whom I have been able positively to identify 218.
That is the scale of the crimes. We are debating the ramifications as they affect not just the Department of Health but several Departments, and we continue to build a system that will reduce significantly the likelihood of any crimes on that scale ever being repeated.
I welcome this opportunity to debate the findings of the Shipman inquiry and the action programme that the Government have set in place to ensure, as far as we can, that a similar tragedy never happens again. I begin with an obvious but vital point. The overwhelming majority of health professionals and staff working in the NHS are dedicated to providing the best possible care that they can for their patients. They bring to their work skills, professionalism, commitment and empathy for their patients, and we in turn entrust them with crucial aspects of our health and the health of our families. In the vast majority of cases, that trust is well placed. Opinion polls repeatedly tell us that, of all occupations, health professionals such as doctors and nurses are the most trusted.
It is therefore all the more bewildering, as was expressed in the Shipman inquirys first report, when that trust is betrayed. Tragically, that is exactly what happened in the case of Harold Shipman. To outward appearances, he was a devoted, caring doctor. In some respects, he was at the leading edge of his professionfor instance, in his approach to clinical audit. It was that outward appearance that enabled him to conceal the evidence of his crimes for so many years and to pull the wool over the eyes of many people who should have been more alert to what was happening.
I believe that I speak for colleagues on both sides of the House when I say that we owe an immense debt of gratitude to the Shipman inquiry, in particular to its chairman, Lady Justice Smith, for the meticulous work that was done in unravelling the story of Shipmans crimes and the failure of the systems in place at the time to protect patients. Anybody who has reviewed the reports, as I have in preparation for this debate, will be impressed by the extremely detailed analysis of every aspect of the Shipman story. A mere glance at the title pages of the inquirys six reports gives an indication of the breadth of the work.
I pay tribute to the skill with which the inquiry sought in its recommendations to balance the need to safeguard the normal processes of patient care with the need to protect the public from the rare cases of professional abuse. It is important to acknowledge at the outset that it is incredibly difficult to get that balance right. It is vital to recognise that the vast majority of health professionals are dedicated to the care of patients and go about their work in an exemplary fashion, doing nothing but good for the communities that they serve.
Dr. Evan Harris (Oxford, West and Abingdon) (LD):
I welcome the way in which the Minister has introduced the topic. May I explore an issue with him? He maintained that doctors are more trusted than most other groups, and I certainly agree with that. The point that I would like him to address is that they are still the most trusted, even after the Shipman inquiry. There is no sign in polls that they are any less trusted. Therefore, does he agree
that policies that the Government wish to put into place following the Shipman and other inquiries must be designed to protect patients and not seek purely to restore or increase faith in the medical profession? That would be a wrong and unnecessary motive, and there is enough work to do if the motive for action is to ensure that patients are protected.
Andy Burnham: I agree entirely with the hon. Gentleman. The guiding principle of every measure that has been and will be introducedthere is, of course, some considerable way to go before we have done full justice to this hugely significant inquiryis the protection of patients and the public. All the measures that we take must contribute to that aim, but, in doing so, they can provide further reassurance to the public that their trust in health professionals, and doctors in particular, is not misplaced. As we all know, that trust is not misplaced, but the perception that the systems are transparent and robust is part of ensuring patient safety. The profession has nothing to fear. Indeed, I am hugely grateful for the constructive engagement that we have had with the British Medical Association, the royal colleges and the General Medical Council in getting this complicated package right. As I said when we published our response to the inquiry in February, this has to be a settlement for a generation. It must produce a conclusive and consensual agreement on the right way forward, and that will be done only by working co-operatively and in partnership with the professionals.
Mr. Andrew Lansley (South Cambridgeshire) (Con): I share the gratitude of our colleague, the hon. Member for Oxford, West and Abingdon (Dr. Harris), for the manner in which the Minister is introducing the debate. As we are establishing the principles that we should apply, does he agree that the enormity of what Harold Shipman did and the huge betrayal of trust that occurred, to which the Minister referred, does not invalidate the principle that the medical profession is capable of self-regulation within a statutory framework? Although the balance of professional and lay participation in the process will change, we should start from the presumption that, with the appropriate levels of transparency, doctors are capable and competent enough to regulate themselves.
Yes, I agree. The package of reform that we introduced in February does retain the system of independent self-regulation and suggests a parity between lay and professional representation within the main regulatory bodies and that those appointees should be independently appointed. It is important to ensure that the public have confidence that the regulatory system balances the public interest alongside professional standards. The system that we have proposed would achieve that aim, but there are different views on that and I will continue to discuss the matter with the medical profession. It is not in the interests of any profession for a closed discussion to take place on an issue of such import. As the hon. Member for Oxford, West and Abingdon (Dr. Harris) rightly said, we are discussing matters of patient and
public safety and it is important that there is and is seen to be openness, transparency and balance in the way we do so.
