Examination of Witnesses (Questions 55-101)
MR NIALL
DICKSON, MR
PAUL PHILIP
AND PROFESSOR
STEVE FIELD
11 MARCH 2010
Q55 Chairman: Gentlemen, welcome
to the second session of our inquiry on the use of overseas doctors
in providing out-of-hours services. I wonder if I could just ask
you briefly to give your name and the current position that you
hold.
Professor Field: I am Professor
Steve Field; I am a GP in Birmingham. I have done one session
on BADGER so there is a conflict of interest, but I am not very
good so she would not employ me for any more![1]
I am Chairman of the Royal College of GPs.
Mr Dickson: Niall Dickson, Chief
Executive and Registrar of the General Medical Council.
Mr Philip: Paul Philip. I am the
Deputy Chief Executive of the General Medical Council. Niall has
been with us merely a matter of weeks so we thought perhaps if
there were any technical questions I would come along to attempt
to respond to them.
Q56 Chairman: You are probably aware
from the end of the last session I do not have any interest to
declare. I am not a member of the General Medical Council but
was for a substantial number of years until the new Council took
place. I have a question for Professor Steve Field at this stage.
Is the quality of out-of-hours GP services good enough? Are local
GPs adequately engaged in designing, commissioning and providing
out-of-hours services?
Professor Field: You will have
seen from the report that David Colin-Thomé put together
with me—that report was our honest feelings about the current
situation and we had no interference from anybody else—that
it is patchy. I think our patients across the whole of the United
Kingdom, not just England, deserve consistently good services
out-of-hours as well as they do in-hours. There are actually more
hours out-of-hours than there are in-hours and I think generally
we can do better. There are examples of excellent practice and
many examples of good practice and unfortunately there are some
examples of very poor practice, for example the Ubani case but
there are others. The second question about whether GPs are actively
engaged is very similar; it is very patchy. When we visited some
of the providers we saw excellent engagement. Fay Wilson, to whom
you have just been speaking, is a provider of our local out-of-hours
service and it is exemplary. I have no criticism of what they
do at all. The engagement is excellent; the provision is excellent.
Sometimes it is difficult for them working with the PCTs to be
clear about what the contract is and I think that came out earlier.
Another example of very good practice would be in Greenwich where
we visited with a team from the Department of Health. The reason
why that is a good example of practice is that it is actually
run by a GP company which was a co-operative so GPs lead the provision.
They have a waiting list of doctors who all practise locally who
want to work out-of-hours and they do that because they have very,
very good education linked into the local vocational training
scheme. The PCT takes it seriously and has strong clinical leadership.
That is an example for everyone.
Q57 Chairman: Is there any evidence
to suggest that local GP co-operatives provide better care than
their commercial counterparts?
Professor Field: The evidence
is very difficult to find actually. Certainly looking at good
practice the Dorset Ambulance Service provides very, very good
out-of-hours care but they have very good GP and pharmacy leadership
there. It does not seem either to be an issue of what the cost
is. There is a basic cost by which I guess you can provide care,
but it is really in the contract for the provision of the care
and the clinical engagement. I do, however, feel that co-operatives
offer an advantage over private providers in that it does mean
that you are more likely to have local GP engagement and local
GP provision therefore out-of-hours as well as in-hours, and the
communication is better. However the evidence, as far as we can
see, is variable.
Q58 Chairman: Would quality and safety
be better if responsibility for out-of-hours services was transferred
back to GPs as it was prior to the new contract in 2003?
Professor Field: I think the problem
is how one uses the English in this and how you define it. Before
2003-04 many of us, including myself in my first six years of
practice, were working every other night, every other weekend
and every day and doing our own deliveries at home and in a GP
unit. We were exhausted, the divorce rate was high and the stress
and burnout rate was high. As Howard will know, many years ago
we could not consistently get other GPs locally necessarily to
join into co-operatives so our small practice was left out of
the local provision in Droitwich in Worcestershire and we ended
up having to bring locums in at weekends. The system was worse
then than after 2004. Coming up to 2004 the majority of doctors
were based in co-operatives and it was improving, but the problem
is—and this is the use of English—if I am responsible
for you, Kevin, as the doctor out there seeing the patients and
I am clinically responsible, it is actually very, very difficult
then. I can remember having a complaint against me as a senior
partner,[2]
which was hugely stressful, and I was not even in the country
when the activity happened. That was actually an in-hours issue,
which was ridiculous at the time because they happened to be on
my personal list. I think the contract has given great opportunities
for patients to have high quality care where in some areas they
did not. The regulatory system was there to make it happen. What
is embarrassing is that PCTs in some areas have not taken this
seriously and as a consequence the contracts have been variable
and the provision also has been variable. Our document does demonstrate
that if everybody did what they should have been doing properly
the quality of care would have been good.
