House of Commons
|Session 2007 - 08|
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General Committee Debates
Health and Social Care Bill
Health and Social Care Bill
The Committee consisted of the following Members:
John Benger, Celia Blacklock, Committee Clerks
attended the Committee
Lady Justice Smith, Judicial Office
Professor Sir Graeme Catto, President, General Medical Council
Findlay Scott, Chief Executive, General Medical Council
Dr. Hamish Meldrum, Chairman of the Council, British Medical Association
Dr. Laurence Buckman, Chairman of the GP Committee, British Medical Association
Frances Blunden, Principal Policy Advisor (Health), Which?
Helen McCallum, Director of Policy, Which?
Councillor David Rogers, Chair, Local Government Association Community Well Being Board, Local Government Association
Anne Williams, President, the Association of Directors of Adult Social Services, Local Government Association
Public Bill Committee
Tuesday 8 January 2008
[Derek Conway in the Chair]
Further written evidence to be reported to the House
H&SC 17 Mental Health Act Commission
The Chairman: It is now four oclock and we have a fairly tight timetable to get through. Obviously, Jimmy was chairing the Committee this morning. Before we begin, does anyone have any preliminary points to make?
Angela Browning (Tiverton and Honiton) (Con): How long before our proceedings today will be available to read?
Angela Browning: So will we be able to read and quote from todays proceedings during Thursdays debate?
Lady Justice Smith, thank you very much for coming to the Committee to answer my colleagues questions. As you know, we are on a fairly tight time scale and our session must end at 4.40 pm, whoever is speaking, and whatever stage they are at in their sentence.
Lady Justice Smith: Yes.
The Chairman: Forgive our rudeness if that occurs. Before I invite my colleagues to put any questions, perhaps you would tell the Committee a little about yourself and say a few words. We shall then move straight to questions.
Lady Justice Smith: Briefly, my job at the moment is Lady Justice of Appeal, a judge of the Court of Appeal. I have been doing that since November 2002. Before that I was a High Court judge in the Queens bench division, doing a mixed bag of crime and civil work. I went off to do the Shipman inquiry in January 2001. It took me four years, I am afraidtwice as long as the Lord Chancellor warned me that it would, but there it is. That is the basis of such expertise as I have on these matters.
I must warn you, before you start questioning me, that since I returned to my day job in January 2005, it has not really been possible for me to keep up as well as I would like with day-to-day developments in medical regulation. Of course, I have a maternal interest in the
The Chairman: Thank you for that. My colleagues understand that there are certain questions that you cannot answer because of your position. If, at any stage, you feel that the questions are not appropriate, feel free to say.
Lady Justice Smith: I will say so, but generally any difficulty will arise out of individual cases. I cannot imagine that you are going to ask me about those.
Q 6161 Sandra Gidley (Romsey) (LD): The Bill makes a number of changes to the regulation of health care professionals, particularly in medicine. Are the changes proposed in the Bill broadly in line with your findings and recommendations?
Lady Justice Smith: Yes, broadly, but this is very much a bare bones Bill. A huge amount of detail will be left for delegated legislation. One of my difficulties at the moment is seeing exactly how it will work because so much is left for secondary legislation. I welcome the creation of an independent adjudicator and the change to the standard of proof, which were recommendations of mine. I am particularly concerned that I do not understand how re-validation will work. The Bill gives only the vaguest of clues about how it will work, and I am a little worried about that.
As far as the independent adjudicator is concerned, I know that the General Medical Council has put in a memorandum, which it kindly showed me in advance, expressing concerns about the independence of the adjudicator, and I share those concerns. It is vital that an independent adjudicator should be independent of Government as well as the GMC. The purpose of my recommendation was that we should have someone adjudicating who is independent of the GMC because it cannot properly be investigator, prosecutor and judge in the same causes. I was concerned about its human rights compliance. That has been accepted, and we will now have an independent adjudicator, but it should be independent of Government as well as the GMC.
Q 62 Sandra Gidley: Thank you for that. I believe that you also made some recommendations about the proportion of lay members. Will you elaborate on them? Did they just seem like a good idea, or did you have any evidence to back them up?
Lady Justice Smith: I did not have much evidence about what the proportions should be. I felt that the proportions were wrong in the GMC at the time and that lay members were not carrying sufficient influence. I recognised that as the GMC was organised at that timeand I think that this will changeit needed quite a lot of medical members to carry out particular functions that required professional qualifications. I did not want to denude it by suggesting that the number of medical members should be reduced too drastically. Besides, it might surprise you to know that I did not want to frighten the horses too much either. I am very content with the proposal here that there
Lady Justice Smith: Not just public perception. I wanted to enhance the influence of the lay members within the GMC. I thought that under the existing arrangements they were too much the underdogs.
Q 64 Sandra Gidley: Okay. I have a final question. Would you like to see any other changes to the Bill? Are we missing an opportunity here?
Lady Justice Smith: There is one matter, which you might feel is quite small. It relates to the fitness to practise panels under clause 93, subsection (2) of which states:
A fitness to practise panel is to consist of...a chair selected from the lay members list or the professionally qualified members list.
I recommended that adjudication panels should be chaired by legally qualified people. I explained a number of reasons why I made that recommendation. The GMC has never done it. It does not think that it is necessary but, of course, we are not talking about the GMC. I had understood that the chief medical officer was more or less in agreement with my proposal, although I noticed that, in his review of my report, he just said that there should be an independent adjudicator and that panels should be staffed appropriately with those who are medically and legally qualified and lay people. I understood from that that he wanted some legal expertise on the adjudication panels, which is what I had wanted.
Now I see that the chair must be selected from the lay members or the professionally qualified members. I then tried to find out the meaning of a professionally qualified member, and the definition section under clause 93(4) states that a
professionally qualified members list means the list of persons eligible to serve as professionally qualified members provided for by section 94(1)(b).
Section 94(1)(b) states that they are
persons eligible to serve as professionally qualified members.
Around we go in a circle.
I suspect that the provision means medically qualified people, but that is not made clear. I would like it to be made clear that there can be legally qualified people on the panels. As the way in which the panels are to work will be decided by the Office of the Health Professions Adjudicator, not by Parliamentreference can be made to an example, under clause 94(6), of the delegated legislation rules that are to be made by OHPAI should like the OHPA at least to have the option of having legally qualified chairs. If you want me to give reasons why I think that that is a good idea, I shall do so, but they are set out in my report.
I believe in horses for courses and in professional expertise being matched to the nature of the tasks in hand. Chairing a disciplinary tribunal is a job for a legally qualified person, not a lay person. Legally qualified people who appear in front of such tribunals are capable of running rings round the tribunal if no
Q 65 The Minister of State, Department of Health (Mr. Ben Bradshaw): May I return to something that you said earlier, Lady Justice Smith, about the status of the independent adjudicator? You kindly acknowledged that your recommendation stressed the influence of independence from the GMC, but you now say that you have some sympathy with the position of the GMC, which is arguing that it should not be the proposed model that is an Executive, non-departmental public body along the lines of the Independent Police Complaints Commission. I wondered what your reasons were for that and whether you had an alternative model in mind that would satisfy the need for democratic and public accountability.
Lady Justice Smith: May I suggest that I leave that issue for the GMC? It has written a memorandum, which you might not have had the chance to read yet. Representatives from the GMC are herethere they areand they will be speaking next. It is a point that they feel strongly about. I confess that the lack of independence of Government had not jumped out and hit me between the eyes. It plainly has now and having read the memorandum, I am sympathetic to that point. I would rather just leave it at that.
Q 66 Mr. Stephen O'Brien (Eddisbury) (Con): Slightly moving on, thank you very much for your observations on clauses 93 and 94. I will be very surprised if there is not a Government amendmentif not, I assure you that there will be another amendment from somebody elsethat will help to give some clarification.
The regulations that have just been sent to us as members of the Committee who support this include the phrase in the wake of a number of high profile inquiries. Clearly that refers to what was I think in the end six inquiries into doctors who had harmed their patients. The Office of the Health Professions Adjudicator is being created as a new body able to make adjudications and decisions. Are you happy with that declaration of provenance?
Lady Justice Smith: Yes. It was very much a recommendation of mine. As I have said, I was concerned that the GMCs arrangements were not compliant with the Human Rights Act 1998. The GMC thought that they were; I thought that they were not.
Q 67 Mr. O'Brien: That is clear, thank you. It strikes us that there will be an opportunity to discuss the element of independence that has been focused on in some of the questions and your replies. That will probably take place early on Thursday afternoon in the amendment that is tabled to clause 2(4), which in relation to the Bill performing its functions of looking
Lady Justice Smith: May I intervene for a moment? I notice that the chairmanor chair as I must call it nowadaysof the adjudicatory body, the OHPA, must be legally qualified. Where do I find that provision? I think that it is under schedule 6, but I have lost the piece of paper on which I had made a note of it. To my mind that gives some reassurance. Here it is: schedule 6(4) states
The OHPA is to consist of the following members-
(a) a chair appointed by the Privy Council
Then schedule 6(6) states
A person may be appointed as the chair only if the person as well as satisfying any requirements...has a 10 year general qualification
under the Courts and Legal Services Act 1990. Broadly speaking, that means part or full-time judicial capacity. That does indicate that there should be a measure of independence. It is other aspects that the GMC is particularly concerned about.
Q 68 Mr. O'Brien: That is helpful. Thank you very much indeed. On the role of the OHPA, in the various recommendations that you made and there were manyare you concerned about how the appeal process might operate?
Lady Justice Smith: The appeal from the OHPA?
Lady Justice Smith: There will, of course, be two different sorts of appeals from it in that some regulators will not be within the adjudication body for the time being, although I understand that it is the intention that they should join eventually. I do not think that that should be a problem. I have not spotted the provisionit may be that it is not there, but I think that the GMC would be shouting if it was notthat states that the GMC is entitled to appeal from a decision. Is there such a provision?
Lady Justice Smith: I have not managed to take on board every single provision. Provided the GMC has a right of appeal, which presumably replaces the old Council for Healthcare Regulatory Excellence provision under section 29, the same process would continue for the other bodies that are outside the adjudicator. The CHRE will appeal from the regulatory bodies who are doing their own thing. The GMC, as a party, will have a right of appeal from the independent adjudicatorthat seems all right to meand the doctor will too. Are you worried about that, because that seemed to be all right?
Q 70 Mr. O'Brien: I do not wish to get into how we will need to scrutinise the Bill in later stages because we are taking your evidence rather than mine, but I am concerned that when the powers of adjudication come
Lady Justice Smith: Standard of proof.
Lady Justice Smith: That is all right. There has never been an argument about the burden of proof.
Q 71 Mr. O'Brien: Looking at the standard of proof, I see that it is to be a graded approach depending on the outcome, and I have difficulty with that. How can you know what standard of proof you need until you have heard what is at stake and the evidence? Often, the standard that you would expect to apply would probably have to be set at the beginning. Otherwise, everyone would be moving at the same time, and I am struggling with that.
Lady Justice Smith: Have we done with the problem of appeals?
Lady Justice Smith: I am not worried, which is to say that I am happy, with the proposed appeal arrangements. On the standard of proof, I recommended that we move to the civil standard because, essentially, we are talking about a protective rather than criminal jurisdiction. I know that the consequence could be loss of livelihood or serious damage to it, but my view, which seems to have been accepted, is that adequate protection could be given to a doctor within the framework using a civil burden or standard of proof. I am pleased that that has been proposed and I imagine that it will go through.
How the measure works in practice will require considerable training. That is one of the reasonsI am glad that you mentioned it and that I rememberedfor having a legally qualified chairman. The chairman will understand how it works. If you tell a lay person how to apply the sliding or variable standard of proof, they might find themselves in some difficulty, but a lawyer would not. You do not want a legal treatise now on how it works do you?
Q 72 Mr. O'Brien: Well, it is not in the Bill. I do not want to over-pursue my line, but that is not in the Bill
Lady Justice Smith: No, it is just says the civil standard.