I do not want to mention any particular regulator, but I have to be honest and say that I have seen evidence that some professions can become too inward in the discussions that they have about regulatory matters among themselves. At times, they are not sufficiently outward facing in the way in which they consider public safety. I do not want to go into detail, but the hon. Member for South Cambridgeshire (Mr. Lansley) may know to what I am referring. It is important that the professionals role in self-regulation is balanced with the voice of the lay representative, but we can discuss those matters further as the debate progresses.
Today's debate is about the Shipman inquiry, but I will mention in passing the work of three other inquiriesthe Ayling, Neale, and Kerr/Haslam inquiriesthat also deal with the abuse of trust by doctors. The details differ, but the underlying issues are similar: the failure of those in authority in the NHS to take seriously repeated expressions of concern about the actions of trusted health professionals, and to take effective action to protect patients. In responding to the fifth report of the Shipman inquiry, we found it sensible to consider at the same time the related recommendations of the three other inquiries, and I propose to do the same today.
I know that the colleague of the hon. Member for Oxford, West and Abingdon, the hon. Member for Harrogate and Knaresborough (Mr. Willis), who is Chairman of the Select Committee on Science and Technology, has a constituency interest in these matters. Indeed, he wrote to me a few weeks ago and asked whether we could have time for a Government debate on the issue. Unfortunately, it has fallen on a day when I believe he is out of the country, but I put my appreciation of his suggestion of a debate on the record.
Dr. Evan Harris: I am grateful to the Minister for his comments. I can confirm that my hon. Friend the Member for Harrogate and Knaresborough (Mr. Willis), who Chairs the Science and Technology Committee, is on a Committee trip to Portugal. I would also be there if I was not participating in this debate, but we wished to ensure that at least one of us took part. I know that he is grateful to the Government for finding time for the debate, even though it fell on the wrong day for him.
As the Shipman inquiry recognised, the NHS is in many ways very different from the NHS in which Shipman practised. In particular, since the publication of the Governments quality strategy in 1998, A first class service, new structures have been put in place to ensure the quality of care, to focus health care organisations on continuous quality improvement, and to identify and deal with poor professional performance. In the new climate it seems unlikely that abuses such as those perpetrated by Shipman, Kerr and Haslam would have continued for so long without coming to the relevant authorities attention. Nevertheless, the list of the weaknesses in earlier systems that were revealed in the four inquiry reports leaves us no room for complacency. We need to learn from the past to ensure that future safeguards are as robust as we can possibly make them.
The inquiry recommendations that we are dealing with today fall into the following broad areas: arrangements for death certification and for critical overview of the information on death certificates; the coroners system; safeguards over the use of controlled drugs; the handling of complaints and concerns in the NHS; routine monitoring of professional performance and conduct;arrangements for professional appraisal and revalidation;anddisciplinary processes, including the fitness- to-practise processes of the national professional regulators.
In the time available, I cannot hope to do justice to the wealth of detail in the recommendations in those areas. Instead, I propose first to set out some general principles, and, second, to mention selectively the most important changes that we will introduce. Our action programme is summarised in the paper that we published in February, Learning from tragedy, keeping patients safe,and in a series of more detailed papers, all of which have been laid before Parliament. The paper that we published in February provides an overview of all Government activity in response to the Shipman inquiry and will, I believe, provide a document of historical importance and use to people who research these matters as it brings together a vast programme of work.
The Minister for Pensions Reform, my hon. Friend the Member for Stalybridge and Hyde (James Purnell) originally asked the Prime Minister whether the Government would produce such a document. I am pleased to have put the document together at his request and that he has joined us today to hear the proceedings. I pay tribute to him for the assiduous and respectful way in which he has pursued the interests of his constituents in this matter. It will be some time yet until those interests are fully resolved and until we can genuinely say that all of the issues that arose from the Shipman inquiry have been properly dealt with.
I am also pleased that my hon. Friend the Member for Calder Valley (Chris McCafferty) is here. Shipman mainly practised in the constituency of my hon. Friend the Member for Stalybridge and Hyde, but he also practised in her constituency. It is pleasing that they and my hon. Friend the Member for Denton and Reddish (Andrew Gwynne) are here. I believe that he also knows people in his local area who were affected. I thank all three of my hon. Friends for their work on the issue, but I particularly thank my hon. Friend the Member for Stalybridge and Hyde for the measured way in which he has pursued the interests of his constituents. On the record, I give an assurance that we will continue to work through the issues until they are resolved to the satisfaction of him and his constituents.
