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Session 2009 - 10
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Delegated Legislation Committee Debates



The Committee consisted of the following Members:

Chairman: Bob Russell
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 GMC’s 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 body—the 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 Patel’s 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 NHS’s 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 time”—to use the hospital jargon—that 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 Department’s 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 Department’s 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 Committee’s 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 happens—that is my understanding—I 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 said—albeit briefly—about 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.
 
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