Lady Justice Smith: Well, the civil standard of proof is part of the common law of England, and there are judicial decisions that explain it. Those must be incorporated into how the adjudicatory body
Lady Justice Smith: Yes it doesmany. It applies particularly in fraud cases, for example. The notion is that if you make a serious allegation against someone,
It applies also in cases in which someone is, for example, accused of murder but has not been convicted and a civil action is brought for wrongful death. In such a case, the judge would apply a higher standard of proof than he or she would when considering an allegation of negligence. For example, if there were allegations that a doctor had indecently assaulted patients, you would require fairly cogent evidence before you would convict him.
The Chairman: Angela Browning, I was going to come to you next but we have moved into an area on which Anne Milton would like to ask some questions, so it makes more sense if we pursue the standard of proof issue.
Q 75 Anne Milton (Guildford) (Con): Thank you, Chairman. To some extent, you have covered what I was going to ask. For clarity, you recommended and approved of the move to a single standard of proof, and you would like to see legally qualified chairs?
Lady Justice Smith: Yes.
Q 76 Anne Milton: If there were not legally qualified chairs, would you then have your doubts about the single standard of proof?
Lady Justice Smith: No, I think it is right anyway,
Lady Justice Smith: I think it is right anyway, but I tagged that on as one of the additional reasons why I want a legally qualified chair. There are many reasons why I think that we should have a legally qualified chair, the main one being that to do the job well requires legal expertise, for the reasons that I explained a moment ago. An understanding of the sliding standard, the variable civil standard, is just one little example of the expertise that would be brought to the task by a legally qualified chair.
Lady Justice Smith: Of which profession?
Q 79 Anne Milton: The medical profession. There would be more competence in the system with a legally qualified person.
Lady Justice Smith: I would have thought so.
Lady Justice Smith: All our tribunals have legally qualified chairs. It is quite bizarre to me that somebody
Q 80 Angela Browning: I will be brief because you have covered a lot of what I was going to ask you. During your initial remarks you said you felt that the OHPA should be independent of Government and you mentioned that the GMC had provided you with the briefing that it has also sent to us.
Lady Justice Smith: You have it there.
Q 81 Angela Browning: I do. Looking through the case that the GMC makes, it says that it believes that the Bill extends the ambit of the state quite considerably. It prays in aid in its document, for example, the requirement to keep accounts as specified by the Secretary of State.
Lady Justice Smith: I do not feel strongly about that.
Q 82 Angela Browning: Perhaps not so much. I understand that one of the GMCs grievances is that this has not gone out to proper consultation and that the measures were not recommended in your report or other similar reports. Would a consultation resolve that problem and make the case?
Lady Justice Smith: It might. I did not make any recommendation about independence of Government because that was not what my mind was focused on; I was focused only on independence of the GMC. However it is important, particularly in the health sphere, that the adjudicatory body should be seen to be independent of Government because the Government are a huge customer of healthcare; the biggest customer of healthcare. Therefore, it is important that there should be no suspicion that the Government are in a position to pull strings behind the scenes, as to what goes on. Absolute clarity and absolute independence are really important. As I say, the fact that you are apparently intending to have a judicial figure as the chairman of the adjudicatory body gives me some confidence. What one wants is a degree of judicial independence.
Q 83 Mr. Bradshaw: As we have a few minutes left, the following question might be helpful for me and other members of the Committee. The Bill deals with a number of other issues. I think that I am right in saying that if they were not direct recommendations that you made, they were things that you would approve of: lay parity; responsible officers; appointments not elections.
Lady Justice Smith: Let us talk about responsible officers for a minute. I really find it difficult to know how responsible officers are going to work and what role they will play in revalidation. I do not get that
I cannot tell from the Bill how it will work, which bothers me. I am worried about responsible officers; I see that they can be appointed by employers and that it is envisaged that medical directors of trusts will also be responsible officers and that they will have some roleI do not know whatin revalidation. I am really unhappy about that for several reasons. First of all, I do not like the idea of a medical director, who already has a lot of jobs, having to take on responsibility for revalidation as well as all his other jobs. I think that that is too much. There is a real tension between, on the one hand, an employers desire to keep all of his employees in post, revalidated and fully qualified, and, on the other hand, the possible need to refuse to revalidate somebody, in which case their services might be lost entirely, diminished or put on hold, from which problems might arise. I am unhappy about that. I cannot tell how it will work, but it looks to me that it might be like that.
I do not know what is happening about GMC affiliates, which are not mentioned in the Bill but, according to the chief medical officers review, are the responsibility of the GMC. I liked the CMOs proposals for revalidation. He picked up on my ideas, ran with them and took them further. I was delighted with that. I was fed up with waiting for him to produce the review, but when he did, I thought that it was well worth waiting for. However, I cannot see the extent to which his proposals are implemented in this Bill, which bothers me.
Lady Justice Smith: Appointments?
Lady Justice Smith: I am opposed to elections. I made that plain. I had very good material before me on how the GMC system was working, and it is not right that a member should have a constituency.
Q 85 Mr. O'Brien: Just one. I am looking now at the part of the fifth report where you highlighted the role of the Healthcare Commission in complaints handling. Are you concerned that the private sector patients in the NHS and self-funders in the social care sector do not have adequate access to complaints procedures, and that this legislation removes the Healthcare Commissions complaints-handling remit?
Lady Justice Smith: I do not know what will happen about complaints handling. When I produced my report on complaints, new draft rules were on foot. The Department rang me up and said, Would you like us to put them on hold for a few weeks while you produce
Lady Justice Smith: Right. Well, it is urgent, because health care complaints are in a mess and causing great dissatisfaction. You can go back and examine some of the things that I said, but at the time when I wrote I was content to give the Healthcare Commissions attempts a whirl. They were new, and it appeared that they ought to be able to do the job properly, but they have not.
The Chairman: May I thank you for coming before the Committee this afternoon and giving evidence? It is much appreciated. Thank you very much for your time.
We were due to start this next section at 4.40 pm, so we are well in hand. Before we do that, Anne Milton, do you want to make an observation?
Anne Milton: Yes, just to declare that my husband is a qualified doctor and a public health physician, and therefore[Interruption.] I am sorry?
Anne Milton: For the record, my husband is a qualified medical doctor and a public health physician, and therefore his job might be implicated by this legislation.
Although it is not exactly 4.40 pm, we can move on if our witnesses and the Committee are ready. I think that we shall do so to make some progress. Thank you for coming before us. Would you first like to introduce yourselves to the Committee? My colleagues have some questions that they would like to put to you when you have had your say.
Sir Graeme Catto: Thank you very much for allowing us to join you. I am Graeme Catto, I am a physician, and I have been president of the General Medical Council since 2002. As you will be aware, our primary purpose is patient protection, so we welcome many of the clauses of the Bill.
Findlay Scott: Good afternoon. I am Findlay Scott, I am the chief executive of the GMC, and I have been there since 1994.
The Chairman: Is there anything that you would like to say to the Committee before we put questions to you?
Sir Graeme Catto: Just that, because our primary purpose is patient protection, we welcome many of the clauses and many of the issues raised in the Bill. We have sent round a note, which I understand most of you have received, indicating one area of concern, but it is one area. We have very few other areas of real concern to bring to your attention. The area that concerns us is the independence of the independent adjudicator.
As you probably know, all our arguments have been advanced on the understanding that independence is important. It is important for the council itselfthat is why we have argued for equal numbers of lay and professional people on it, so that we are seen to be independent of the profession and any vested interest. At present, adjudication is undertaken by the General Medical Council, which itself is quite independent of the monopoly employer. We are facing a situation where there are clear links between the new adjudicator and the Department of Health, and that gives us cause for some concern.
Findlay Scott: No, thank you.
The Chairman: All right. Laura, I wonder whether I can ask you to lead the batting for the Committee.
Q 87 Laura Moffatt (Crawley) (Lab): Professor Sir Graeme, you kindly gave us a briefing note, and it was very helpful to us that you clearly said that the general direction of travel is exactly what you would like to see. You touched on your area of concern. If the Bill were to change, in what direction would you like it to change, and what specific measures would you put in place to promote so-called independence, about which you are concerned?
Sir Graeme Catto: Within that memo, we have mentioned some issues that might help to address the problems that we identify. The least important are the financial issues, which we discuss in general terms. Our concern starts from the difference between what was proposed in the White Paper and the Bill. It is not clear to us how that important definition of independence will be taken forward, given the new remit of the independent adjudicator. Some issues can be addressed by securing from the Department and in the Bill a guarantee of independence about the status of the adjudicator. That might be combined with a report to Parliament directly, rather than through the Secretary of State for Health.
We also want to touch on the operational effectiveness issues that relate to the independent adjudicator. Finally, we want to consider effectiveness and value-for-money issues. There may be some questions about other models that might be consideredother models that would provide the safeguards we seek. I am happy to discuss those with you, too.
Q 88 Mr. Stephen Crabb (Preseli Pembrokeshire) (Con): On the office of the health professions adjudicator, perhaps we can take a step backwards. Will you tell the Committee why we need a new and separate body to take over from yourselves?
Sir Graeme Catto: Lady Justice Smith explained it reasonably well in the previous sitting. The issue is as much about perception as it is about reality. If you consider the effectiveness of the General Medical Council and the way in which we have organised cases in the past, we have done pretty well. The proportion of decisions that are opened up to review, go through either the High Court or the Court of Appeal and are reversed is very small. On effectiveness, it is hard to see how any new body would do better, but there is the difficulty of being perceived to be judge and juryof being partly comprised of doctors, but making decisions about doctors. We have said in the past, and it is still our position, that the factual case has not been made, but if that is the view of Parliament or the Government, we are very happy to work with you to see how best we can produce an effective new adjudicator.
Q 89 Mr. Crabb: So, just to be clear, the problem of perception notwithstanding, you do not believe that there are any substantive deficiencies or problems with your processes?
Sir Graeme Catto: No, Lady Justice Smith mentioned the Human Rights Act and European legislation. There are differing legal views on it, and not everyone would agree that it creates a problem, so from our perspective, the issue is about perception rather than factual necessity.
Findlay Scott: If I may just deal with the civil rights issue, the European convention on human rights point has been tested in the courts, and our arrangements were found to be compliant. Lady Justice Smiths concern in her report was that at some point in the future, when the requirements become more rigorous, the arrangements might be found to be non-compliant. Currently, however, they are undoubtedly compliant.
Q 90 Angela Browning: You said that apart from the briefing that you sent us, you are generally content with the Bill. In clause 92, the GMC will still be able to publish guidance telling the OHPA what sanctions to impose on professionals found unfit to practise, but it will lose responsibility for conducting the work itself. I assume from what you have said that you are happy, because that is a classic example of judge and jury. Do you agree?
Sir Graeme Catto: I am not sure that it is a classic example, but we have received assurances from the Minister that our standards will apply. We set the standards for the medical profession in the United Kingdom, and if the regulator is to be responsible for the integrity of the register, it is important that all doctors abide by those standards. We have assurances that our standards and indicative sanctions on the panels will apply. As I understand it, the concept is to remove adjudication away from the GMC to an independent adjudicator, but everything else remains more or less the same.
Q 91 Angela Browning: May I follow up with a supplementary question? Can you update us as to the GMCs position on the question of doctors who are deemed to be fit to practise, but who offer themselves as expert witnesses in disciplines in which they clearly do not have the sort of experience that one would expect from somebody who puts themselves forward in that position? How does the GMC address that matter?
Sir Graeme Catto: Let me move from the specific to the general to begin with. Our guidance states clearly that all doctors should work within their competence. That applies to doctors in any situation, including working as an expert witness. We have issued further guidance for doctors who work as expert witnesses, and Findlay may wish to speak on that.
Findlay Scott: Yes, I would like to add to that. In 2006, there was a case at the Court of Appeal testing the proposition advanced by a judge in the High Court which stated that expert witnesses should be outside the reach of the regulator. We resisted that strongly and we won in the Court of Appeal. Our position is clear. As Sir Graeme says, doctors should practise only within their competence. If they do not do soand that includes acting as an expert witness when they are not an expertthen we will not hesitate to take action.
Q 92 Mr. O'Brien: We kicked off with Laura Moffatt moving into the question of independence, and we have heard from Lady Justice Smith and yourselves. You talked about seeking to secure a guarantee of independence for the Office of the Health Professionals Adjudicator, and to ensure that it delivers value for money. As we scrutinise the Bill, it is important for us to understand how it will impact on specific amendments in order to establish that. General information, unfortunately, has now got to reach the detail, and there are a number of amendments tabled that we will look at in order to tease this out.