Q59 Chairman: You hinted there that
you were sort of brought into order for something that happened
when you were not in the country. If you, as a GP, are getting
other GPs to come and work in your out-of-hours service, do you
have professional responsibility for them? This flashed up in
a debate in the House of Commons a few weeks ago.
Professor Field: As it stands
at the moment the responsibility is for the commissioning of the
care. Of course you would have responsibility for what happened
while you were looking after the patient in-hours but there is
a professional responsibility for the doctor who goes out and
visits who sees them in that consultation.
Q60 Chairman: Would any doctor who
is running the out-of-hours service have wider personal responsibilities
if they do employ somebody to do that?
Professor Field: That came out
in the Bristol inquiry. Ian Kennedy was very clear that if you
are a medical director or a chief executive who is a doctor you
have responsibilities and the GMC might want to comment on that
because that is very important.
Q61 Stephen Hesford: In light of
recent reviews of out-of-hours services, what action has the GMC
already taken to respond to the recommendations made? What further
measures do you intend to take?
Mr Dickson: The first thing is
we have written to every PCT in the country and indeed to all
employers simply setting out first of all what the GMC is able
to do in relation to the doctors who are on our Register and what
we are not able to do, and drawing attention to the gaping hole
in the registration system of doctors who come from the European
Union and also reminding employers that while the GMC, where we
are able, check language skills and competency, it is the employers
and those who contract who have responsibilities not least around
fitness for purpose. We are not in the fitness for purpose business,
we are in the fitness to practise business and so if you are getting
a doctor to perform a set of duties and tasks it is your duty
as both a contractor and a provider to ensure they have the competence
and skills to be able to carry out those tasks.
Q62 Stephen Hesford: Are you then
dodging the issue that Richard Taylor talked about before, that
the GMC should do more?
Mr Dickson: No, the GMC should
have the ability to test the language skills or to check the competency
in terms of language of doctors who come from the European Economic
Area, and we cannot do that at the moment.
Q63 Stephen Hesford: They can speak
English but they could be a rubbish doctor; that is okay?
Mr Dickson: That is the first
point; I was coming onto the second point. We would also wish
to test the competency. At the moment there are broadly three
categories of doctor who go on to the Register. There are first
of all doctors who qualify in the UK, and we are not saying that
all doctors who qualify in the UK are all perfect as I think was
hinted at earlier, but we are able to quality assure medical education
in the country; that is our responsibility. So we have some assurance
around the quality of doctors who qualify in this country. Secondly,
we require international medical graduates—that is to say
all those not from the UK and not from the European Union—to
demonstrate proficiency in English and secondly clinical competence,
so if necessary we put them through a series of tests, both written
tests and practical tests. The third group is doctors from the
European Economic Area (the EU plus a couple of others) and for
them we are not allowed to language test and we are not allowed
to competency test. What we can do is check who they are; we can
get from the competent European authority a certificate saying
they are somebody of good standing, and thirdly we get the qualifications
they produce. What we cannot do is look behind those things. We
cannot say, "Well that qualification doesn't mean very much".
If it is approved and it is on the European list then we simply
have to accept them and in the case of Dr Ubani that was of course
what happened.
Q64 Stephen Hesford: Would you want
to do that or do you devolve that responsibility to the actual
provider that the medical practitioner will then work for?
Mr Dickson: We absolutely want
to do it. We would like a change in the law. We would like a change
in the law both in this country to the 1983 Medical Act which
in our view goldplates the European Directive and actually makes
it even more difficult in relation to language and we would like
a change to the European Directive which would enable us to check
competency of doctors coming from the European Union and we are
taking active steps to try to bring those things about. We have
had discussions recently with the Department of Health about whether
there might be a possibility at least of getting the language
issue sorted out by changing the 1983 Medical Act through a Section
60 Order. There is concern. The Department of Health is worried
about the possibility of infraction proceedings, that is to say
that if we change our Medical Act and do it in such a way that
the European Union would say we are running against the Directive,
then of course the Government could face big fines and all the
rest of it. We are having on-going discussions with the Government
about that. We believe there is a way forward and we would encourage
them to work with us in order to try to achieve that as quickly
as possible and at least we would close off the language thing.
The competency thing is more difficult and that requires the European
Union. The European Union is looking at this Directive again in
2012 and we will continue to put pressure on. I think there is
a recognition at least at a political level in Europe, that this
is an issue. Free movement of labour is fine but in our view patient
safety trumps the free movement of labour and we need to look
at this across the whole of Europe because it is not working now.