On the general principles of the matter, our overriding priority has to be the protection of patients and the general public. Secondly, that should be done in a way that minimises any potential impact on the delivery of normal patient care and that affirms and supports health professionalsthe overwhelming majority of whom, as I have already noted, aspire to do their best for their patients. Thirdly, any additional safeguards should build on existing processes,in particular on the processes in the NHS for ensuring clinical quality and safety, which are collectively known as clinical governance. Finally, those additional safeguards should apply consistently across all sectors of health careand on a proportionate basis to all health professions, not just to doctors. Shipman was, of course, a doctor in general practice,
but it would be deeply irresponsible for us not to consider the further implications for secondary care and for other health professions.
On the detail of the coroners system and, in particular, the proposed changes to that system, generally coroners and coroners officers do a good job in often difficult circumstances, but the inquiry exposed a range of limitations. Proposals for reform of the coroners system were set out in February last year and a draft Bill was published in June. A substantive Bill will be introduced as soon as parliamentary time allows. There was a Westminster Hall debate on the proposals in March this year, so I do not propose to go into great detail, but some of the main proposals are to allow bereaved people a greater opportunity to contribute to coroners investigations and to appeal if they are unhappy about decisions taken; to reduce variability in service and spread best practice by introducing national leadership for the service through a new chief coroners post and inspection programme; to make investigations more effective by removing some archaic, restrictive legislation and giving coroners additional powers; and to make coroners posts whole-time appointments, and to provide them with better medical support and advice.
Dr. Evan Harris: I am sorry to interrupt the Ministers flow, and I do not know if he is coming back to the coroners system, but can he give some idea of the timetable for those reforms, because, as he knows, the Governments initial draft Bill, although well motivateda great deal of work went into itdid not meet with wholesale approval, so to speak, when it was scrutinised? It is not clear when that Bill is coming back into what is, I accept, a crowded Government legislative programme. If he can provide some information about Government thinking, it would be useful.
Andy Burnham: I appreciate the hon. Gentlemans frustration, perhaps, and the need to make progress. We all feel that. Obviously, I cannot pre-empt future Government decisions on the future legislative programme, but I hope that he accepts that in publishing the draft Bill, we showed good faith in consulting on these important matters. Indeed, we listened to the Select Committee on Constitutional Affairs, which commented in detail on the draft Bill.
The Committee talked about the importance of the system of death certification, and, because of the interrelationship between the coroners system and that for death certification, to which recommendations 5 and 6 of the report apply, asked the Government to come back to it. AgainI hope that this shows to the hon. Member for Oxford, West and Abingdon that the Government have listened to those concernsI have taken a personal interest, partly owing to the promptings
of my hon. Friend the Member for Stalybridge and Hyde, but more generally because the system is incomplete, in my view, without reform in the system for death certification. I hope that when any Bill for reforming the coroners service is introduced, the hon. Gentleman will look at it in tandem with proposals soon to be published for arrangements to improve death certification.
The Shipman inquiry found that existing arrangements for scrutinising death certificates were confusing and inadequate. The main problems are that arrangements are different for burials and cremations, with very little oversight at all for burials; scrutiny in cremation cases is not always sufficiently independent and is not subject to effective quality assurance; and there is no systematic analysis for local clinical governance purposes of the information on death certificates. As Lady Justice Dame Janet Smith pointed out, the system relies heavily on the honesty of the certifying doctor and she felt, partly for that reason, that the system was inadequate. She pointed out also that the doctors involved do not get full access to the medical records so that they can make a careful and detailed judgment, and that it must be integrated with clinical governance arrangements.
As I said, I have looked in detail at that whole area on the prompting of my hon. Friend and others. Parliamentary colleagues will know that this issue has a history, in recent times and before. I refer hon. Members to chapter three of Dame Janets third report where she talks in detail about the origins of the existing cremation certification system. In particular, however, she focuses on the more recent attempts to reform that system, beginning essentially with the report of the Brodrick committee in September 1971, which was a major change. It was set up in March 1965 following the British Medical Association paper Deaths in the Community, which was published in 1964. In particular, the committee dealt with the suggestion that homicides were passing undetected through the existing certification system. That suggestion was based on the book The Detection of Secret Homicide by Dr. John Havard, who was, at that time, assistant secretary of the BMA, and played a prominent part in its dealings with the Home Office over a period of several decades.
It is important for us to remember the history. Dame Janets report deals with that history from the publication of the Brodrick committee report, which recommended a fairly detailed overhaul of the system. In paragraph 3.82 of her report, she states:
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