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21 Jun 2007 : Column 534WH—continued
I subscribe to the view that we should have a risk-based system. Dame Janet Smith seemed, on my reading, to set out in a very competent and comprehensive way to examine what had happened and to expose how, if people had acted on the information that was available to the respective parts of the system in place, it would have been possible, in a better system, to identify wrongdoing and risk, and to deal with it. However, because Dame Janet considered many aspects of the regulation of the medical profession and identified deficiencies in it, she has made wide-ranging recommendations geared to the reform of the system as a whole. On any reading, those recommendations go beyond what is necessary to identify and deal with—I hope far more effectively—someone who is behaving even remotely in the way Harold Shipman behaved.
To bring that back to specifics, she recommended that revalidation should be conducted not on the basis of concerns about somebody’s fitness to practise but on the basis of a positive effort to secure revalidation.
Andy Burnham: That is what we propose.
Mr. Lansley: Exactly—that is indeed what the Minister is proposing. However, we are dealing, in that sense, with two different things. They are not alternatives. In order to combat the risk of any eventuality arising in which a medical practitioner’s responsibility for malfeasance, wrongdoing, malice or incompetence was such that we needed to act on the basis of risk, we must have a very robust system for acting on concerns.
We must be very clear that we are trying to ensure that practitioners are fit to practise; that part of the system has to be robust but proportionate. It is for us to work out how much effort and time and how many resources need to be put into revalidation to make it work in a way that commands the confidence of the medical profession and the public. Enormous amounts of resources are going to be involved.
I do not want to anticipate the Second Reading debate of a future health professions Bill. However, as the Government published their White Paper in February, it would be useful to air some issues; if, in the next parliamentary Session, we can secure legislation that commands consensus across the House and creates a stable system for the long term, it will be the better for that. I am content for us to move towards a structure of governance for the GMC that is balanced in respect of its representation of the professions and of lay people. We just need to talk a bit more about how confident we are of what “independent appointment” means in practice.
I know that the Government are clear that they have to set out the specifications and criteria for appointments and that things will be conducted through the Appointments Commission, which is independent, but we are placing a large amount of confidence in the ability of the commission to secure the right candidates for posts. I am not yet clear about how confident we can be about that; we should go further.
I turn to revalidation. As I said, I have questions about the risk that, by putting in place a rigid structure, we will not only incur large costs and a diversion of effort, but may end up with something that becomes
routine rather than proactive. If we looked, as we must, at where the real deficiencies lie, we would find that clinical governance in the hospitals—the secondary sector—has developed enormously in recent years. From my vicarious experience, it is far stronger now than it was many years ago.
I do not want to underestimate the efforts that those working in primary care put into continuing professional development. However, I do not think that the sector’s process of clinical governance as a whole—particularly the effort put into audit of outcomes, adverse events and risks—is anything like as strong or systematic as that of the hospital sector. That is why the medical examiner should not only be concerned with assuring people about the certification of deaths, but should be integral to securing that quality of audit trail through primary care. We need to be confident that we are creating structures in primary care, for GPs in particular, that are at least as strong as those in the secondary sector.
There are many single-handed general practitioners, and I do not disparage them in any sense. However, we must be aware that large numbers of doctors practise in the community in a highly professional independent way. When we debate the pay and remuneration of GPs, we often forget how independent and responsible they are. With that responsibility must go an equal level of audit and clinical governance.
I turn to some questions for the future, if not for today. I am not clear about how far we are, literally, going to maintain a self-regulated professional structure and how far we are shifting from a statutory framework to Government regulation. I listened with interest to what the hon. Member for Oxford, West and Abingdon (Dr. Harris) said. He accused the Government of imposing Government regulation, but I am not sure whether the Government are proposing that. However, there is a difficulty: if we go too far and the statutory framework becomes too intrusive and prescriptive, it will become, in effect, the same thing. What is intended is professional self-regulation that secures a high level of confidence and good results, within a statutory framework that gives us powers of intervention.
Andy Burnham: That will be an area of debate on the legislation, but can I be clear that the hon. Gentleman accepts—I think he does—that there has always been an element of hybridity about medical regulation? A parliamentary process lays down the framework through which self-regulation happens. By definition, there will be some prescription in the legislation of the basic structure of that self-regulation. Perhaps I did not say it clearly enough to the hon. Gentleman, but that is exactly what is being developed. There will be no diminution of professional self-regulation.
Mr. Lansley:
Yes, I am sure that that is a shared intention. However, let me give two relevant examples that will illustrate the nature of my concern. We have already gone down a certain path. In medical education and training, responsibility for undergraduates and continuing professional development are with the GMC, but responsibility for postgraduate education and training is with the Postgraduate Medical Education and Training Board, which, from the profession’s point of view, has been substantially
nationalised. I do not understand why one bit in the middle of that spectrum—from undergraduate to specialist and continuing professional education and training—has been taken out and is something on which the profession does not lead.