There is not even good exchange of information between regulators
at the moment about doctors who are not up to scratch.
Q65 Stephen Hesford: He is not bad,
is he, for two or three weeks? Is there anything you want or need
to add to that, Paul?
Mr Philip: I do not think there
is anything that we need to add. We have for some time been calling
for the ability to test the knowledge skills and language skills
of doctors from the EU. That has been our position for quite a
significant time now and we have not changed that position. From
our point of view I was very interested in Mike's comments earlier
about the quality agenda. We have minimum standards in practising
medicine and that is about fitness to practise. Fitness for purpose
in developing quality across the patch is a slightly different
issue. I do not disagree with what Mike Farrar said earlier in
that respect but we must, as the regulator of doctors in the UK,
be able to maintain the integrity of the Medical Register. We
do that easily with UK graduates, we do it through special arrangements
we have in place in relation to international medical graduates,
yet we do not do it for EEA doctors and that cannot be right.
Q66 Chairman: What proposals do the
GMC have in relation to ensuring that there is regular monitoring
of doctors' competence and continuing professional development?
Mr Dickson: You are talking about
doctors across the piece. At the moment we have just put out a
document consulting on the proposals for re-validation which,
if we manage to get this through—and I believe we will—will
mean that Britain will lead the world in terms of the way that
it regulates the medical profession. At the moment our Register
provides limited assurance—we have just talked about the
limited assurance in relation to doctors from the EEA—in
the sense that it is essentially a record of qualification. Of
course the longer ago that that qualification took place, the
less assurance in a way the Register provides, so what you are
talking about is a doctor who, on such-and-such a day, had a primary
medical qualification at that time, or indeed went through a course
to become some form of specialist such as a general practitioner
or some other form of specialty. That is what the Register does
and it also demonstrates whether the doctor has had any conditions
or restrictions placed on their practice. With revalidation what
we will be doing instead of the historical record of qualification
is to provide something nearer a contemporary record of performance,
in other words demonstrating that that doctor on a continuing
basis is competent and fit to practise. That will be a big advance
and the healthcare systems will do that by putting in place robust
systems of clinical governance underpinned by a good appraisal
system over a period of five years so that we would expect all
doctors within a few years' time to be able to have access to
a good system of appraisal which tests how well they are doing,
enables them to reflect on their own practice and then if they
have done that five times their licence will be revalidated for
another five years. That is an additional form of assurance and
we believe we will lead the world if we manage to do that across
our whole healthcare system.
Q67 Chairman: How will that affect
doctors from the EEA coming in and working on out-of-hours services
on a temporary basis?
Mr Dickson: They would be subject
to exactly the same rules as any other doctor working in this
country. They would be required to have a responsible officer
who would be responsible for ensuring their revalidation; they
would have to demonstrate that they had a robust system of appraisal
and they would be required to do the same things as any other
doctors in this country.
Q68 Chairman: Of course revalidation
is not pan-European and it does not happen overnight. Are you
confident that doctors coming in will have the same level of checks,
for want of a better word?
Mr Dickson: Revalidation does
not solve the check problem. What it probably will do over a longer
period of time is that it will mean that if doctors from the European
Union come here and are subject to a process of appraisal and
so on, then it may at an earlier stage identify if there are any
problems in relation to their competency and fitness to practise,
but it will not deal with the entry point.
Q69 Charlotte Atkins: How will you
ensure that a doctor coming in from the EEA has relevant experience?
To have a cosmetic surgeon jumping into a role as a GP, surely
that does not make very much sense. Would the GMC like a system
by which the experience of foreign doctors is taken on board before
they are let loose on general practice?
Mr Dickson: We run a number of
registers so we have a general register and we also run specialty
registers as well, so there is a separate register of general
practitioners. The problem in relation to Europe is that again
the definition "general practitioner", which is happily
used and we have to accept, does not really apply so that in Germany
they do not have general practitioners as they do here. In fact
Dr Ubani was supposedly a qualified general practitioner according
to the rules of the European Union and we had to register him
on the GP register, which simply goes to show that system absolutely
does not work. However, I do not think the GMC, even in their
post-revalidation world, even if we closed that gap in Europe,
would be doing fitness for purpose type checks and, as Paul said,
there would still be an obligation on employers to say what job
they are expecting that doctor to do. The doctors of course have
a responsibility themselves to not practise beyond their competence
but the GMC's role would be to say doctors who have been in practice
for a while would have to demonstrate that they were competent
and fit to practise and have proof of doing that. We would have
an entry system which would say what are your qualifications and
then we would put them on specialist registers which entitle them
to work in particular settings, but beyond that I do not think
it would be the GMC's role. I think there is still a critical
role for employers.