One of the areas that I feel very un-briefed on, as we move toward a line-by-line discussion of the legislation on Thursday afternoon, is the argument about independence. I would like to know what point the GMC has reached, either with the Department or in its own understanding in discussions, in securing the OHPAs operational effectiveness. What will be the financial arrangements for the cost of the OHPA? Will they eventually fall back as a burden on the profession? Will they be met from central funds? Where is the understanding? As an Opposition Member who has looked at this carefully, I am at the moment feeling somewhat unsighted, so I would grateful if you helped me out.
Sir Graeme Catto: There are two issues which are separate but linked. One is the question of independence, and the other is that of value for money and how we will deal with that. If we take the independence issue first: we have had helpful discussions with the Department over many months, but comparatively late in the day, towards the end of November, came the suggestion that the independent adjudicator might be an executive non-Departmental
Sir Graeme Catto: Yes, but nevertheless, in legislative terms the Secretary of State holds overall governance of the non-departmental public bodies within his or her empire.
Sir Graeme Catto: So the question of independence from a monopoly employer looms large with us.
If we return to the question of money and who is going to pay for this, the General Medical Councils viewand my viewhas been that if you are going to run a professional organisation for a major profession, you need to take responsibility for those people who fail to abide by the appropriate standards. Therefore, to a large extent, the costs should fall back on the profession. Having said that, it cannot mean a blank cheque; we must have some understanding of where the additional costs will arise. If you are going to set up a new organisation, there will clearly be additional costs at the beginning.
We are close to an agreement with the Department that those additional costsaccommodation and all the other facilities that would be required for a new organisationwill not fall directly back on to the profession. They will not fall on to the General Medical Council; we simply pass our costs on to the individual doctors. However, there are a number of areas to be resolved in setting that up, and there are technical matters such as whether or not value added tax will be added. It is entirely possible that there could be an extra 17.5 per cent. simply to set this up, without getting any gain from it whatsoever. There are quite a few issues yet to be resolved. The short answer is that we are still in discussion with the Department and the Minister.
Q 94 Mr. O'Brien: I would like to follow that up, briefly; perhaps the Minister will speak about this, as well. From my point of view, therefore, trying to understand our role in scrutinising the Bill, it seems a bit unsatisfactory that there are unresolved matters. As you rightly said, the point that I raised is both separate and linked, and a lot of what we will find ourselves discussing may centre around what we truly mean by establishing the principle, as well as the practice, of independence. Unless those unresolved issues are resolved before we get to that point in the Bill, we will have a cart-and-horse situation. Do you feel the same, or do you think that I am perhaps being a little too pedantic?
Sir Graeme Catto: No, from my perspective it has been unfortunate that the question of independence came up so late in the day and without our understanding what was happening. The financial issues are important, but probably less so. That is my feeling.
Findlay Scott: There are issues of substance and of perception. I have no doubt that Ministers on the Floor of the House will offer assurances about their desire not to interfere in day-to-day decisions, and that may
Q 95 Mr. O'Brien: That is why I used the expression arms length. What one would want to achieve as we go through the detail is possibly to move away from a non-departmental body, however it is defined, to an arms length body. That should be set in the Bill as a matter of principle rather than a question of perception, which I think will be rather important.
Sir Graeme Catto: If I may come back on that, somebody asked Lady Justice Smith at some point if she might be able to suggest other models that might link in, and the Minister mentioned the Independent Police Complaints Commission. In a sense, that is not a very fair analogy, because the IPCC does not make the final decisions. If issues come out of the IPCC, they end up being determined by the courtsa truly independent arrangementwhereas this is the adjudicator, an apparently independent adjudicator, on our part.
There are quite a few other organisations that would pretty much fit the remit. One, of course, is the Solicitors Disciplinary Tribunal itself, which is quite independent. Members are appointed by senior judges, but the tribunal remains completely independent of the Government. There are different models that could be used. It is not as if we are seeking to establish something that is completely de novo. Models exist for this situation.
Q 96 Mr. Bradshaw: Sir Graeme has partly answered the question that I was going to begin withthat is, what exactly is not independent enough about an NDPB? I was going to use the IPCC model, but there are others. I think that members of the Committee need a little more clarity about exactly which alternative model you prefer, or whether you would simply be looking for special guarantees about independence within an NDPB model.
There are a couple of follow-on questions from that. Is it not the case that the more distant and the more independent, the less power there is for any financial control or control of costs, which I know is of great concern to the GMC? Also, how does one ensure democraticthat is, publicaccountability the more distant an independent body is from any governmental oversight or control?
Findlay Scott: In a sense, the easy answer to the Ministers first question is that we would like a body rather like the GMC to run adjudication. It is a statutory body; it is not a non-departmental public body. The White Paper published in February 2007 very helpfully proposed that the GMC should be accountable to Parliament. There has never been any suggestion that we should be accountable to or within
Findlay Scott: Cost control is clearly an issue. I hesitate to speak for the entire council. I think we start from the assumption that mechanisms can be found to ensure that costs are reasonable, but the principle of independence is one which has been at the heart of the councils proposals since November 2006. I am very glad that the Government endorsed and picked up those points in the White Paper. In a sense, if the trade off was between more independence with the risk of less control over costs, I think that that is a trade off that the council would accept, because of the importance that it has consistently attached to the need for all elements of the regulatory system to be independent of the near-monopoly supplier of health care.
Q 98 Mr. Bradshaw: Would it be fair to say that the GMC has moved a considerable distance on a number of issues over the recent years, and that that has not always be easy for your council?
Sir Graeme Catto: It is very interesting that, as the war is being fought outside our building, we have been quite united within it. It has not been a troublesome or a turbulent council, so the recommendations in the Bill reflect very much the views of the council.
Sir Graeme Catto: We have lively debates every time we meet, but they have been friendly and collegial. We have had less turbulence in the past few years than we had during the 1990s, as a council.
Q 100 Mr. Bradshaw: The British Medical Association does not like the way that you have shifted your position, does it?
Sir Graeme Catto: We are quite separate from the BMA. We are not a trade union organisation. We are quite independent of the professional bodythat is the great advantage in the United Kingdom of having two separate organisations. We are totally independent of the BMA.
Findlay Scott: That is why the council attaches such great importance to ensuring that we can command the confidence and support of all the key interests: patients and the public, the profession, the NHS and other health care providers, medical schools and medical royal colleges. The council came to a very firm conclusion in 2006 that if confidence and support depended on the presence of a majority, then clearly it could only command the confidence and support of one interest group. That was not acceptable for a regulator, hence the module based on parity, which the council proposed and, I am delighted to say, you have endorsed.
Q 101 Richard Burden (Birmingham, Northfield) (Lab): May I ask a couple of questions about the standard of proof in medical malpractice cases? In
consistent with protecting patients and the public interest,
and at the same time fair to doctors. Is that still your view?
Sir Graeme Catto: It is more than our view, it is now our policy. The council took a decision at the beginning of December that we would be moving, regardless of legislation, from a criminal to a civil standard of proof, for the reasons that you have just given and for the reasons that Dame Janet gave.
Q 102 Richard Burden: There are some who have suggested that to move to a civil standard would be unfair to the medical profession. What is your answer to that?
Sir Graeme Catto: I think that it is based on a misunderstanding of the way the civil standard of proof can accommodate cases of significant severity. My understanding is that the amount of evidence required and the cogency of the argument need to be increased in accordance with the severity of the charges and, therefore, the likelihood of the severity of the sanction on the individual practitioner. Without going into sliding scales, the civil standard itself can accommodate that type of case. Already, six of the regulators have moved to the civil standard of proof, and it seems to be working well for them. I do not see any reason why it should not work well for doctors.
Q 103 Richard Burden: Do you have any idea, or would you speculate at all, on whether, if the standard of proof was changed to the civil standard, you would expect any change in the number of doctors who may be found guilty of malpractice or misconduct?
Sir Graeme Catto: We think it is not going to have any significant effect at the serious end of the spectrum. The situation for doctors who at the present time are erased from the register because of serious issues relating to fitness to practice would remain unchanged. There may be an impact on doctors whose practice has failed to a lesser extent and whom the council may therefore be able to pick up at an earlier stage in the processnot to seek erasure or that sort of sanction, but perhaps to make sure that they abide by conditions and undertake appropriate training before the situation further deteriorates. Looking at the numbers that we are dealing with, we think that any impact is likely to be small and it is likely to be at that end of the spectrum rather than at the serious end.
Q 104 Greg Mulholland (Leeds, North-West) (LD): May I ask a quick question about evaluation of the impact of the Bill? First, will the GMC be involved in evaluating the effect on professional regulation, which is fairly key to the GMC? If so, could you give us some more detail about how the GMC intends to do that?
Findlay Scott: We are fortunate in having developed a partnership with the Economic and Social Research Council. That partnership is leading to the development of a number of research projects which we are funding through the ESRC public partnership programme. Our intention would be to work with the ESRC to evaluate both the changes that will result from this Bill but also, as Lady Justice Smith mentioned, the many other changes that will flow from other forms of legislation.
Sir Graeme Catto: It is important that we do that. The evidence base for regulation across the world is relatively weak, so getting information and making sure that we can make changes based on factual information will be extremely useful in future.
Q 105 Sandra Gidley: I want to move on to responsible officers. We heard some concerns raised in the earlier session. How do you see the concept of responsible officers working in practice?
Sir Graeme Catto: May I start by moving revalidation to one side? It is not in the Bill at the present time. As you probably know, a number of working parties in the Department of Health, with which we participate, are looking at that. Findlay is very much involved in that, but it does not directly impact on the Bill at this stage.
From our perspective, the concept of the responsible officer helps us to bridge what Liam Donaldson described as the regulatory gap between what happens locally and what happens centrally. We believe that quite a number of cases that come to us might be much better dealt with at local level before necessarily being escalated up to us. Clearly, we want to deal with the serious issues, but quite a number of items that are brought to our attention might be much better dealt with locally and we see the responsible officers working in that way.
The Bill indicates that we may have a role in the appointment of a responsible officer, but we would see that only in the broadest of terms, seeking to define what their role might be, rather than being involved in any individual appointments of responsible officers. It would be very helpful, from our perspective, to have people working in the local areas who understood the GMC processes, knew when it would be sensible to refer a doctor to us if they were concerned and could link more effectively with our own staff.
Sir Graeme Catto: It is making the workload appropriately based, rather than having it sucked through. It must be right that people working in the local situation, where they are more aware of what is going on, take greater responsibility for what is happening and send centrally those cases that need to come our way.
Findlay Scott: Our starting point has consistently been, as Sir Ian Kennedy said in his report on events in Bristol, that it must be for the employer first and foremost to deal with issues of poor performance and misconduct. The challenge within the national health service has been translating that into effective practice. Clinical governance has come a long way in the past 10 years. We see the appointment of responsible officers as a further strengthening of local governance and as a
Q 107 Sandra Gidley: The Medical Protection Society has argued that medical directors will not have enough time to act as effective responsible officers, a view with which Lady Justice Smith went along to a certain extent. Does the GMC have a view on that?
Findlay Scott: Only in the sense that for any function, adequate resources must be provided. It will help no one if the responsible officer function is a theory rather than a practice. There is a gain to be made. There is substantial evidence from our procedures that early and effective action could have saved doctors careers, if problems had been identified sufficiently early and not allowed to drift. Clinical governance has already made a substantial contribution to that. Responsible officers, provided that the concept is adequately resourced, could further add to the opportunity to identify problems early and effectively.
Q 108 Sandra Gidley: You talk about being resourced adequately, but it seems that we are talking about the time factor as much as finance. How do you find more time in the day for the average medical director? That is a challenge, is it not?
Findlay Scott: I agreeit is a challenge. When I talked about resources, I had primarily in mind the scarcest resource of alltime. I have no doubt that trusts will have to look carefully at the other responsibilities of medical directors and consider how they can be supported.