I come back to the GMC. I have never understood why the profession and the GMC will lead on revalidation and fitness to practise, yet if somebody’s practice has a difficulty that does not get to the point of their fitness to practise being investigated, that will be the responsibility of the National Clinical Assessment Service, which is effectively part of a Government agency. I get rather confused by that; perhaps it is my ignorance, although I suspect that it is not entirely that. There seems to be a discontinuity in the spectrum of support for professional competence. I would rather that it were a professionally-led and professionally-delivered structure that commanded confidence in the profession.
I shall not go all the way with the hon. Member for Oxford, West and Abingdon in respect of how much the profession is concerned about the issue, but we certainly need professional confidence, as well as public confidence, in the structure. If we give the profession the responsibility and a proper structure, we shall be able, as the hon. Gentleman said, to rely on the medical profession to be sufficiently well informed, concerned and responsible to identify and root out problems at least as well as any group of lay people.
Dr. Evan Harris: I am grateful for the intelligent way in which the hon. Gentleman is going about this discussion. However, the issue is not only about professional confidence. I did not give this example in my earlier remarks, but let us say that a doctor is accused of not meeting Government targets because he thinks that they are not right for his patients. I think that the profession would think that other doctors —independently of that doctor—would be more likely than lay people and those appointed indirectly through a Government-organised process to uphold the importance of putting patient care above the need to meet Government targets. The profession is concerned about that sort of example.
Mr. Lansley: I understand; the hon. Gentleman slightly tempts me, but I shall not go too far along that line. The moment that the hon. Gentleman mentions Government targets, one has to embrace the thought that the medical profession will be able to deliver the kind of professional self-regulation that we are discussing in circumstances in which responsibility for the care of patients is exercised by clinicians on the basis of their professional judgment. The chief medical officer, in his conclusions to his document “Good doctors, safer patients”, which was published last year, said:
“The quality and safety of the care received by patients is not yet central to the goals, culture and day-to-day activities of every organisation and every clinical team delivering care to NHS patients. Financial and activity targets often have a higher priority.”
That comes back to the point made by the hon. Gentleman. If we are looking for professional regulation, it has to be in a structure within which professionals understand that the structural framework and the organisational framework are entirely consistent with the care and priority that they give to the care of patients.
The next sentence in the report from Sir Liam Donaldson stated:
“It is misguided to think that these considerations are mutually exclusive. In the best healthcare organisations in the world, the ‘business plan’ and the ‘quality plan’ are one and the same.”
To be fair to the chief medical officer, we know exactly what he is aiming at, and I hope that we would see it in policy terms. Professionals would not find a conflict between Government targets or the objectives of an organisation and their professional responsibility, because they all point in the same direction. That is what we are aiming for.
I managed to raise most of the points that I wanted to make in my interventions. One was about the standard of proof in particular. It is right to proceed on the basis of a civil standard of proof, flexibly applied. The point that I made in my intervention was that flexibility must be carefully applied in determining the severity of penalties that might ensue from accusations. I hope that that will be understood in the medical profession. As the Minister rightly said, most doctors are worried about the standard of proof that would be applied to deprive them of their livelihood and bring them in to public disrepute. That sanction would be applied only where there was evidence to support the accusation beyond reasonable doubt. A range of penalties are available that do not have quite the same impact and do not require a “beyond reasonable doubt” standard of proof. That seems logical to me, but everything that I read suggests that we have not yet got that message across to the medical profession. We need to have that debate, even if it is in the few months before we discuss the legislation.
Dr. Harris: Will the hon. Gentleman give way?
Mr. Lansley: I shall give way, and then I must finish.
Dr. Harris: Is there not a problem? I have to say that I have not investigated the matter fully, so these are initial thoughts, but the hon. Gentleman is implying that the person who makes the decision about guilt has the sentence in mind when deciding the burden of proof that is to be required. That might be possible, but it might break down if an appeal is made only on the sentence, as can be done through the Council for Healthcare Regulatory Excellence. It might increase the sentence without a commensurate increase in the level of the burden of proof required.
Mr. Lansley: Yes. I am not a lawyer, so such a subject trespasses slightly outside my expertise. The hon. Gentleman is not a lawyer, either, but he clearly has great expertise, not least because of his participation in discussions on the subject at the BMA. As I understand it, it is impossible not to have in mind the nature of the penalty that might ensue from the accusation. It does not mean that the person has to have the penalty in mind. There is an interplay between the nature of the charges and the nature of the penalty. My point, however, is that one should start from an understanding of the extent of the penalty that might ensue from an accusation.