Q70 Charlotte Atkins: So it is really
the PCT that has to make sure that the doctor they are employing
is fit for purpose in the role they are performing. Do you see
a role here for the strategic health authorities? We seem to have
been very quiet on what their role is.
Mr Dickson: In a way it is not
for us to say exactly how the healthcare system should operate.
I should add that we have talked an awful lot about doctors working
for PCTs, the NHS and so on. One of the areas of course that we
are also concerned with are doctors who work on their own, who
are in private practice and who may come from Europe and simply
put their badge outside their surgery, as it were. They are relatively
small numbers but it is a significant area of risk. Clearly any
healthcare system, whether at SHA or PCT level, has to have systems
of supervision and clinical governance and assurance that they
are putting those systems in place. I do not think it would be
up to us say which bit should do what, but certainly in broad
terms and what we said in letters we have sent out to employers
is that you have specific responsibilities either if you are directly
employing doctors or even if you are contracting or commissioning
services to ensure that those doctors are competent and fit for
purpose.
Q71 Sandra Gidley: Professor Field,
I just wondered if you thought the criteria for admitting doctors
to performers lists were robust enough. Do you think it is right
that it is possible for a doctor to be admitted on to one list
and then just work anywhere else?
Professor Field: It is useful
following the example of a doctor going through the system. The
short answer is no. I am really worried about the standard of
European training which is brilliant in Denmark and Holland, for
example, but, as Niall quite rightly said, the definition of GP
does vary as you go south and across Europe. In April the GMC
takes over the Post-Graduate Medical Education Training Board
which has a role for overseas doctors but the European doctors
could come in. As the doctors come in we are very worried about
the quality. Even those excellent doctors who train arguably at
an even better standard in Denmark and Holland to what we have
and their training programmes are generally better because they
are longer and more intense and they get more experience with
patients, they are not accustomed to the NHS in- or out-of-hours
and the drug names are slightly different. In 2008 we issued some
guidance from the College to PCTs which helped with interpretation
of the performers list and we tried to work with the post-graduate
deaneries (those who provide the education) so that they might
assess the doctors if they were coming in. In Wales, which has
a single deanery (a small country, the size of a small SHA) they
have a centralised system where they have induction, assessment
and they use a knowledge test as well as clinical skills. In England
the responsibility is with the PCTs. If the existing rules on
the performers list were applied consistently that would be acceptable,
but it is the interpretation and the Department of Health did
issue further guidance at the end of March last year for PCTs
as part of the suite of papers to support revalidation. It is
an excellent paper but most PCTs were not aware of it; it was
not publicised enough. It was on the DH website but most PCTs
were not aware of it. We had issued guidance, the DH has issued
guidance and, as you will read in the detail of our report, that,
if implemented, is sufficient. I do support the GMC's need for
English language testing before doctors come into the country
and a section 60 order to sort that out I believe should be done
urgently irrespective of the election; this is really important.
Actually the PCTs working with their deaneries locally should
be able to provide consistent assessment. When I did my last session
out-of-hours the provider—Fay Wilson, who is sitting behind
me—even though I was a local GP for a couple of decades,
made me go to a training session and actually there was an assessment
about how we handled people over the phone. I am not very good
out-of-hours because I like to see patients and I am not very
good at that sort of telephone stuff and do not do it any more,[3]
but actually that was the provider doing the assessment. The PCT
should also do an assessment to go on the performers list. There
are enough checks and balances in the system if the system was
working. The SHAs frankly also need to take this seriously and
make sure that the PCTs are doing their job properly. Clearly
Mike Farrar in the North West is doing that. All SHAs should do
that in England. There are enough checks and balances to make
sure there is a safe system but it is not taken seriously and
consistently from PCTs all the way through the system.
Q72 Sandra Gidley: You mentioned
the word "patchy" earlier a couple of times; would it
be fair to say that a locum doctor wanting to work in this country
might be able to get to know where it might be easier to get on
the List?
Professor Field: As we have said
in the press and in committee many times, we believe that there
has been a network where people know which PCTs to target. A number
of recommendations in the Department of Health's own report include
sharing information more and tightening this up. Clearly Dr Ubani
got in through the performers list in Cornwall and the Scilly
Islands. He was rejected in Leeds I understand because of his
language. Cambridge PCT took him on and there were no checks.
Now you have three PCTs there all meant to be doing similar checks
with different outcomes.