Q 109 Sandra Gidley: Do you concur with the view expressed by Dame Janet that there is almost inevitably a tension between having such a responsibility and wanting to keep your trained work force? On the other side of the equation, you might be required to push people through a procedure whereby they might lose their job.
Findlay Scott: Many of us have seen a huge change in the past 10 years. There was evidence 10 years ago that blind eyes were being turned, often to enable a service to continue to be delivered notwithstanding the fact that the professionals involved were not fully up to the job. The evidence of our fitness to practice procedures today is that trust managements are alert to their responsibilities and, like us, they have patient safety very much at the forefront of their mind. Although there was such a risk 10 years ago, it is much less today.
Q 110 Mr. Bradshaw: The supply of doctors, which has changed significantly, would also make a difference to a responsible officers reluctance or otherwise to get rid of a qualified doctor.
Sir Graeme Catto: I am with Findlay on the matter. I was a medical director some years ago. Having spoken to medical directors recently, I think they would very much welcome clarity in their role and knowing
Q 111 Anne Milton: Moving back to the time needed to do the job, do you share my concern that the danger for an organisation is that it ticks the box marked We have appointed a responsible officer and considers the job done, but there is no resourcingmoney and time are the same thing in the NHSor no additional resources are put in, or resources are diverted because there is no new money coming in to fund the set-up. The new set-up is ideal; as you rightly say, it is evident to most people that resolving issues locally prevents bigger mistakes further down the line, but it is enormously time consuming if done properly. It is not something that can be squashed in on a job description. Perhaps you are not as cynical as I am, but I am concerned that there will be no additional funds to support the change, and that it will therefore not be done adequately.
Sir Graeme Catto: I do not think that you can be president of the General Medical Council and a real cynicyou must be unreasonably optimistic if you are president of the General Medical Council.
Your point is absolutely right, but we keep looking at only one part of the NHS or at only one part of medical practice, and not at the whole. The medical director does not work in isolation: he or she works within a clinical governance framework and there are clinical directors who know in much greater detail what is happening in their specific specialties. If the measure is to work, we will need to ensure that leadership and management arrangements throughout the NHS make it clear to medical students, doctors in training and established doctors precisely what their role within the organisation is, as well as within the NHS itself. We have been slow to do that in this country.
Q 112 Angela Browning: May I return to the question before that one, where you were talking about the changes you felt had been brought about in the past few years, in terms of doctors turning a blind eye at one time when they knew colleagues perhaps had some problems and questions to answer? Could you just clarify for me where we are now? This applies particularly to very senior doctors at consultant levelthe Minister will be only too familiar with this, as we both share a general hospital in Devon, where some years ago a consultant was suspended after an investigation and it turned out that the problems we experienced in our hospital had been experienced in his previous hospital. I would like you to talk us through how you sorted the problem of one colleaguea senior colleague perhapsgiving references to another senior colleague. Would the medical directors be involved in that part of the process when people move, at senior level, from one hospital to another?
Sir Graeme Catto: May I make just a couple of points? One is that I did not mean to sound complacent and say that we had cracked this issue, because I am quite sure we have not. Indeed, the cases that have come to uswith the possible exception of Harold Shipmanall had a long history in the locality where the doctors were known and action was not taken, for whatever reason. Often other doctors were aware of
Q 113 Angela Browning: But within the hospital system, would you see the medical director having a role in terms of new senior people coming to work in the hospital?
Sir Graeme Catto: Well of course they will, and as Dame Janet Smith was indicating, when revalidation comes in, that will be an absolute reality. In terms of getting references that may be inappropriate, we have, as you probably know, already taken action against a very senior doctor who was accused of doing precisely that, so we take these things very seriously. The point you are making though is that they ought to be dealt with long before they come to the GMC, and it ought not to be part of a medical culture.
Findlay Scott: If I may, two things: Sir Graham says that we have been very clear on the issue of references, both in terms of our guidance and also of the action taken. But also within the White Paper published in February 2007, there is a very clear expectation that when doctors move, information will move with them within the national health service, which does not always happen at the moment. That is in the context of revalidation, so one of the responsibilities of responsible officers in relation to revalidation will be to pass a package of information from hospital A to hospital B as the doctor moves, so there should be no opportunityas there has been in the pastfor a doctor simply to leave their problems behind.
Findlay Scott: The same with GPs. There would be a responsible officer for general practitioners and the same thing will happen then: a package of information will follow all doctors in fact as they move from one job to another. There will be a transfer process from one responsible officer to another.
Q 115 Mr. O'Brien: Immediately following on that discussion, and one other issue: who will trainand have responsibility for trainingthese responsible officers?
Findlay Scott: Inevitably it will be a joint venture with the NHS. Their responsibilities primarily will be local responsibilitiesfor the reasons we discussed earlierbut a key gain from the appointment of responsible officers will be the opportunity for better co-ordination between local and national arrangements, and consequently we very much want to play a large part in their training.
Q 116 Mr. O'Brien: That is something we could usefully seek to ensure is properly articulated during the course of the Bill. It is no good inventing a concept without having the practical ability to deliver, and training is going to be key to thisparticularly because, as I read it, these are not going to be full-time equivalent posts. They will be part-time responsibilities within other very serious responsibilities, in all
The other point I wanted to raise, as we have a few minutes left, is that I presumecontradict me if I am presuming wronglythat you were with Lady Justice Smith when she talked about clauses 93 and 94, about the need for a legal chair?
Findlay Scott: Yes.
Q 117 Mr. O'Brien: And on the need for us to either look for a Government amendment or to put one down to resolve that issue on the OHPA? Also, could I ask your views on the balance between lay and professional members, assuming there is a legal chair of the adjudication panel? To have your views on that would be helpful.
Sir Graeme Catto: As I understand the Bill at the present time, it does not preclude the possibility of having a legal chair. Indeed, that has been the situation at the GMC for many years. We want to have the best people as chairmen and it does not matter whether they are legally qualified, lay people or whether they are professionally qualified. We have always adopted that.
As regards the independent adjudicator, I think it is for the independent adjudicator and for yourselves to make that decision. It would be outwith the GMCs remit.
Findlay Scott: I wonder if I could answer that. There are essentially two models in play. The current model, which is the one envisaged in the Bill as it stands, is that the panel normally of three or more people is supported by a legal assessor and the requirements of the legal assessor are set out in the Bill. They have essentially to be a senior lawyer. That is the system we operate at the moment.
As we were saying earlier, judging by the consistent quality of the decisions that our panels make, that system appears to work well, but it does not preclude the possibility of the second model, which is to have a legally qualified chair. I think if you were to insist on there always being a legally qualified chair that would raise an obvious questionwhy do you need a legal assessor?
What we have sought to do within the current arrangements is persist with the model based on the legal assessor but occasionally have legally qualified chairs where that is an advantage. I would be cautious about having both a legally qualified chair and a legal assessor. That would seem to be creating a little more employment for lawyers than was strictly necessary.
Q 118 Mr. O'Brien: I declare an interest, being a qualified solicitor who was in practice for a few years before becoming non-practising 19 years ago.
I found Lady Justice Smiths train of thought as to the merits of a legally qualified chair very persuasive, as one might expect somebody of her calibre to be. That said, perhaps as we take that issue forwardit clearly is an issue that has been left on the table for this afternoons proceedingswe may consider whether, if
In terms of the balance of lay members, currently an Order in Council cannot impose a lay majority on the council of a regulatory body. The question I had was whether we ought to be considering whether that needs to be a consequence of what we are looking at. That might need to be reviewed. If there were a lay majority, what would the GMCs reaction be to that?
Sir Graeme Catto: We are looking at two slightly different things.
Sir Graeme Catto: The original discussion related to adjudication panels, the ones we run now and the ones the new independent adjudication panel will run. What I think you are talking about now is the composition of the council itself. Our view has been the argument of independence. We strongly believe in being independent of Government and the Secretary of State and of any vested interest, including that of the medical profession, which is why we argued for equal numbers of lay and professional people. The councils current view is that that is what we believe strongly and we are pleased that the Government have accepted that argument so far.
Q 119 Kelvin Hopkins (Luton, North) (Lab): I would like to reinforce the point that Stephen OBrien was making. I must say I found the arguments of Lady Justice Smith very persuasive, compelling indeed, about a legally qualified chair. One of the points she made was that it would shorten proceedings because the chair would know what to do, know the full legal implications of decisions being made and there would be less need for a legal assessor if that were the case. No doubt there are many other arguments but you sounded neutral; it sounded like a lack of enthusiasm.
Findlay Scott: I do not mean to be unenthusiastic about anything Lady Justice Smith says. I think the key point is this: by any objective measure, our panels make consistent, high-quality decisions that are rarely overturned by the courts. So if there is an argument for a legally qualified chair, I do not personally believe it lies in the quality of the decisions. There may be real arguments in relation to the ability of a senior lawyer to control the proceedings in a way that constrains costs while remaining fair to doctors, and I think that that is an argument that deserves to be fully explored.
Sir Graeme Catto: May I just add that all our chairmen go through an assessment procedure, so it is not just a question of whether they fit into one category or another. They need to clear that hurdle, regardless of whether they are legally qualified, medically qualified or lay people.
The Chairman: Sir Graeme and Mr. Scott, thank you. We have sadly run out of our allotted time, but I think most people have made the points they wanted to make and we are most grateful to you for coming before the Committee. Your evidence was very much appreciated. We invite the British Medical Association representatives to take the chair.
If you are comfortable and ready to go, can I thank you both for coming before the Committee this afternoon? As you know, our session cannot go beyond 6 pm and my colleagues have a number of questions, but if you would like to introduce yourselves for the record, that would be helpful.
Dr. Meldrum: I am Dr. Hamish Meldrum, chairman of council at the BMA, also a practising general practitioner, now only one day a week, I am afraid, in Bridlington in East Yorkshire.
Dr. Buckman: I am Dr Laurence Buckman, I am a GP in north London and the chairman of the BMA GP working group. We are responsible for issues to do with revalidation, medical regulation and as such, I am in regular contact with the GMC.
The Chairman: I watched you with the Minister on Newsnight last night, but I will not sneer like Mr. Paxman, I promise. Anne Milton, would you like to put the first question?
Q 120 Anne Milton: Thank you very much. This is the BMAs opportunity to give full vent to your opposition to the move from the criminal to the civil standard of proof, unless you have changed your mind?
Dr. Meldrum: No, we have not.
Dr. Meldrum: Well, just by way of introduction, contrary to what might be believed, we are passionately signed up to wanting to protect patients. But we believe that one of the chief ways of doing that is to have a regulatory system that everyone, patients and doctors, have confidence in. Hearing some of the earlier evidence, I think that there has been a welcome move over the last few years to more openness, more willingness to own up, not only to ones own faults but to faults in colleagues, and we would not want to see anything that puts that back. Turning to your question on the standard of proof, we have consulted very widely on that at meetings, at our annual conferences and such like, and there is an overwhelming view in the profession that that move would be seen to be a retrograde step, partly for some of the reasons I have mentioned, and partly because they feel that to take away a doctors livelihood, which is effectively what you are talking about, on the balance of probabilities would seem to be unfair.
Dr. Buckman: Yes. I think that there are several elements to the concern about the standard of proof. You talk about a sliding scale as if, somehow, it will be different when you have got to the end of the case. But of course, the standard of proof begins the moment either party starts to speak. You do not know at the beginning, necessarily, what evidence is going to produced during the course of a hearing and it may turn out that the standard of proof that is tested at the beginning of a hearing may subsequently be required to be reviewed because it has turned out to be a more serious case than we thought.
Most punishments that the GMC can currently deal out are such that the GP, or indeed, most doctors, will find it difficult to continue in practice of some sort. Anything beyond a warning issued to a general practitioner is going to result in their potential dismissal from future practice. That is quite serious. You may not know this, but a single days suspension from the list is enough to render you permanently off your PCT provider list. That means that any punishment beyond a withholding gets you written off. As a result of that, and the fact that the standard of proof will be seen as softer, many perfectly good GPsit will apply to other doctors as wellwill start to practise in a more defensive way. That defensiveness includes both behaviour and what they do for patients.
