The
Committee consisted of the following
Members:
Blunkett,
Mr. David
(Sheffield, Brightside)
(Lab)
Creagh,
Mary
(Wakefield)
(Lab)
Ennis,
Jeff
(Barnsley, East and Mexborough)
(Lab)
Keen,
Ann
(Parliamentary Under-Secretary of State for
Health)
Kelly,
Ruth
(Bolton, West)
(Lab)
Ladyman,
Dr. Stephen
(South Thanet)
(Lab)
Lamb,
Norman
(North Norfolk)
(LD)
Mulholland,
Greg
(Leeds, North-West)
(LD)
O'Brien,
Mr. Stephen
(Eddisbury)
(Con)
Riordan,
Mrs. Linda
(Halifax)
(Lab/Co-op)
Scott,
Mr. Lee
(Ilford, North)
(Con)
Soames,
Mr. Nicholas
(Mid-Sussex)
(Con)
Timpson,
Mr. Edward
(Crewe and Nantwich)
(Con)
Wicks,
Malcolm
(Croydon, North)
(Lab)
Wilson,
Phil
(Sedgefield)
(Lab)
Wilson,
Mr. Rob
(Reading, East)
(Con)
Eliot Barrass, Committee
Clerk
attended the
Committee
Second
Delegated Legislation
Committee
Monday 11
January
2010
[Bob
Russell in the
Chair]
Draft
General and Specialist Medical Practice (Education, Training and
Qualifications) Order
2010
4.30
pm
The
Chairman: Before I call the Minister, I inform the
Committee that we have a time limit of one hour and 30
minutes. That is not a target to reach, but a time that we must not
exceed.
The
Parliamentary Under-Secretary of State for Health (Ann
Keen): I beg to
move,
That
the Committee has considered the draft General and Specialist Medical
Practice (Education, Training and Qualifications) Order
2010.
It
is a pleasure to serve under your chairmanship, Mr. Russell.
The order being debated today is the first in a series of legislative
instruments implementing the recommendation made in the
report of the Tooke inquiry, Aspiring to Excellence: Findings
and Final Recommendations of the Independent Inquiry into Modernising
Medical Careers. The draft order is made under powers in
section 60 of the Health Act 1999. It abolishes the Postgraduate
Medical Education and Training Board and transfers its functions to the
General Medical Council by making provision in the Medical Act 1983 and
facilitating the making of provision similar to that currently in the
General and Specialist Medical Practice (Education, Training and
Qualifications) Order 2003, which established the Postgraduate Medical
Education and Training Board. The new functions to be conferred on the
GMC will be contained in the 1983 Act and in subordinate legislation to
be made under new powers taken in that
Act.
The
Postgraduate Medical Education and Training Board was created in 2003
and took over the functions of its two predecessor bodies: the
Specialist Training Authority and the Joint Committee on Postgraduate
Training for General Practice. It approves standards for assessments,
trainers and programmes for the delivery of postgraduate medical
education and training, and it monitors training, quality standards and
outcomes through inspection visits and other arrangements in the United
Kingdom. It awards certificates of completion of training and
determines the eligibility of doctors for inclusion on the specialist
and GP
registers.
The
draft order transfers to the GMC statutory responsibility for
delivering those functions, which are central to ensuring the delivery
of effective patient care. The GMC already has responsibility for
setting and assuring standards in undergraduate medical education and
for ensuring that all doctors participate effectively in continuing
professional development to ensure that they keep their skills up to
date after completing training. Although taking on responsibility for
postgraduate medical
education and training is a significant extension of the GMCs
remit, it is in a functional area in which the GMC already has a very
strong track
record.
When
the Postgraduate Medical Education and Training Board was created in
2003, it brought together for the first time responsibility for setting
and maintaining standards both in postgraduate general practice
education and training and in specialist medical education and
training. The rationale for merging the functions of the Postgraduate
Medical Education and Training Board with the GMC originates from the
Aspiring to Excellence report of the Tooke inquiry.
However, the aspiration to bring responsibility for setting standards
in medical education under a single body is not new. The 1975 Merrison
report first recommended that the regulation of the entirety of medical
education and training should come under the auspices of a single
bodythe GMC. A further rationalisation of the number of bodies
involved in setting and assuring standards of medical education in 2009
would be a continuation of a trend towards a more integrated approach
to postgraduate medical education and
training.
The
Tooke inquiry demonstrated dissatisfaction among those in the
profession with the current fragmented system. It noted that there was
a lack of co-ordination between undergraduate and early postgraduate
education, as well as a lack of continuity between the processes for
setting and monitoring standards of training and continuing
professional development. It also suggested that the existence of two
separate bodies permitted the development of different cultural
approaches and philosophies.