Q73 Sandra Gidley: You did say there
were recommendations about exchange of information between PCTs
and the GMC and you are saying the report back should be improved.
Do you think it would be better to have a single performers list
that was held nationally?
Professor Field: I believe it
would be better to do that and actually the GMC would be the place
to do it. There are difficulties about keeping it up-to-date.
As Niall said earlier on, your qualifications and your experience
are only as good as when you actually go on the list so it has
to be a living document. When you have doctors currently working
between four, five or six PCTs, different performers lists and
maybe five, six or seven different providers, it is hugely difficult
to keep track of them. I do believe that revalidation as a system
will help this. With any doctor coming from Europe, the UK or
wherever having a named responsible officer should be able to
manage this. However, again we have evidence of PCTs taking appraisal
seriously and not seriously in different PCTs over the last couple
of years. We have had doctors writing to us even in the last three
months that PCTs in some areas have been considering stopping
the appraisal system because of financial issues. None of them
have actually done that but we know three years ago that happened.
Unless we have GPs on the boards of the PCT making this work,
unless we have robust clinical governance systems, unless the
PCTs follow the regulations that are already there, we are going
to continue to have this mess as has happened in Cambridge and
elsewhere.
Q74 Mr Scott: Professor Field, the
Cambridgeshire Coroner recommended that the Royal College of GPs
should institute a national training and assessment programme
for overseas doctors who want to work as GPs in the UK. What action
are you taking on that recommendation?
Professor Field: Before they wrote
we had already, at the end of 2008, started working with the deaneries
to offer what I suggested before which was an induction offer.
We think doctors coming from Europe should actually be spending
about three months in the UK before they work in- or out-of-hours
to understand the system. If they are serious about working here
then that is a good thing. We have started working with the deaneries
on some work on knowledge tests and communications skills and
I think you heard from those in the West Midlands that the deanery
there has started to do some work on that. However, it is very
patchy. In Wales it works well; across England it is variable
partly because the PCTs do not ask and there is an issue about
whether they will fund that system. Personally I think they should
not need to fund it, it should be the individual doctor or the
provider who actually pays for any additional training. The deaneries
are in flux in England as well at the moment; they are going through
some re-organisation, some discussion of purchaser/provider splits,
and there is an inconsistency there, whereas Wales has an advantage.
We welcome the Coroner's request to do something nationally because
we believe we can then tie all these loose ends together. We have
written to the Department of Health and look forward to their
response about how that might be resourced to set it up. If it
is a national system then if a doctor is coming in from Germany
the issue is who pays for his induction and who pays for the training
and the assessment. It is my belief that it should be the doctor
who is responsible or the provider of that care, but that is a
debate we need to have because otherwise what we keep doing is
providing more and more things people could do which cost more
and more money. I think the incentive should be that local providers,
local PCTs, should work with local GPs to encourage them to provide
the care then we would not need these assessment systems in the
first place.
Q75 Mr Scott: Professor Field, you
mentioned earlier that from some countries—I think you mentioned
Denmark and Holland—where the standard of GPs is high you
do not have a personal difficulty with anyone coming in from there,
but for other countries—you mentioned going further across
southern Europe and perhaps possibly some of the former republics
that are now involved in the EEA—do you feel there should
a two-tier policy, that from some countries we do accept them
but from some countries they do need more training perhaps?
Professor Field: I am not an expert
in European law and that is the problem. Well, the problem is
not that I am not an expert in European law, it is the European
law! Our training is modelled on Denmark and we think in England
we should have longer training for GPs. I do not believe that
our training for out-of-hours is adequate at the moment and that
is also in the report asking us to review that. I do not think
the training is consistently good in this country. Not all GPs
in training in this country can do a placement looking at acutely
ill children so there are improvements we have to do with our
own training. If you go to Germany or to Italy in some training
programmes they do not see children, they do not look after children.
If you go to Denmark it is brilliant actually but I would still
expect a Danish doctor working in England to be inducted into
the British NHS. So it is not just about knowledge, skills and
language, it is actually about understanding the environment they
are working in and, as you will know from the report from the
Coroner, Dr Ubani came in and there was a whole series of errors.
Professionally he should never have worked here; as a professional
he should never, ever have wanted to work here because he knew
he was not competent in the first place. It was the doctor, it
was the PCT, the provider who provided the drug bags; there was
a whole systems error. I think we have enough commitment now to
sort this out and I was really encouraged by the evidence given
from the PCTs and the SHA earlier on because they are now taking
this seriously. It is just a shame that did not happen before.
Mr Scott: Thank you very much. I guess
if we need out-of-hours we should perhaps go to Denmark.
