The use of overseas doctors in providing out-of-hours services - Health Committee Contents

Examination of Witnesses (Questions 55-101)


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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