The inquiry
found evidence that the medical profession sought a body to set
education and training standards which was independent of the
Government and the national health service, which had strong lay
representation and which could work in close partnership with the
profession. Such a body would also need to draw on relevant specialist
expertise to facilitate flexible training and to set standards across
the continuum of medical education, from undergraduate studies to
postgraduate qualification and continuing professional
development.
The inquiry
suggested that a merger of the two bodies responsible for medical
education and training would provide the potential to share expertise,
develop a shared philosophy and facilitate economies of scale. The
merger will enable the development of a common approach to
undergraduate and postgraduate education and training and facilitate
the sharing of expertise, which will, in time, improve the efficiency
of processes that support the continued improvement of medical practice
and, more importantly, patient care. The merger will also simplify the
regulatory structure. It will create a single competent authority for
medical education and training and a single point of contact for
doctors, employers and partner organisations.
Historically,
the financial burden of standard setting in postgraduate medical
education and training has fallen primarily on the trainee. The Tooke
report revealed that there is strong support for the view that it would
be more appropriate for the cost to be borne by the profession as a
whole. Transferring responsibility for setting and assuring standards
of postgraduate medical education to the GMC will enable changes to be
made to the current funding structure so that the system of assuring
postgraduate medical education and training could be funded through GMC
fees, with the burden of costs shared across all licensed
doctors.
The GMC and the
PMETB support the merger and recognise that it creates an opportunity
to realise much more far-reaching improvements in the way in which
medical education and training are regulated. During the public
consultation on the proposed legislation, there was also strong support
for the proposal, with the majority of respondents supporting a merger
of the two bodies as soon as possible.
The PMETB and
the GMC have developed a close working relationship, which includes
sharing responsibility for setting standards in the foundation
programme and for the process of certificating doctors for inclusion on
a specialist and general practitioner register. The PMETB has been
working with the GMC to ensure that the knowledge and experience of
both organisations are brought together in a way that builds on their
individual strengths following the proposed merger. The board will
continue to fulfil its statutory functions as a separate legal entity
until April 2010.
On the
proposed transfer of functions, I said that the draft order makes
provision similar to that made in the General and Specialist Medical
Practice (Education, Training and Qualifications) Order 2003. The draft
order makes no changes to standards of postgraduate medical education
and training, the process of certifying that doctors have completed
postgraduate medical education and training or the undertaking of
quality assurance functions in relation to such education and training.
That is because it was felt that changing procedures at the same time
as making significant personnel changes would increase disruption, and
there was a need to maintain the operational stability of both
organisations during the transfer. However, the need for a
comprehensive review of the system of medical education and training is
recognised.
Lord Naren
Patel, chairman of the National Patient Safety Agency and former chair
of the Specialist Training Authority, was invited by the General
Medical Council and the Postgraduate Medical Education and Training
Board to lead the ongoing review of the current arrangements, which is
due to make recommendations on an appropriate, contemporary approach to
medical education and training in March 2010. A merger in advance of
Lord Patels report also makes sense, as it will allow the GMC
to take an overview of the whole continuous system. The GMC will then
be better placed to identify and implement any changes required. I
commend the order to the
Committee.
4.40
pm
Mr.
Stephen O'Brien (Eddisbury) (Con): It is a great pleasure
to serve for the first time with you in the Chair, Mr.
Russell. I look forward to it. Luckily for you and the rest of the
Committee in heeding your advice, I do not believe in targets, so I do
not believe in aiming to achieve them. Far better outcomes can be
delivered, I hope, by detaining the Committee for a little less time
than your
target.
There
is broad support for the order from respondents to both the Tooke
inquiry and the consultation on the draft order itself. The British
Medical Association, the General Medical Council and the Postgraduate
Medical Education and Training Board support the decision to merge the
PMETB and the GMC. Stakeholders have pointed out that the merger will
not only enhance the efficiency of the regulation provided by the two
bodies
but provide a single unified point of contact for all those undertaking
medical training or practice throughout their
careers.
However, the
order entails two issues warranting brief consideration by the
Committee. The first concerns the automatic re-registration of GPs in a
national emergency. The purpose of new part 4A, which amends the 1983
Act, as the Minister mentioned, is to enable doctors previously
registered as general practitioners to be re-registered automatically
in an emergency. It is evident from the added pressure recently placed
on the NHS by the swine flu pandemic that national emergencies such as
pandemics require a rapid and sustained injection of resources and
extra staff, including medical professionals. I therefore welcome the
overarching intent of the amendments to the
Act.
Section
18A of the Medical Act 1983 gives the registrar power to grant
temporary full registration to an individual or specified group of
individuals in the event that a national emergency is declared. To be
eligible, a person or group of persons must be
fit, proper and
suitably
experienced.