Q76 Dr Stoate: I would like to place
on the record an interest and that is I am currently on the GMC
List and hope to remain so. I am also a Fellow of the Royal College
of General Practitioners and also my practice is covered by the
out-of-hours co-operative that Professor Field mentioned, it is
called GRABADOC and it does in fact provide an extremely high
level of cover to my patients. I just wanted to put that on the
record in case there is any confusion. Much of what I wanted to
ask has already been covered, but I have a question I would like
to ask Niall. Can you clarify the current arrangements regarding
indemnity insurance for practitioners in this county?
Mr Dickson: I am going to defer
to Paul.
Mr Philip: There is no legal requirement
for a doctor to have indemnity insurance to be on the Medical
Register at this point in time. However there is legislation which
is on the statute books but, as I understand it, is not enacted
which would allow such an arrangement to come into place. I understand
the Department of Health has a working group at this point in
time looking at the feasibility and the proportionality of those
arrangements.
Q77 Dr Stoate: So currently there
is no requirement for any doctor to have any sort of personal
indemnity insurance?
Mr Philip: That is my understanding,
yes.
Q78 Dr Stoate: Do you think that
should be a requirement?
Mr Philip: I think we need to
come up with an arrangement whereby patients who are subject to
adverse outcomes—medical accidents or whatever—are
appropriately compensated and within the NHS Crown indemnity applies.
The real issue is for those independent practitioners who do not
practise within the NHS or do not have sufficient funds or have
insufficiently deep pockets as it were in order to compensate
an individual who has been adversely affected by their care.
Q79 Dr Stoate: So in other words
if a doctor is working for an acute trust, the trust covers their
indemnity; if a doctor is working for a general practice or a
practice organisation they are not covered by indemnity automatically?
Mr Philip: That is my understanding,
yes.
Professor Field: That is right;
it costs me £1,900 a year to do one session a week.
Q80 Dr Stoate: Is it compulsory?
Professor Field: No.
Q81 Dr Stoate: Is that anything to
do with the NHS redress scheme? Does that have any part to play
in this issue in terms of covering patients for adverse effects?
Mr Philip: I have to be honest
and say it is not my area of expertise.
Q82 Dr Stoate: If legislation is
enacted and it is a requirement to have indemnity insurance, would
that automatically apply to doctors from outside this country?
In other words, would EEA doctors be required to provide the same
level of cover? My understanding at the moment is that should
a doctor come over from Germany, for example, and damage a patient
in this country and then go back to Germany, there is no recourse
for that damaged patient or that damaged patient's family against
that doctor in terms of claiming indemnity.
Mr Philip: Common sense would
mean that should a doctor come onto the Medical Register for any
period of time whatsoever they just comply with the arrangements
that are in place at the time, so one would suggest that that
would be the case but in all honesty I do not know.
Q83 Dr Stoate: So there is need for
clarification then?
Mr Philip: Yes.
Mr Dickson: It is worth saying
that most doctors who are coming over—and I agree that may
not cover some—should be working for an organisation and
that organisation, if PCTs are commissioning them, should be making
sure that organisation is fully indemnified for the practitioners
that it is contracting with. I think the bit that the new indemnity
is not covering is really around independent practice, people
working on their own, not people who are working for the NHS.
Q84 Dr Stoate: That is fair enough;
I accept that. I have a question for Paul and that is, is there
any reason why doctors qualified outside the UK are disproportionately
over-represented in GMC cases?
Mr Philip: First of all, international
medical graduates have, for some time, been over-represented in
the fitness to practise arrangements at the General Medical Council.
We have commissioned various pieces of research to explore this.
What has become clear in research which has only just been published
is that it has much more to do with their place of qualification
than their ethnicity as it were.
Q85 Dr Stoate: I appreciate that
and that is a very important point to make. Nevertheless, is there
any reason why that should be the case?
Mr Philip: I am afraid I do not
have the empirical evidence to postulate in relation to that.
What I could say, however, is that doctors coming from the EU
are every bit as overly-represented as doctors coming from the
wider world.
Q86 Dr Stoate: You do not have any
evidence as to why that might be so?
Mr Philip: I am afraid I do not.
Q87 Dr Stoate: Obviously all these
EEA rules apply to every country so that if any doctor from, for
example, Italy decided to work in Germany they would have the
same registration arrangements applied to them as we do here.
Is that right?
Mr Dickson: Yes, although I made
the point at the beginning around the role of the Medical Act
goldplating this. For example in France if you come from a non-French
speaking country the regulator will ask to have chat with you
and if they think your French is not up to much on an individual
basis they might ask you to take a test or to go away and learn
French and then come back again. The 1983 Medical Act actually
prohibits us from doing that.