On the behavioural theme, you may say that doctors should practise with an eye to being defensive anyway, yet when it comes to doing things to patients, we have opportunities to X-Ray them, to scan or to do other things to them that may be perfectly reasonable in some senses but are inappropriate in othersboth in terms of cost to the Exchequer and in safety terms.
For example, I would be more tempted to consider investigating somebody with, say, a CT scan. That might seem quite reasonable, but actually be inappropriateand be offering someone an excessive radiation exposurebecause I was concerned that I might somehow have to answer for my actions later.
Dr. Buckman: Yes.
Q 123 Richard Burden: Perhaps I could explore that a little further. Is the point you have put there that the standard of proof for a doctor should generally be higher than one would expect in other sorts of employment relationships?
Dr. Buckman: Yes.
Dr. Meldrum: I am not sure that we are actually saying that. Obviously, we are here to represent doctors and other organisations must look after their people as they think fit. However, in areas where you are effectively taking someones livelihood away, to do that on the balance of probability seems to us a backward step.
Q 124 Richard Burden: Would you be aware that the standard of proof based on the balance of probability would of itself be a significantly higher burden than in virtually any other employment relationship, where if someone were to lose their livelihood from, say, alleged gross misconduct, all that an employer would have to demonstrate to a tribunal would be a reasonable belief that the employee had committed the offence of which he or she was accused. They would not even need a presumption of guilt, just a reasonable belief.
I do not know whether you were in here earlier for Lady Justice Smiths evidence
Dr. Meldrum: I am afraid that we missed most of that.
Q 125 Richard Burden: Well, would I be right that a balance of probabilities standard of proof is actually of itself quite a high standard of proof, or do I have that one wrong?
Dr. Meldrum: It does not seem to be as high a standard of proof as the one that exists at present. It is not really for me to try to justify what might or might not happen in other employment areas, but if you are saying that employees can lose their livelihood on a much lesser standard than the balance of probabilities, then that seems to me grossly unfair.
Q 126 Mr. Crabb: Dr. Meldrum, you say that you are not here to talk about other areas of employment, but perhaps there could be something about other areas of health care professions. Our Committee was told that most other health professions use the civil standard of proof. What makes medicine so different?
Dr. Meldrum: I think Sir Graeme Catto referred to this, but there seems to be quite a lack of evidence around the whole regulatory system process, wherever you work. We would want to see evidence that such a change is actually going to make a great deal of difference. I think that the GMC has admitted that, at the higher end of the scale, this might not make much difference at all. We obviously welcome that. Now, if it is genuinely part of a supportive, helpful system at the lower endrather than a punishing system, as many doctors see itwe will be prepared to look at that, but we need to see the evidence for it.
I do not think that we are trying to say that doctors are in some way special and should be different from everybody else. However, we have a system at the moment that uses the criminal standard and we have not really seen much evidence of why a change is needed for doctors. Again, I have to let other professions speak for themselves.
Q 127 Mr. Crabb: Dr. Buckman, could I follow up on one comment that you made about potential changes in the way that a doctor might behave if there is a move to a civil standard of proof? Again, looking sideways at other health professions, have those fears been borne out in other professions where they use a civil standard of proof?
Dr. Buckman: I cannot speak for other professions. I do not know. The difficulty for the medical profession is that we have greater opportunity than other professions to practise defensively in a way that might put those we look after at greater risk. I am not suggesting that we would risk patients lives, but doctors could feel threatened. It does not matter if I am a good or a bad doctorin fact good doctors are likely to feel more threatened than bad ones, because generally bad doctors do not know that they are bad, whereas the rest of us are scared stiff that we might be. Doctors will practise defensively and be more careful and cautious out of fearbe it real or unrealthat somebody will ask them difficult questions, so they will tend to do more. Doctors have a greater opportunity to do that than many other health care professionals, because of the level of seniority and the opportunities to do things that many other health care professionals do not have in quite the same way.
Q 128 Lord Commissioner of Her Majesty's Treasury (Steve McCabe): I am trying to understand something. I might have missed the point here: you said that
Dr. Buckman: I operate in the best interests of my patients.
Q 129 Steve McCabe: And being more careful and cautious would not be in the best interests of your patients? I am struggling to understand.
Dr. Buckman: I shall give you a very simple example. The vast majority of patients who come to me with a headache do not have a brain tumour or a serious brain disease. They might have a variety of illnesses, but serious brain disease would be very low on that list. In future, if I think that I might be taken to the GMC because I failed to investigate a headache, I will be referring people for CT scans. Forget the costlet us assume that they are free. It is inappropriate to irradiate people for a disease that they do not have because you are scared that somebody will be worried about it. No one will scan everybody, but there is no doubt that some people will be submitted to investigationsnot wildly ridiculous ones, but ones that probably would not be indicatedbecause the doctor is playing more carefully. We will see more blood tests and so on, none of which is done to punish the patient but to be extra careful. You go to your doctor for good clinical advice and expect him to provide the best possible service, not to be over cautious, which results in unnecessary measures for the patients. That is what I am talking about.
Q 130 Laura Moffatt: May we continue this point, because I, like Mr. McCabe, am intrigued? I doubt that any of the cases that we know about, in which doctors have sadly run into trouble, were about over-investigation; they were about a cavalier attitude and not investigating properly. For me, that is where the risk lies. Did Steves question not touch on the real problem, which is quite the reverse of what you are saying?
Dr. Buckman: That is precisely what I said about behaviour. Doctors who practise good medicine will feel that someone is looking over their shoulder all of the time. Doctors who do not do things right will continue to do so. I am not here to defend them. If the GMC is going to sort them out, it is perfectly okay with me. I am talking about the vast majority of doctors who practise careful medicine, who do the right thing and who will perceive that lowering the standard of proof will mean that they will have to be more careful. That will subject patients to a higher degree of investigation.
Q 131 Stephen Hesford (Wirral, West) (Lab): If I may say so, I am frankly worried, Dr. Buckman, that you seem to personalise your answersI was doing that, and I was doing this. Can you furnish the Committee with survey evidence that would persuade us, if we were persuadable, that your colleagues have told you, in huge numbers, that they have this fear about defensive medicine? Personally, I am not convinced that you represent what you colleagues would really be saying.
Dr. Buckman: No, I cannot present you with such evidence.
Stephen Hesford: You have given your personal view, which is useful to some extent, but I am talking about the rest of the profession.
Dr. Meldrum: What we could provide as evidence is the more general view about the changes in the standard of proof and the fairly overwhelming view, both in surveys and through confidence motions, that they are opposed to such a change.
Stephen Hesford: I understand the opposition, but that was not my point. I was talking about defensive medicine.
Q 132 Judy Mallaber (Amber Valley) (Lab): I, too, am very puzzled by this attitude. My worst case in recent years concerned a child in my constituency who died of meningitis. There was a great cry for a full local inquiry, and a number of changes in practice took place in both the ambulance service and the childrens hospital. How would you explain to my constituents whose child died why the signs of meningitis that they thought were there were not investigatedwe are talking about a good competent doctor here? How could you justify the idea about a more defensive attitude when that defensive attitude might have ensured that that child was investigated? Those are the sorts of cases that you will have to answer. You will have to explain to my constituents, and others in similar situations, why you do not believe that it is reasonable to have this burden of standard of proof.
Dr. Buckman: I am not trying to defend inappropriate or unfortunate behaviour. In cases in which there is sufficient doubt about a diagnosis, the doctor has to investigate as far as they think appropriate. It is easy to say afterwards, when someone has been damaged, that they should have done something.
The difference is that in cases in which doctors do not need to do these thingsand it is always a grey areathey will have to make a judgment on whether or not they proceed with an investigation. If there is any doubt about someones illness, clearly the doctor will proceed with the investigation. My point was that there will be the temptation to investigate more than there would have been otherwise. I am not talking about not investigating a kid with meningitis. Clearly, there is no argument. That case should be investigated fully and appropriately. It is in cases in which you do not think that someone has meningitis.
Q 133 Judy Mallaber: It still does not fully explain why the standard of proof for doctors should be different from that of other employees. I still do not understand exactly what makes you special.
Dr. Meldrum: I do not think that we are trying to claim that we are special. I have tried to make that point quite clearly. Taking away ones livelihoodthat, in effect, is what losing your licence to practise meanson the balance of probabilities is likely to lead to more unfairness and a change from the present system. I am not here to answer for other employees or other parties. I would like to see the evidence base that such a move is going to improve things for the patients.
The Chairman: I am conscious that we have other areas to cover, and two other members of the Committee want to come in.
Q 134 Angela Browning: I do not know whether I am in order here, but would it be helpful if the BMA or the GMC provided the Committee with recent statistics about the nature of the inquiries that doctors have been subjected to in disciplinary matters? I am beginning to find this a rather bizarre conversation. I would be interested to know how many patients have taken action against doctors for things such as over-exposure to scans. The Committee needs to consider the classifications of complaints against doctors and the outcomes of those different classifications. Before we consider the Bill line by line, I as a Committee member would find that information very helpful, wherever it comes from, so that we can focus on what, in the main, doctors are being asked to account for and the outcome of disciplinary action against them for those types of complaint.
The Chairman: We must not discuss the merits of the Bill just yet, but obviously if the witnesses want to comment on that, they can. If there is evidence that you wish to give, not necessarily now but subsequently
Dr. Meldrum: We can look at that.
Q 135 Kelvin Hopkins: I just wish to pursue the point, if I may. I shall paint a scenario that is not so distant in reality. An elderly, single-hander GP in a poor inner-city area, who does not have a high reputation with the primary care trust, will not retire and has a long list because the more patients they took, the more money they received. They have a lack of confidence in their own ability and therefore refer a very large number of patients to the hospital, which upsets the hospital. The logical thing to do in those circumstances would be to persuade that elderly doctor to retire, yet because of the shortage of GPs, particularly in unpopular areas, they do not retire. Of course, they have many of the type of patients who do not complain, because they do not have the skills that some of us here might have to make complaints. What would you recommend for dealing with that situation, other than what is proposed in the Bill?
Dr. Meldrum: It might take quite a long time to go through all the things, but I am as eager as you that we resolve that situation. I am certainly aware of the type of practice and doctor in inner cities to which you refer. There is a long legacy of under-investment in and a lack of support for such people.
The BMA is being portrayed as anti-everything that is in the Bill. We are not; we welcome a lot of things in the Bill. We first suggested a system of re-accreditation back in the early 1990s, so we are thoroughly in favour of re-accreditation, revalidation, re-licensing, appraisal of doctors, more support for doctors and the National Clinical Assessment Service to help retrain and support doctors. We are certainly in favour of not allowing doctors who are isolated and clinically detached not to be properly supported, and in some instances they must be encouraged. If they cannot be encouraged, they may have to have their fitness to practise taken away. We are not arguing against certain doctors losing their right to practise, we are questioning the mechanism for deciding who those doctors are and whether it is fair and appropriate and the profession perceives it as being so. I could talk a lot more about how we support inner-city practice, but that gives you a flavour.
Q 136 Sandra Gidley: Is it not the reality that most doctors will carry on practising in pretty much the same way, because the difference is going to be very small? If GPs suddenly started referring people for a lot of tests, the referrals committee at the local PCT would be on to them like a shot.
Dr. Buckman: Ultimately, doctors would say that they were being more careful, because they felt that they should be. Nobody would do a test that they could not justify somehow, so I think that that is what would happen. The number of referred matters would go up. We can argue about whether that is a good or bad thing, but it is probably what would happen. That reflects they way that practice would go, and I advance that case to the Committee because I believeI am sorry, the BMA believesthat we should raise it and bring it to your attention. But do I believe that people would behave hugely differently? No, at first they would not. They would start to feel more defensive, and that is the concern that we are trying to avoid.
Q 137 Sandra Gidley: Dr. Meldrum, you mentioned that there should be an evidence base for changing. Is it not also up to the BMA to provide some sort of evidence base for staying as you are? Is there any evidence from other countries that have changed the system that there has been any change in practice?
Dr. Meldrum: Not a lot of evidence, as far as we have been able to ascertain. I accept that a lot will depend on how any system is seen to operate. We have discussed sliding scales, which I do not like for many practical and philosophical reasons, but unless there is clear and cogent evidenceand the more severe the case, the more clear and cogent the evidence must bethe profession will perceive it to be an unfair system. Part of the problem is that there is not much evidence. When there is not much evidence, I would stick with the status quo rather than make a change for changes sake.