Doctors
will still be required to meet the eligibility criteria before they can
enter the GP register automatically.
However, there
is no mention of whether the GP register will carry out a similar
eligibility check to ensure that doctors are still specifically fit for
practice in general medicine. What guarantee can the Minister give that
automatic registration will in no way diminish the standard of doctors
included on the GP register? Although it is vital that we enhance the
NHS work force at times of medical crisis, we must ensure that patient
safety is not jeopardised by doctors who might have been fit for
general practice at the time of retirement but no longer meet the
criteria for inclusion on the GP register at the time of an emergency.
Automatic registration might remove a level of registration in order to
increase the NHSs capacity to respond to a national emergency,
but that should not come at the price of patient safety or at the risk
of it.
That is my
first and primary question. Within it is another question on which the
Minister might care to comment. Declaring a national emergency is
exceptional. Understandably, Governments of all colours tend to be
nervous about doing so unless they really have to, due to all the
consequences that tend to flow from it. Although it obviously
introduces various powers, it opens up questions at the same time about
whether the Government were sufficiently in control of events and
whether a national emergency was warranted. Does the Minister have any
further comments to make about whether the power of automatic
re-registration could extend beyond what is technically described as a
national emergency? Are there circumstances less than a national
emergency that would give us access to this extra emergency medical
work force, which we might need? That is question one, with a small
addendum.
My second
point relates to proposed new section 34H of new part 4A, the effect of
the European working time directive and the new role that the General
Medical Council will adopt should the order pass successfully into
legislation. As stated in section 34H, the GMC will have responsibility
for both general practice and specialist medical training. Subsection
(4)(e) states that it will oversee
the
outcomes
to be achieved by education and training...including the levels of
skill, knowledge and expertise to be achieved.
Given that
responsibility, it is clear that the GMC in its new form will have a
large role to play in ensuring that the standard of doctors
training in the UK does not diminish as a result of the European
working time directive, with which all NHS staff now have to fully
comply. More specifically, the GMC will have a statutory duty to
determine the desired outcomes of doctors
training.
There
have been reports from across the NHS that trusts are struggling to
maintain the same level of training for their junior doctors due to the
restrictions on working hours imposed on them by the directive. Over
200 trusts have applied for derogation from the 48-hour working week,
which, as the best objective information that we have, indicates the
scale of the problem. We have all had people come to us in our
constituencies or on hospital visits and say that they are worried
about the amount of cut timeto use the hospital
jargonthat trainee surgeons now have and have the chance to
have while training under the supervision of an experienced surgeon, as
a result of the new restrictions on the working week, compared with the
time available in the past.
What
assurances can the Minister give that she will support the GMC in
maintaining training standards in the face of that restrictive
legislation? The order will come under the directive as it restricts
the available hours to work. When will she publish the
Departments long overdue review of junior doctors
training, which will surely impact widely on the work of the GMC in its
newly formed state? Patently, that is a much needed
report.
There
is a danger that the burden the directive places on the NHS waters down
the outcomes and standards of doctors training established by
the GMC. The Government must confront that danger, publish the
Departments review and support the GMC as it seeks to ensure
that medical training and, consequently, patient safety remain at a
high level. I look forward to hearing what the Minister has to say on
that
point.
I
have three minor points that I wish to ensure are on the record. The
only concern raised in the consultation document was whether the GMC
would be required to consult its members and stakeholders on future
changes. The explanatory memorandum states that the GMC
has
no
legal requirement to consult on subordinate
legislation
but
that it has a good track record on consultation, which I accept. Did
the Minister consider introducing a legal requirement to consult when
drafting the order? What are her reasons for not introducing one? The
BMA suggested that further clarification would be helpful on the fees
that the combined GMC and PMETB would charge for membership. I hope the
Minister can offer further details on that issue. There is a proposal
to add £10 to the fee to enter the special register. We need to
be sure that that is what is being thought about and proposed and to
know whether she thinks that that is both reasonable and
sustainable.
4.49
pm
Greg
Mulholland (Leeds, North-West) (LD): It is a pleasure to
serve under your chairmanship, Mr. Russell. I can assure you
that I will not be taking much of your or the Committees
time.
Those on the
Liberal Democrat Benches think that this is a sensible move, and who
are we to argue with the view of 82 per cent. of the people who
responded to the public consultation? It is a very high figure. The
move also has the support of the two organisations involved and the
wider industry, and the backing of the Health Committee. There is a
pretty powerful body of opinion saying that this is a sensible move. I
simply want to point out to the Minister that there has been no time
for a review of the long-term implications of this change and any
challenges that may arise. I believe that a review is currently under
way, led by Lord Patel. However, because that review is not going to
report before this change actually happensthat is my
understandingI ask the Minister to say that she and her
Department will take very seriously the recommendations that come out
of that review, because there is not an opportunity to consider those
recommendations before the merger takes place. It is important that
they are not simply ignored because action has already taken
place.