Q88 Dr Stoate: Can I just clarify
this? The French are allowed to do it but we are not?
Mr Dickson: The French are not
allowed to do so systematically. They cannot say that any doctor
from anywhere must have a test. What the French can do and do
do is that when an individual doctor comes forward they can assess
that doctor in an informal way and then decide, "I don't
think your French is up to much". We are prohibited. The
advice we have from counsel is that we cannot do that because
of the 1983 Medical Act which is why I was making the point earlier
that we believe we can and should be able to change the 1983 Medical
Act.
Q89 Dr Stoate: So it has nothing
to do with European law then, it is to do with our law?
Mr Dickson: Our law goldplates
a bit of European law. The 2005 Directive actually says that professionals
who are moving from one country to another should—must,
as it were—be proficient in the language of the host country
they are going to work in. So in one sense the European law pushes
us in the right direction, but it also says, "You are not
allowed to have systematic testing". We are not allowed to
have systematic testing.
Q90 Dr Stoate: That is playing with
words. If, for example, I wanted to get onto a French register
and I do not speak much French, I would not be allowed to. However,
a French person who does not speak much English would be allowed
to come and join your list.
Mr Dickson: Yes, that is absolutely
right. That is the point.
Q91 Dr Stoate: That cannot be equitable
across Europe, can it?
Mr Dickson: It is not equitable;
it is about our 1983 Medical Act rather than a European Directive
which is the reason why we believe we are not able to do that.
Q92 Dr Stoate: So it is another bit
of French le fudge, is it? They get away with it and we
do not.
Mr Philip: The Directive allows
in appropriate circumstances to language test; the question is
what is "appropriate circumstances"? The 1983 Medical
Act prohibits the General Medical Council in any circumstances
from language testing. There is a difference.
Q93 Dr Stoate: That needs to be put
right rather urgently.
Mr Dickson: I have had a discussion
with the Secretary of State. As I mentioned before, the Department
is concerned about infraction proceedings from Europe but we would
be very keen to work with the Department, if necessary, to go
and get counsel's advice together, as it were, to see if we can
get round this because we believe there is a way forward where
we could change the 1983 Medical Act without the risk of the Government
facing the ire of the European Union.
Q94 Dr Stoate: This is vital. Steve
has made the point, quite rightly, that because the word "GP"
does not have the same meaning in Europe as it does here, we potentially
have people with no experience whatsoever in general practice—Dr
Ubani almost certainly fits into that category—and they
can do almost what they like in this country.
Mr Dickson: We were only having
a discussion a moment ago about language testing; we were not
talking about competency and that is again more the European Union
that puts up that barrier.
Q95 Dr Stoate: We need to bear in
mind he was rejected by Leeds because of his language.
Mr Dickson: Absolutely.
Professor Field: Language is an
issue. When we published our report the Minister who has just
come in behind was more assertive than we were over making sure
the PCTs assessed on skills. The provider—the PCT—is
there to look at the knowledge skills induction. That is there;
they should be doing it. I do believe language is something which
should be sorted nationally as well as locally. The problem with
when you are on the GMC Register, as you know Howard, is that
it is a historical document at the moment. I have not done out-of-hours
for many years therefore I would have to go back and be trained
and get more experience and have somebody sit with me. That is
what BADGER would do to me. Other providers just want to fill
the rotas. The PCTs have a responsibility in their contracting.
The guidance needs to be there and that is what the Department
of Health has done. I must say they have been impressive on how
they have taken on all of our recommendations and gone further.
I cannot fault the fact that they have supported it. The problem
is what went on before at a local level. It must be hugely frustrating
being in Whitehall either as a minister or in the Department of
Health that this has happened and that there are so many inconsistencies
at PCT level.
Dr Stoate: It is pretty frustrating for
this Committee which is why we are carrying out this inquiry.
Q96 Chairman: How long is it since
the General Medical Council have spoken to the Government about
changing the 1983 Act to make this a little bit more flexible?
This is news to me.
Mr Dickson: The last time I spoke
to them was to the Secretary of State last week.
Q97 Chairman: Was that the first
time the GMC had spoken to them about changing this legislation?
Mr Dickson: No. In the eight weeks
I have been at the GMC we have had a number of exchanges with
the Government both around the 1983 Medical Act and also what
other things we could do to help support the Government in its
efforts to tighten up this whole process.
Q98 Chairman: The absence of this
English language test is several years now, is it not?