Q 138 Sandra Gidley: You mentioned the sliding scale, and Dr. Buckman seemed to intimate earlier that on an alleged offence, the committee might think you needed 60 per cent. probability, but the evidence would emerge and you would have to change it. I do not think that it would be like that; we must trust the peoples
Dr. Meldrum: I am not keen on the sliding scale, but I am a pragmatist and a realist. If we lose, as I suspect we might, I want not only proper training for those who sit on panels, but the training to include how one operates, to ensure there is clear and cogent evidencenot hearsay or one persons opinion against anothersto convince people that what was alleged actually happened. Let us move away from the standard of proof. There should be clear and cogent evidence that that doctor has significant failings that would invite one to take away their right to practice.
Q 139 Sandra Gidley: Is it just about the training of the panels, or does something more need to be written in stone?
Dr. Meldrum: It is quite difficult to put into words how you operate a system, but perhaps we could include in the Bill a review period, if there were a change to the civil standards, so that we could look at how the changed system was operating. We could try to obtain more evidence and consider whether it was doing what people hoped and intended it should do.
Dr. Buckman: No.
Q 141 Kelvin Hopkins: Indeed. Do you agree with the creation of a separate bodyperhaps the OHPAto oversee fitness for practice proceedings? What is wrong with the way the GMC has performed its role to date?
Dr. Meldrum: Strangely enough, the profession has been fairly ambivalent about this one. Comments range from, No, lets take the status quo, to, Well, we couldnt be any worse off than we are now, therefore anything would be better than the present system. I am conscious that the president of the GMC is sitting behind mesorry, Graeme. Much of our uncertainty has been about the composition and operation of any new body, and we have always said that whether the body is part of the GMC or not, the profession must perceive it to be reasonably fair and independent. If it is to be separate from the GMC, that independence should be from both the GMC and the Government in order to secure doctors confidence in how it operates.
Q 142 Kelvin Hopkins: Your GMC colleagues emphasised earlier that they are part of an entirely separate organisation and that you are effectively a trade union. I am trying to phrase this carefully: you are quite friendly with each other, shall we say? You are not hostile to each other.
Dr. Meldrum: On a personal basis, I hope I am friendly with almost everybody I come across. I am sure that, were Sir Graeme Catto able to say so, he would
Dr. Meldrum: I am less careful about that.
Q 144 Kelvin Hopkins: There has been a lot of talk of perception this afternoon. The perception is that you are in the medical field, that the Government are clearly not in the medical field, and that there is the independent world representing the public, which is again entirely separate. What is being proposed is seen as a move away from the medical world, with some people unhappy about the fact that it is moving towards Government and there is Government involvement. Would it not improve perceptions if there was a higher degree of independence?
Dr. Meldrum: It depends whose perception you are talking about. I think that if the body is independent both of Government and the GMC, there may well be that perception. I said at the beginning that the profession would want very much to see the proposed structure and operation of the independent body. We have some idea within the Bill, although there are some problems with that in that some of the links with Government, which Sir Graeme and Findlay referred to, are perhaps still too strong. There are certainly concerns about how such a body would be funded, following experiences with, for instance, the Postgraduate Medical Education and Training Board, which oversees medical training. The profession feels that it has almost had a licence to set its own agenda and its own fees without any check or hindrance, so there would be concerns about that. In terms of seeing a degree of independence, within the whole context of what the profession still believes is important to professionally-led regulation, and therefore a profession in some way having responsibility for its members and those it represents, I think that an independent body would be looked on quite favourably by the profession.
Q 145 Mr. Bradshaw: What pressure have you put on the GMC on the issue of more independence from Government?
Dr. Meldrum: What pressure have we put on the GMC?
Q 146 Mr. Bradshaw: You acknowledged in your comments that you have a political problem with your membership because it wants the body to be independent. If it is to be independent from the medical profession
Dr. Meldrum: Are you talking about OHPA?
Q 147 Mr. Bradshaw: The independent adjudicator, yes. If it was to be independent from the medical profession, the quid quo pro, as you implied, was that it should be completely independent from Government. I am asking what discussions or pressure you have put on the GMC in that regard.
Dr. Meldrum: I do not think that we have put any pressure on the GMC. I do not think that I quite said that it would be independent from the profession; I said independent of the GMC and independent from Government.
Q 148 Mr. Bradshaw: So you had no discussions with the GMC through Laurence Buckmans official role as your link-person over the issue of independence from Government?
Dr. Meldrum: The issue of the new body has been discussed; it would be untrue to say that it has never been discussed. To some extent we would share the GMCs view about the potential for this body to be seen to be too closely associated with Government, but we have not put pressure on the GMC on that opinion. We would share their view on that point.
Q 149 Mr. O'Brien: We have six minutes or so left to get back to the delicious subject of responsible officers. You have made representations that the responsible officer function should be separate from the employment one, as regulation has to be independent of the employer if it is to retain professional confidence and credibility. It would be helpful, as we have been desperately trying to understand the matter during previous hearings, to know how you believe it will work in practice. If that is different from what you think would be ideal, we should like to know about that difference as well.
Dr. Meldrum: I shall try to be brief. We feel, as I think you feel, that some of it is perhaps a little unclear. What we have concerns aboutsome of those concerns were expressed earlieris that if there is not that degree of separation of function, there will be quite considerable conflicts of interest about whose behalf the responsible officer is working on. To come up in five minutes with an exact plan for how we believe responsible officers should operate would obviously be impossible, but we can certainly try to furnish you with more details.
It comes back to the whole business of having confidence. We are aware of peoplemedical directors in trusts, or whoeverwhose loyalties have been primarily to their trust. We are not saying that their loyalties should be to the profession, but they should be to the wider benefits of health care. It is about achieving that balance by a degree of separation of function and a degree of separation of loyalties from the employer, and having an effective and practical operation. That is quite difficult; I accept that.
Q 150 Mr. O'Brien: Do you feel that having a responsible officer who is also the medical director, for instance, might give you that problem?
Dr. Meldrum: It certainly gives the potential for that problem. I think that the vast majority of my colleagues who are medical directors would try to carry out that
Q 151 Mr. O'Brien: In the previous hearing with the GMC, we raised a point about training. I am glad that came out, because I think that we shall have to pursue it. Although the GMC did not say so in their evidence, I got the impression that what lay behind their discussion was that there is a degree to which there is merit in having a medical director who is also the responsible officer, because they have the credibility of somebody who understands what it is like to practice medicine, and who is therefore a peer. That can help when it comes to making a judgment about somebodys ability and so forth.
Dr. Meldrum: There is a huge overlap in function, too. When revalidation comes in, and as appraisal has come in, a lot of the information that people will be using to make those judgments will be information that they rightly have as medical director.
The Chairman: That is the end of our formal questions. We have a couple of minutes left if there is anything that you wish to say to the Committee before we conclude the session. You do not have to.
Dr. Meldrum: Obviously, we have concentrated very much on the standard of proof. I reiterate what I said at the beginning: we welcome a lot of the direction of travel. We want to weed out incompetent, poorly performing doctors, but we want to do so as much as possible in a climate of support and rehabilitation, because we do not believe that most doctors set out to be bad doctors; there are often circumstances that perhaps make it easier for them to be less than adequately performing doctors. We want to try to continue a move towards more local resolution and more support for doctors, at the same time coming down very hard on those few doctors who are not only performing poorly but are not amenable to or will not co-operate with remediation. We feel that that is the best way to protect patients.
I return to my earlier comment. A system that has the confidence of the profession is much more likely to encourage doctors to be honest about faults in themselves and colleagues. In my experience, that has always been the most common way that problems with doctors come about. We have heard about casesSir Graeme alluded to themin which, after the case comes out, lots of people come out of the woodwork to say, We knew for ages that he wasnt a very good man. We want a system that makes such people come forward at the beginning, which is why we want a system that has the confidence of the profession.
The Chairman: Thank you very for coming before the Committee and for the robustness of your replies.
Will the representatives from Which? take their place? If the witnesses are comfortable, we shall
Helen McCallum: Thank you very much for inviting us. I am Helen McCallum, the director of policy at Which? I am sure that members of the Committee will know that that is an independent charity supported by 670,000 members. It has been campaigning and researching over a number of years in the area of patient-focused health care.
Frances Blunden: I am Frances Blunden, principal policy adviser working on health issues. I have had a long-standing involvement pre-dating my Which? employment in regulatory issues. We are concerned about regulation delivering better health care rather than regulation for its own purpose.
Q 152 Mr. Crabb: I shall start with a general question. Is it your view that the new integrated care quality commission as set out under the Bill will help to drive up the quality of health and social care services in the United Kingdom?
Helen McCallum: Yes, it is. Which? is very supportive of a merged health and social care regulator. From the perspective of the user or patient, the mystery of the boundaries between health and social care has certainly been confusing for people. We think that it will provide a real opportunity to drive a more patient-focused approach, but we should like to see two things to strengthen that. We feel that it is an omission that the Bill does not set out clearly a distinct purpose for the body, which articulates its role as being primarily for the protection of patients. I do not know whether you would agree, but I am not certain that clause 2(5) cuts the mustard in terms of intelligibility to the average lay person. We would like to see something more along the lines of the Food Standards Agency, which has a very clear statement of purpose. It allows for the lay person to understand what the body is for. It allows the focus of the body to be clear to everyone and it allows for a revaluation of whether the body has, in fact, met the functions that it has been required to meet. That is one thing that we would like to see.
Associated with that is the fact that we would like to strengthen the Bill in terms of a duty to take on board and listen to the views of patients and service users. At the moment, the Bill states that the CQC will have regard to the views of the public. We are not sure that that is specific enough. Our research has shown that patients and service users have a number of issues that, for a variety of reasons, they are reluctant, unwilling or feel unable to raise. It is there that the real signals of what might be going wrong with the system are to be found. We would like the Bill to strengthen that for the CQC.
Q 153 Mr. O'Brien: Following that answer and having looked at your submission, we can see that you are calling for a duty on the care quality commission to consult patients. It would appear that that has arisen as a result of the changes in the Commission for Health Improvement and ultimately the community health
Helen McCallum: Obviously I do not want a draft here, but we would like the wording to be changed from have regard to to have a duty to consult with patients and users of services. The duty being part of the change in that patients and users, as distinct from the general public, would be part of the point. Those are the two changes that we would like to see.
Q 154 Mr. O'Brien: I take it that your reading of the Bill included the schedules, where some of the duties are laid out albeit in a somewhat short formbut that is a matter for us to deal with at a later point. You are looking for a more expansive and persuasive whole approach to the range of duties, is that right?
Helen McCallum: That is exactly right. And to bring it in line with other bodies who have a duty to consult.
Q 155 Mr. O'Brien: I am pleased to see that you are calling for the CQC to have explicit responsibility for monitoring hospital food issuesyou will be aware that I have been exercised about this over the past few days. The Governments dignity in care agenda, as you know, focuses in part on malnutrition issues and it would be helpful for us to understand the degree to which that as an initiative, not a legislative approach, is not necessarily delivering in the terms that you wanted. How could you see this measure being able to deal with that, and helping to underpin a more deliverable approach to a concern that is widely shared across the HouseI do not seek to make any kind of partisan point here.
Helen McCallum: Which? believes that nutrition and hospital food and social care services are as fundamental as cleanliness to the delivery of patient progress care. We are delighted to see that the Bill addresses those issues, and there is clearly a significant need to address those matters of cleanliness. The service that we have, has shown that patients and service users are concerned about the standard of food that they receive. That is not a question of whether or not they like it, but is about the nature of the food with respect to certain medical conditions and the extent to which people actually receive the food as it arrives. It seems to us to be another potential scandal waiting to happen, in the same sense that there has been a real consumer detriment around issues of inefficiency and cleanliness. We think that this issue is just as important, and it should therefore be stated as a responsibility of the regulator.