4.50
pm
Malcolm
Wicks (Croydon, North) (Lab): This is a conversation about
medical education and training. One aspect of medical education in a
modern and democratic society is the interaction between health care
systems and the public that those systems serve, particularly the
relationship between doctors, including specialists, and patients. In
that area, I think that things have improved over 30 or 40
years.
However, I
would like to ask two questions relating to that aspect of what one
might call social medicine. First, I have not had a chance to read all
the evidence, but I note that Sir John Tooke consulted 4,630 doctors
and then made recommendations. Was there a wider consultation with the
public and with patient interests, or was there only the consultation
with the professionals concerned?
Secondly,
given the enhanced role of the GMC, which I fully support and
understand, can the Minister remind us of the constitution of the GMC?
I know that wider interests are represented, but apart from the medical
interests and other specialist interests on that council how widespread
is membership now? Does it represent wider public opinion and patient
opinion? Given what I have saidalbeit brieflyabout the
importance of social medicine, that component on the council is clearly
important and it will become more important if, as I suspect we agree,
the GMC should have enhanced responsibilities in
future.
4.51
pm
Ann
Keen: The Government are grateful for the support given to
these proposals by the GMC, the Postgraduate Medical Education and
Training Board, the medical royal colleges and all the bodies that have
an interest in improving the quality of medical education and
training.
I shall now
try to respond to the points that have been raised, in particular by
the hon. Member for Eddisbury in relation to registration in an
emergency. The order also contains a provision to allow a GP to be
automatically re-included on the GP register where he or she has been
temporarily re-registered as a doctor in an emergency, for example
during a major pandemic that severely affects health services. Section
18A of the Medical
Act 1983 already gives the registrar power to grant temporary
full registration to an individual person or to a specified group of
individuals in the event that a national emergency is declared. To be
eligible, a person or group of persons needs to be fit, proper and
suitably experienced.
The order will
provide for the automatic re-inclusion on the GP register of doctors
who have previously been on the GP register or returned to the register
of medical practitioners as temporary registered doctors for the
duration of a national emergency, as declared by the Government. What
is an emergency declared by the Government? The new powers
for registration of doctors are linked to the declaration of an
emergency under the Civil Contingency Act 2004. That is how it would
work and how the responsibilities would be outlined.
In relation to
the hot topic of the European working time directive, doctors
hours have been falling since 2004, from 58 hours in 2004 to 56 hours
in 2007 and to 48 hours, averaged over six months, from 1 August 2009.
There is strong evidence, and I am sure that you, Mr.
Russell, and the Committee would appreciate, that tired doctors make
mistakes. Therefore, reducing the working week to 48 hours will improve
patient safety and provide a good work-life balance for doctors. The
provision regulates those hours, and hence the health and safety of
both patients and doctors. Training is now structured, curricula are
approved, and changes in the service mean that more patients are
treated as day cases or outpatients by a multi-professional, clinical
team with good clinical leadership. Those practices shorten waiting
times and length of stay, and formalise handovers, requiring a
different approach to the training of doctors from that of 20 years
ago.
From my own
clinical experience as a nurse, ward sister and, at times, a theatre
nurse, I appreciate entirely the reason for the European working time
directive. I would prefer a doctor who is not tired, I would
want that for my family and I am sure that the Committee would want the
same for their families.
On the point
about whether the GMC would be obliged to consult on future changes to
rules, there are general requirements in paragraph 9 of schedule 1 to
the Medical Act 1983 for the GMC to have proper regard for the
interests of patients, the public and doctors. It must co-operate with
bodies concerned with employment, education and training, the
provision, supervision and management of health and other services when
it exercises its statutory functions. In practice, the GMC consults on
rule changes, and I have every expectation that it will continue to
consult on any proposals that affect the system for overseeing and
setting standards in medical education and training.
Regarding the
comments about a fee, I believe that we are looking to address that
matter and I will get back to you, Mr. Russell, and to the
Committee. My right hon. Friend for Croydon, North raised the question
of the consultation, and in particular who we consult with. A wide
consultation took place outside the medical profession, which was right
and what we intended to do. At all times, we have to look to patient
safety and at the standard of training for our doctors, and it is
paramount that patients in the health service are treated in the safest
manner possible. I feel that what we have done today has enhanced that,
and I am sure that we all look forward to supporting the GMC in its new
endeavours.
Question
put and agreed to.
4.58
pm
Committee
rose.