Mr Philip: It is, yes. Niall's
predecessor, Finlay Scott, has been making this point for some
considerable time. There is an issue here—there is a lacuna,
as it were—between what the Medical Act stops us from doing
and what European legislation might allow us to do. To be absolutely
clear, however, the issue is a wonderful EU word "proportionality";
what would be proportionate in order to decide whether an individual
could speak English or not, and that is why you cannot simply
systematically say that because you are French or Italian or whatever
then you have to be tested.
Q99 Mr Scott: I accept what you are
saying about proportionality, but surely the basic test is whatever
country the doctor comes from they either can understand what
a patient is saying or they cannot understand what a patient is
saying, and whether it is European law or whether it is the 1983
Act surely the pressure should have been brought, maybe from yourselves,
to get this changed? It has to be ludicrous that we can have doctors
coming in, however well qualified and whatever ability they have,
to our country when they cannot speak the language.
Mr Dickson: I agree entirely and
that is why we are doing everything we can both to put pressure
at a European level (Paul gave evidence before Christmas on the
subject at European level) and I think there is some political
buy-in at the European Parliament level but I am not sure there
is at Commission level; we still have a difficulty there. Likewise
certainly the Secretary of State's comments to me last week indicated
that the Government wanted to do everything it could to try to
bring about this change. The legal technicalities are not absolutely
straightforward but I believe there is an opportunity now; we
should press ahead and try to get this change through.
Q100 Mr Scott: With some urgency?
Mr Dickson: With urgency, I agree.
Chairman: For your information, when
this Committee was in the European Commission taking evidence
on health inequalities, we did have a meeting with the Commission
themselves who were changing Commissioners at the time. I brought
this matter up and I do not think there was any disagreement about
what I was saying about the ability or the responsibility for
communication being thrown back to employers maybe not now as
we have more doctors in the system but many years ago we were
hard pressed to find doctors to work in these types of areas and
consequently had to take what was on offer. I hope it is pursued
and pursued nationally as well. If we could alter any Act that
we have here that will give some flexibility but not get rid of
the rigid system that we have now, I hope that is looked at.
Q101 Dr Taylor: This question is
to Niall or Paul, is there sufficient exchange of information
between the GMC and your counterpart bodies in other countries?
Dr Ubani may be a very good cosmetic surgeon, but he is obviously
not a good doctor in any other way. Are there talks about limited
registration, if he could be registered just as a cosmetic surgeon
and not as anything else?
Mr Dickson: Again we are conflating
two issues. First of all, there is the issue of the ability of
us to communicate with other regulators and the situation is again,
to use the stock phrase, "profoundly unsatisfactory".
The GMC issues a monthly circular to all regulators throughout
the world listing the doctors who have come before our fitness
to practise procedures, people who have had restrictions and so
on. I have to say that from the rest of Europe there is a very
mixed and patchy picture and there are regulators who produce
absolutely nothing. Again you are not always talking about a national
regulator and the picture of medical regulation varies enormously
around Europe so, for example, at German level there is an over-arching
German body but there are also key bodies at the level of the
Länder. We have written to the German authorities
about Dr Ubani. I think we have sent 22 letters, including questioning
whether he should still be practising given what has happened
and we have not had a response. So the level of communication
around Europe is unsatisfactory. Paul may wish to comment on this.
There have been efforts to try to get a pan-European system and
we have been putting pressure on the European Union to have a
mandatory system. If you have free movement of labour you should
have free movement of information and it is not satisfactory to
allow people to wander around without clear issues about the free
movement of information.
Mr Philip: That is an extremely
good point. We have for some time been lobbying for a mandatory
requirement that disciplinary action taken against doctors in
Europe is automatically brought to our attention in a systematic
way. That is not the position at the moment. We are by far the
most open and transparent medical regulator in Europe if not the
world. Our disciplinary outcomes are all on the web; they are
automatically updated on a daily basis and, as Niall said, we
send a circular round to all regulators on a monthly basis. That
is not reciprocated in any shape or form, particularly in old
Europe. Scandinavian countries are outstanding in this respect
but if you go back to France, Germany, Portugal, Holland, Italy,
it is extremely patchy. Part of the problem, as Niall says, is
because we are not dealing with a single country competent authority;
there are something like 28 in France and in the 50s in Germany,
so trying to actually engage with such a fragmented process is
extremely difficult.
Chairman: Could I thank all three of
you very much indeed for coming along and helping us with this
session. Thank you.
1 Note by Witness: This was a light-hearted comment
intended to put the committee at its ease and was not intended
to be taken too seriously Back
2
Note by Witness: Complaint subsequently not upheld Back
3
Note by Witness: This is meant to convey my preference for face
to face consultations rather than telephone triage. Back
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