Frances Blunden: To add a bit of colour to what Helen has said, in an article for Which? magazine in 2006, we had one member who had spent four weeks in hospital. He had a broken jaw and should have been on a liquid diet, but most of the time when food came to him, it was not in an appropriate form. Yesterday,
Q 156 Greg Mulholland: You have already mentioned the issue of cleanliness, and you are well aware that one of the publics biggest concerns is that of healthcare-associated infections. Can I pin you down and ask you whether you think that the new powers given to the new commission will tackle those infections in a meaningful and successful way?
Helen McCallum: Yes, I think that on the whole we do. It returns to my point about triggers with regard to the regulators listening capability in receiving intelligence from patients and service users, who are often concerned about cleanliness as well as food and a variety of other issues about the organisation of care. Our research has shown that a significant number of those do not at the moment feel able to make the right representations in the right place. The powers are adequate, but we should ensure that the intelligence comes to the regulator in the most effective way. The best way to do that is for the regulator to have a duty and responsibility to enable people to indicate that there is a problem.
Frances Blunden: In this context, we can look to practical examples provided, for instance by Maidstone Tunbridge Wells. It was a year before the Healthcare Commission report came out and one presumes that there was a long lead-up time to the commission going in. Research that we did for the consultation on complaints reform last year shows that fewer than one in three people who felt that they had some cause for complaint actually made a complaint, so it is important to learn to listen and to find ways in which to get information into the system and trigger things quicker.
Q 157 Greg Mulholland: So do you think that it is to do with the system rather than the new powers specifically? We were interested to hear earlier from the Healthcare Commission, which said that it felt that new powers were not necessary and that it had not asked for them. Do you think that it is not so much to do with new powers as with the system? Do you think that the new bodythe new commissionwill be helpful?
Helen McCallum: Yes. We believe that the issue is not so much the powers, but the means of indicating that there is a problem. The issue is the upward feedback from the local source, which is why the regulator will need very strong mechanisms by which to listen to patients and service users in addition to satisfying, obviously, the thoughts and needs of the general public.
Frances Blunden: That said, it is no good finding things out if nothing is done about them. Ultimately, people want the issues they raise to be sorted out. Certainly, through our impatient for change campaign, we highlighted the good focus on sorting out hospital
Q 158 Greg Mulholland: Do you think that a care home secretary will be sufficiently involved? Everyone talks about hospital-based infections but, actually, there has been a lot more exposure to care home-based infections.
Helen McCallum: We are tending to answer on the basis of health care because our most recent research has been into users of health care services rather than social care services. However, the same thing applieswe are concerned that there is sufficient root for indicators to trigger action in the regulator.
Q 159 Mr. Bradshaw: To play devils advocate on the duty issue, the Healthcare Commission would say that most if not all of its recent major inquiries resulted from patient complaintsI am thinking of Cornwall, Stoke Mandeville, and Maidstone Tunbridge Wellsor from patient complaints and a combination of data. Is there a danger that by placing a duty on the commission, you could create capacity issues for the regulator that might mean that it is less alert to any patterns of problems that emerge. Such patterns have spurred its inquiries to date.
Frances Blunden: If you dont find out about an individual case, you will not find the patterns. Identifying individual situations will feed up into those patterns. I do not see how you could do one without the other.
Helen McCallum: The duty would help to give confidence in the new regulator that consumers and patients were genuinely being listened to. It would also, in some sense, create systematic feedback as well as a reliance on patients themselves to have the confidence to make a complaint. Our research shows that at least one third of those who wish to make a complaint, or feel that they have grounds for making one, do not in fact do so.
Frances Blunden: It has a number of initiatives, and the indications from CSCI is that it is trying to listen to patients. However, when you create a new body, it is important that it is given those duties at the outset. This is the third major reorganisation of heath and social care regulation since 2000. It would be really good to get it right. It would be good, I am sure, for the providers and the regulators. It would certainly be good for the public to know who to go to, if they have concerns, and who they can trust to set standards.
Q 161 Angela Browning: Is not one of the difficulties with individuals making complaintsI am thinking particularly of those who have had a hospital staythat a large percentage of the hospital population is elderly
Frances Blunden: Returning to our research on why people do not complain, a large number did not do so because they did not feel that it would make any differencethat accounted for more than half of those who did not complain. Nearly half wanted to forget about the experience and another 40 per cent. or so did not want to make a fuss. Those surveyed could choose more than one answerin case your maths worked out that that added up to more than 100. For a number, the process was too complicated or they did not know how to make a formal complaint. However, of most concernthis is reinforced by a report produced by the Healthcare Commission earlier this yearabout one third feared that it would jeopardise future care. Those reasons need to be kept in mind. Importantly, we found no such substantial differences, although that might be a result of limitations in the survey results80-year-olds were not necessarily interviewed.
We have not talked about a commissioner for older people and it is not something that we have necessarily thought about. Certainly our view is that older people in hospital are very vulnerable, but actually even younger people and your classic middle-class individual can end up being very vulnerable in hospital as well. We need to think about how needing health or social care can make anyone very vulnerable. Discussions about focusing just on vulnerable adults can negate that. We need to think about it much more widely.
Q 162 Angela Browning: May I ask as a supplementary whether you have considered end-of-life issues? I am not suggesting for one minute that complaints about something that has caused the end of a life might come forward. However, they will concern issues involving the care of those nearing the end of their lives, whether they are in hospital or moving to a nursing home. As MPs, we hear of such issues almost on a daily basis. Do you feel that there is a need for more consideration of that group of people and of the care of people nearing the end of their lives, who would of course include mainly the elderly?
Frances Blunden: We have not done any work on end-of-life care. Other organisations in the voluntary sector are more focused on that issue. Our focus tends to be more general. Certainly as part of the impatient for change campaign, we have received a huge number of poignant stories about, for example, carers experiences of watching their loved ones die in absolutely degrading circumstances. That was not happening 10 or 100 years ago but in the past year.
Q 163 Anne Milton: I have just one point to make before I get on to the health in pregnancy grant, which I would like to ask you about. The fact that people do not complain because of a fear that it would jeopardise
I would appreciate your views on the health in pregnancy grant, and whether you feel that a one-off payment will make a difference to the nutrition of women who are expecting a baby.
Frances Blunden: Again, that is something that we do not work on or focus on. Other voluntary sector organisations are better placed to do that. They are better connected to people who are in that situation. We are not seen as the natural place for people to come with their views on such subjects. What we very much try to do is to reflect the experience of ordinary people using health and social care services.
Q 164 Anne Milton: You have no expertise in nutrition for pregnant women? Have you done any research on it?
Frances Blunden: Not specifically around pregnant women.
Q 165 Mr. O'Brien: May I try a different tack? Given that Which? is, as I understand it, a consumer association, do you see patients as consumers?
Frances Blunden: Personally, I think that that debate is a bit narrow. We talk about consumers because we are a consumer organisation. The people who come to us are using out-of-hours services, NHS dentistry services, cosmetic treatment services or hospital in-patient services. The language that we use for them is around consumerism. How people describe themselves
Q 166 Mr. O'Brien: The debate is not intended in any way to be a narrow one. The health in pregnancy grant will be a one-off financial payment at a specific point in a womans pregnancy, with the stated objective that she will be encouraged, even likely, to use the money for the proclaimed purposes. Based on your expertise, experience and understanding of how consumers behave, how do you react to it as a consumer issue? How are people likely to receive the payment, and would their behaviour be natural if the grant delivered on its stated objective? Ultimately, fiscal policy has to work with the grain of human behaviour rather than simply be an announcement from on high. That is what I am trying to elicit from you.
Frances Blunden: We have done a lot of work at Which?not me personally, because I work only on health issues, but I have an experienced colleague who does a lot of work on food and nutrition. The intuitive reaction is that a one-off pregnancy grant may tackle the problem at that particular time, but to build good nutrition for the future of the child, more needs to happen to ensure that all children have access to good food, a good diet and plenty of exercise, as Gordon Brown was saying yesterday.
Q 167 Mr. O'Brien: Sorry, I wish to pursue that point further because I am conscious of the expertise that Which?, as a research organisation, has. If you were to
Frances Blunden: Probably you would want to talk to our food colleagues.
Helen McCallum: We would prefer that. Otherwise, we would be offering you random personal thoughts, which is not quite what you are after.
Helen McCallum: Yes, I do. We can certainly supply you with something once we have consulted some of our colleagues who have more expertise in this particular area, if that would be acceptable to you.
Helen McCallum: That might be more useful than something that we could give you off the cuff now.
Q 170 Angela Browning: I thought that I might just float this idea to you. I am old enough to be of a generation that was provided with horrible tasting orange juice to ensure that our vitamin C was high and something even worse called cod liver oil. It was provided on the NHS, and I used to bury mine in the garden whenever I got the chance.
On using public money to improve the nutrition of specific groups of people, such as pregnant mothers, would delivery to consumers be more likely to be guaranteed if the money were spent on providing supplements and so on through midwives and GPs surgeries? Would that be a better use of public money? Would it be more likely to be delivered?
Frances Blunden: Again, that would very much be conjecture on our part, but there is a general point to make. We live in a world very different from 1950s Britain.
Frances Blunden: The issues of the responsibility of individuals, the right to make choices and so on are key to how people expect to be able to live their lives. It is a fundamentally different environment. But certainly we can take that back to our colleagues, talk to them and send something to the Committee in the not-too-distant future.
Q 173 Sandra Gidley: Yes, just very quickly. You welcomed the broad definition of health care in clause 5(2) but seemed to be concerned that it did cover some cosmetic procedures, which are becoming increasingly popular. Would you like to elaborate on that a little?
Frances Blunden: At the moment, the administration of dermal fillers, including some that are semi-permanent and permanent, of Botox injections and of such things as chemical peels do not come under the Healthcare Commissions remit. It is a rapidly growing market and is likely to grow even more rapidly. The consequences of things going wrong and not being done correctly are significant, and the report that we published this week highlighted an industry that is, to use a word that was used earlier, cavalier. Poor practices and rule breaking are prevalent, and we have also found in our research that the drive to make a saleit is very much a private marketcan put consumer safety at risk.
The consequences of getting it wrong can be significant, including long-term permanent harm, even in apparently innocuous cosmetic treatments that, if you watch 10 Years Younger, seem like a five-minute fix. In addition, with changes in technology, some of the currently more invasive treatments are moving towards the non-invasive spectrum. That is why we would like an explicit reference to cosmetic treatments. We recognise that the Department believes that the taxpayer should not pay for regulation in that context, but actually the taxpayer often ends up paying if it goes wrong, because the NHS often picks up the pieces. Providers pay a registration fee that covers at least some, if not all, the costs of regulation.
Frances Blunden: We argue that it needs to be slightly wider than just surgery. It needs to include treatments, which would cover some of the things that are not traditional knife-on-skin surgery.
Q 175 Mr. Bradshaw: I would like to explore, although we probably shall not do so in the course of the Bill, the justification for expecting the taxpayer to pay for the policing of procedures that are purely cosmetic and not available on the national health service. I think that we are going to run out of time.
Helen McCallum: It is certainly the case that an awful lot of people who undertake such procedures think that they are regulated, and are quite unaware that they are not protected in any sense. It is a choice that people are increasingly taking. Our research shows that one in five of the British adult population considers some form of cosmetic treatment. It is potentially a growing problem. If we do not prevent it now, it will cause significant detriment to consumers and significant cost to the NHS.
The Chairman: Sadly, we have come to the end of our allotted time. If any witness intends to write to members of the Committee about anything that has been discussed, they should do so in the next few days because the evidence session will end this week and then we will be into consideration of the Bill. So, there is not an awful lot of time. Thank you for coming before us and for the helpfulness of your replies.
Thank you for coming to meet members of the Committee. Will you introduce yourself for the record?
David Rogers: I am Councillor David Rogers. I chair the Community Well Being Board of the Local Government Association, which covers adult social care and the whole interface with health issues. On my left is Anne Williams, who is the president of the Association of Directors of Adult Social Services.
The Chairman: I remind the Committee that the clock is ticking to a Division, so we must be fairly robust in our questions.
Q 176 Anne Milton: Thank you. I will offer you a challenge. Your very useful memorandum raises a number of issues that you feel should be changed in the Bill. It would be useful if you could run through them now.