The hon. Gentleman makes a fair point, given the nature of an appeal process that might change the penalty. One has to think about that, too. However, unless I am much mistaken, in considering on appeal
what should be the penalty, any responsible tribunal would bear in mind the standard of proof that had been achieved.
I said that I was going to conclude, so I should. I wanted to make one point about what lies at the heart of the matter—happily, I know that such subjects are at the forefront of thinking among doctors. I was with the Association of Surgeons in Training in Belfast back in late March, and listened to a number of presentations. There was a fascinating presentation by someone whose name I forget, who had suffered the loss of his wife. Clinical negligence had not taken place, but mistakes had been made during the course of her operation. He had devoted an enormous amount of effort to communicating with doctors about how to achieve quality and safety. He was qualified to do so because he was an airline pilot. One can stretch the analogy only so far, but it is an important one. In the airline industry, it is well understood that people make mistakes. If someone makes a mistake in the airline industry, they are held to blame or penalised not for making the mistake, but for not reporting the mistake, since reporting the mistake allows the problems to be eradicated.
If we are confident that we do not have a culture in which we try to escape blame, pass blame or cover things up, and that we have one in which all adverse events are brought out, not only will we disclose mistakes and deal with them but we will make it harder for all those who are guilty of wrongdoing or behaving with malice to carry on and to hope that the things that they do will be dealt with on the inside rather than exposed and dealt with through the system of regulation that we all hope to achieve. I hope that we can be confident that we will achieve that culture.
4.37 pm
Andy Burnham: I echo the last remark of the hon. Member for South Cambridgeshire (Mr. Lansley). If we can create such a culture, we will have done something truly valuable for the country for many years to come.
I am grateful for the way in which all hon. Members contributed to the debate. If we can continue our deliberations on these matters in the same vein, we will do politics, our parties and Parliament a service in trying to get the right settlement for the future.
When my hon. Friend the Member for Denton and Reddish (Andrew Gwynne) spoke about the effect on the borough of Tameside, it got me thinking. The borough does not want to be remembered for those terrible events—nor should it be, because it is a fantastic part of Greater Manchester, which I represent, too. In some ways, I hope that my hon. Friend’s constituents and those of my hon. Friend the Member for Stalybridge and Hyde (James Purnell) will see some of the positive legacy of the improvements to Tameside general hospital that we hope to implement quite soon through the substantial redevelopment scheme under the private finance initiative.
It is a matter of some coincidence that tomorrow I shall open a new practice in the fine borough of Tameside, near the constituency of my hon. Friend the Member of Stalybridge and Hyde—Dr. Kailash Chand’s practice at
the Stamford House surgery. In many ways, what matters is not raking over the coals but bringing forward positive progress to the borough of Tameside that shows that the health service can take a stride forward and do something significantly better than before. That is the challenge that faces us all.
I shall answer the questions that colleagues have asked, although I do not intend to speak for a long time, as we have had a full debate. My hon. Friend the Member for Calder Valley (Chris McCafferty) eloquently asked how it was possible for Shipman to continue his criminal activities for so long without being detected and how the system could not have been adequate to pick up the clues and warnings and protect patients. That is the key question that I have asked myself in considering the right response to the matter, and it was why I re-examined the issue of death certification when I was asked to do so.
The hon. Gentleman is correct to say that the matter should sit within the clinical governance function of PCTs, so that information is used for commissioning and public health purposes, for general good governance in a locality and to detect any patterns of disease or illness. That would make it part of an integrated system, working with a reformed coroners system and system of professional medical regulation to do precisely what my hon. Friend said. That is a crucial piece in the jigsaw of creating systems that give us the satisfaction that we want.
My hon. Friend asked whether we could create systems to ensure that such a thing never happens again. I am not sure whether we can ever be so arrogant as to say that any piece of legislation could do that, but we can work to close the cracks and limit as much as we can the weaknesses and the likelihood of it happening again. That is my objective in bringing forward our package of proposals. If the system is to work it is crucial that PCTs examine the whole range of indicators of clinical quality, including death rates, analyse information from death certificates and have an overview of complaints. They must use all that information to inform the strengthened system of scrutiny and accountability.
My hon. Friend and others asked about the timetable for the implementation of the system. We propose to publish a consultation document on death certification shortly—that is not Department of Health-speak “shortly”; it does mean shortly. The timetable for implementation is still to be determined, because it will be subject to legislation. One of the problems, and the reason why I referred to Dame Janet’s third chapter of the third report, is that there is legislation controlled by and relating to different bodies such as the Ministry of Justice and the Office for National Statistics, and the Home Office has a considerable interest in some of the issues that we are debating. The matter is complicated and subject to legislation, but it makes sense to consider a timetable for putting the reforms together.
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