David Rogers: I will set out three particular concerns that we have, and Anne may then wish to add to them. We certainly want to see a duty to co-operate and share information locally because that is where service delivery happens and where mistakes are sometimes regrettably made. Anything that can be done to prevent such a situation arising is to be welcomed. The relationship that the new regulator would have with service deliverers in local communities up and down the country is very important from our perspective.
The second major issue is about performance indicators. As I am sure that members of this Committee are aware, a concordat has been entered into between central Government and local government, which was agreed by the Secretary of State Hazel Blears and Simon Milton on behalf of the Local Government Association. It is all about co-operation in general and, in particular, about a much smaller set of indicators198 as opposed to the previous figure of more than 1,000. Therefore, we do not want to see any more specific indicators added to that bundle.
The third element is that public health powers relating to things or premises, rather than to individuals, should remain with local authorities. We feel that the proposal for that to go to JPs could cause unnecessary delay in certain circumstances. We can elaborate on any of those should you wish.
Q 177 Anne Milton: To pick up one point on the public health powers. The Health Protection Agency feels very comfortable about them and does not think that there will be any delays.
David Rogers: The example that we could quote to you was here in Westminster in the Litvinenko case of the polonium poisoning. There were 47 different premises that had to be examined, and 47 separate applications had to be made to magistrates in order to do that. There could have been some delays that would have prevented those premises reopening as quickly as they otherwise would have done. The existing powers with local authorities would have been quicker than that.
Anne Williams: Yes, I should like to make a couple of points about the first pointthe duty to co-operate and share information. It comes from several operational experiences. First, we want to avoid duplication between the commission and local authorities powers over contract monitoring and commissioning. There are concerns that people who want to make complaints can fall through the net, and it is important with the rising concerns about adult protection that we have robust local systems whereby information is shared between all local agencies, including what the commission, local authorities, the police and other agencies know. The issue is about operating in a joined-up way and the willingness to be open and share information. It goes both ways.
Q 179 Anne Milton: Right, so your concern is that which is always a concern of local authorities: partnership and working across the board. Imagine that the Bill goes through as it is, what impact will it have on local authorities?
Anne Williams: Practice is varied. In some areas, there will be a great deal of information and co-operation, in others less so. We want a clear message nationally, through the legislation, making it absolutely clear that there is a duty to co-operate and to share information.
David Rogers: There are examples in other fields where the measures work very well. For instance, we could talk about the practice with Ofsted in child care settings, whereby local authorities have responsibility for food safety and hygiene, and Ofsted has responsibility for inspection. Increasingly, locally, relevant information is shared so that if one body becomes aware of circumstances that relate more to another, the information is passed on and the responsible body can take action. You might know about that situation in particular, because councils in Surrey are trailing an aide-mÃ(c)moire for Ofsted on that very issue so that there is good practice in Surrey.
Anne Williams: Yes.
Q 182 Angela Browning: We heard evidence this morning from the three individual regulatory bodies that will come together as one, and they flagged up areas in which they have difficulty with inspectionsome of which can be read across into local government. For example, when local authorities set the eligibility levels for support, either elderly, learning disabled or whatever, there are inevitably people below the threshold. The individuals expressed concern about their inability to check whether there is a problem with that group below the eligibility threshold. Equally, on mental health, there was concern about their inability when they inspect to access records and more detail about individual people in a hospital or in residential care. Could you outline the problems with practice, so that sharing, in terms of inspectorates, can be improved in those areas?
Anne Williams: We are in favour of one commission largely because so much provision is currently integrated and more and more will be. The public do not care who delivers services as long as they are of a good quality, flexible and treat people with dignity and respect. The public want to be assured that one body is responsible, and that it does not duplicate or focus on different things. As the Bill outlines, there is much scope for the reviews to be joint reviews of, say, provision for older peoplehow people are treated with dignity and respect throughout health and social care. There is much to be learned from practice across the existing commissions, because some have had far more involvement of users and carers in inspection processes than others. In one way, there should not really be difficulties for, say, the Mental Health Act Commission accessing records and information, but obviously it has told you that there has been. I cannot comment in any detail on that, because it is able to interview people and staff.
Eligibility levels are difficult, and that is a concern to us as an association and to the LGA, because we do not want to be in a position where people do not get the services they clearly need at a lower level. That is why we are pleased that the reform grant has now been published around early intervention, but there is an awful lot more that can be brought to bear on that. As we integrate more and more, it is also about seeing the public money that is available locally to narrow some of these gaps, and to use wider local authority services through neighbourhoodsculture, leisure, and housing particularlyfor early intervention.
David Rogers: To add to that, the wider picture is of enormous demographic challenges; in 20 years time, 20 per cent of the population will be over 65 and, therefore, whatever the situation is now, there will be greater demands then. Of course, that is already true in some less urban parts of the country. The number of children with disabilities has risen by 62 per cent over the past 25 years, we know that there are good reasons for that. It shows that, in relation to eligibility criteria, the challenges that individual local authorities are facing, especially at this time of the year, as they come to setting their budgets, are very severe indeed.
Q 183 Kelvin Hopkins: We have heard concerns that the new commission will be dominated by health care responsibilities, and may neglect social care. What changes to the Bill would help to prevent that from happening?
David Rogers: Anne as a practitioner will be able to add to this, but the principle is that services are increasingly being provided jointly or in an integrated way at local level, therefore, whatever the regulatory framework is, it needs to reflect that. That is good for the individuals concerned, because sometimes it is hard to discern where social care ends and health care begins, and vice versa. That is something that we are entirely comfortable with, and it is also why we support the integration of regulation, but the practicalities of it need to ensure that it works, is effective and has the right balance between regulation, which is of course necessary, but without spending too much on it at the expense of those front-line services.
Q 184 Mr. Bradshaw: I am interested to know why you feel comfortable with it and you do not feel that there is a risk of the social care side being overwhelmed by the health care side, whereas the current CSCI expressed a very different view. Why might that be?
Anne Williams: As the Association of Directors of Adult Social Services, clearly we have a huge investment in making sure that there is detailed attention to the quality and regulation of social care. As we have said, the way forward is integration, and we have to make sure that the commission works in an integrated way. That is going to be the key. In local government, we have as much investment in making sure that health services are of high quality and people are treated with dignity as we have in social care, because we are dealing with these people and they are crossing between health and social care all the time. It will be down to who is appointed as the commissioners, and their background, who the staff are and having a true, joined-up approach to the reviews. We already have some joined-up performance indicators; as time goes on and practice emerges, we would like to see morewithin the overall basket of 198 indicatorsthat really focus on the integrated nature of what we are trying to do.
Q 185 Mr. O'Brien: On a point of clarification, arising in parallel with the Ministers question, when you say that you are much in favour and that integration is the way forward, are you talking about the regulatory system or about the whole of health and social care provision becoming integrated? In which case, are we in danger of letting regulatory frameworks and processes get way ahead of where we are in the delivery of services on the ground, given the very sharp divide between what you, as local government organisations, can offer versus what the NHS offers in terms of health careand, of course, given the massive difference between the central taxpayer-funded NHS versus local government, local taxpayer-funded social services? I just wonder whether you are getting ahead of yourselves.
Anne Williams: In terms of our vision and aspirations?
Q 186 Mr. O'Brien: The vision being to deliver a regulatory unity while, at the same time, not having a unity of approach delivered on the ground.
David Rogers: So much of this is already happening in practice on the groundand increasingly, through local strategic partnerships, local area agreements and, in future, multi-area agreements. Local authorities are working with PCT partners to deliver increasingly joint services; therefore we feel that the time is right for regulation to be brought together in that way.
Q 187 Mr. O'Brien: Is that in addition to the individual personal budgets that have already been announced?
David Rogers: Yes, although you are of course right to say that the funding frameworks are different, as are the eligibility criteria and all that sort of thing.
Q 188 Kelvin Hopkins: I think you were saying earlier what I think about the distinction between social care and health care being, in reality, difficult to make. In fact, the Government make that distinction for charging and funding purposes. If that was overcome, and there
Anne Williams: The association I representI am answering as president of ADASShas never argued for free personal care, because of the financial consequences. But you are quite right that it causes problems at the front line because of the wavy line, if you like, between health and social careand, often, continuing care. That should be no reason not to be able to integrate as much as we can. I would agree with Councillor Rogers that an awful lot is happening on integration, which is moving apace. There is not such a sharp distinction as there once was, and we are working hard to see it as a whole system.
David Rogers: I do not think that we are saying that, but we are engaging vigorously with the debate that Ivan Lewis is holding on all of these matters and the future of funding
Anne Williams: And the Green Paper.
David Rogers: And the anticipated Green Paper. We very much want to be part of that debate, but we are not quite there yet.
Q 190 Mr. Crabb: A few moments ago, you touched on the demographic changes in society and, specifically, the increasing significance of the elderly population in British society. You spoke about some of the anticipated general benefits of creating a new, integrated Care Quality Commission. How specifically will the new commission help to improve the quality of care for older people in society?
David Rogers: Well, there is of course the proof of the pudding. Some elements that Anne has already mentioned are partly relevantwho will head up the commission, who the individual commissioners will be and how they will choose to operate and particularly, returning to a point we have already made, their local relationships with service providers and local authorities. If that operates in the way that I believe it could, there will be one port of call for everyone concerned. That will inevitably lead to improvements in care. I suppose it is also true to say that we cannot be certain of that until we see the shape of the new body and how it intends to operate.
David Rogers: I am trying to avoid saying things that I have already said, but because so much integration of service delivery is already happening on the ground in towns, villages, cities and suburbs up and down the country, to have a single regulator rather than different people doing different things, which is the situation at the moment, will be an improvement. There will be a single port of call. Perhaps Anne can add to that.
Anne Williams: It is the same point. An individual, particularly an older person, is likely to move between health and social care all the time if they have long-term conditions. A regulator with an overview of the whole system is much to be desired as against a
Q 192 Mr. OBrien: This mornings evidence, in contrast, was that that will depend entirely on what the new regulator is asked to do to ensure that there are no gaps through which things will fall.
Anne Williams: It will, yes.
Q 193 Anne Milton: Have you any concerns about the creation of the new organisation and the loss of focus that there will inevitably be, because it is a major reorganisation? What happens to services during that time? We can look at the experience of the reorganisation of PCTs.
David Rogers: Organisational change always causes some short-term disruption and some loss of focus for a short period. If any change is to be made, everything must be attempted to try to minimise that, but I think the long-term benefits outweigh it. That is always the judgment that has to be made. There may, of course, also be transitional costs, but I think it is for you to pass judgment on whether you think that is a reasonable thing.
Q 194 Mr. Bradshaw: Councillor Rogers, I was interested in what you said about the Litvinenko case. The Health Protection Agency said this morning that it thought that moving to JPs would make the process quicker and that was why it preferred that. You are saying the opposite. Why in the Litvinenko case would you have had to have 46, I think you said, separate applications for each separate premises? Could you not have had a single application to a JP for all those premises?
David Rogers: My understanding is that each place would require a separate application. If that is not the case, your information is different from mine, but that is our understanding of how the process would work. Of course, there is the cost as well. We understand that Westminster city council spent some £250,000 on that particular matter. That is more likely to happen within London perhaps, but if such a cost were to fall on the environmental health department of a district council, it would be an enormous sum.
Q 195 Mr. OBrien: There may be a point arising from what the Minister has just said. I think that most of the premises were licensed premises, which has an effect potentially as well. To return to a point that my colleague Anne Milton raised, have you had any discussions or, indeed, assurances on the question of transitional costs?
David Rogers: No, we have not looked at that in detail. I was just making the general point that any structural changeMrs. Milton referred to PCTs, for instanceinvolves transitional costs and sometimes, regrettably, a lack of focus in the short term, but there may be longer-term benefits.
Q 196 Mr. OBrien: Do you feel that the Bill provides enough of a framework and enough detail about how the transition will take place, or is that an area that you hope that we will be able to develop as we scrutinise the Bill?
Anne Williams: I hope that there would be a detailed transitional plan, and that any loss of focus would concern us in social care, given the extreme vulnerability of people. We know that there are issues about quality all the time. We have seen several instances in the past
Further consideration adjourned.[Steve McCabe.]
Adjourned accordingly at four minutes to Seven oclock till Thursday 10 January at Nine oclock.
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