Health Committee - Minutes of EvidenceHC 566

Back to Report

Oral Evidence

Taken before the Health Committee

on Tuesday 4 September 2012

Members present:

Mr Stephen Dorrell (Chair)

Andrew George

Barbara Keeley

Dr Daniel Poulter

Mr Virendra Sharma

David Tredinnick

Valerie Vaz

Dr Sarah Wollaston

________________

Examination of Witnesses

Witnesses: Professor Sir Peter Rubin, Chair of Council, Niall Dickson, Chief Executive and Registrar, Una Lane, Director, Continued Practice and Revalidation, and His Honour David Pearl, Chair, Medical Practitioners Tribunal Service, the General Medical Council, gave evidence.

Q1 Chair: Good morning, ladies and gentlemen. Thank you for coming again. It is right to say that, to the Committee-formally, at least-there are two familiar faces and two new faces on the panel this morning. Perhaps I could ask you to introduce all four members of the panel briefly, and then to tell us in simple and relatively brief terms where you have got to in the revalidation process so that we have the uptodate picture before we start the discussion. That is obviously one of the issues we want to focus on as the morning goes on.

Professor Rubin: Thank you very much, Chairman. I am the Chairman of the GMC, as you know. I am accompanied by Niall Dickson, the Chief Executive of the GMC. We have both appeared before the Committee previously, of course. We are joined on this occasion by His Honour David Pearl, Chair of the new Medical Practitioners Tribunal Service, and Una Lane, who is the Director of the GMC with responsibility for revalidation.

If it is acceptable to you, I propose to give a brief overview, which will include revalidation, of the top spots, as it were, of the last year and then stop. Will that be okay?

Q2 Chair: It would be welcome, provided it does not take all morning.

Professor Rubin: It will take five minutes exactly, if that is okay with you.

Chair: That is fine.

Professor Rubin: We are the independent regulator of the medical profession and we are UK-wide. We have statutory functions which include keeping the medical register, education, fitness to practise and standards. I will touch briefly on all of those.

Top of our list of priorities, of course, is revalidation. We are conscious that it has been a very long time coming. When the GMC last appeared before the Committee, the introduction of revalidation had been put off a year by the Secretary of State to give the NHS in England more time to prepare. All the feedback that we are getting from the NHS around the UK now gives me great confidence that we are ready to start. I will be able to write to the Secretary of State later this month to say that the legislation, which has been in place for about 10 years now, can be switched on. I am confident that we can start before the end of this calendar year. Obviously we will have many more questions about revalidation as the morning goes on.

I have a few comments about education. I gave evidence to your inquiry into education and training in the health area in the autumn and we all agreed then that, with the new landscape in England, it is important that there is clarity of accountability about who does what and who we can hold accountable. We continue to work very closely with the Department of Health to make sure that that is the case. We have already been working with NHS Education for Scotland for some years in this regard so we do have a track record there.

We continue to be very proactive in education and training and ensuring that young doctors are exposed to the quality of education and training that they deserve. We have intervened in a number of locations around the UK in the last year where we found that the standards of education and training had fallen below what we expect. This was not the only year we have done this. We do it year on year, but again we have been quite interventionist in a number of locations.

Finally on education, we have an annual national trainee survey which has very high credibility with young doctors. It has a response rate of over 90%, which, as you know, for any survey is pretty stellar. This year for the first time the questionnaire included a free text part about patient safety and 5% of responses highlighted issues of patient safety. We are following up every one of those to ensure that the loop is closed and action is taken.

Moving on to standards, in the last year we published new guidance for doctors involved in child protection work and guidance for parents and others whose children may be involved. This is a very contentious, sensitive and emotionally charged area. We knew doctors were looking for guidance and help in this area so we drew together all shades of opinion across the spectrum for the new guidance. It has been widely welcomed by all concerned in child protection.

We also published new guidance for doctors in management, and guidance for doctors about raising concerns. We know what an important area this is, and in October we are starting an advice and helpline for doctors who are trying to raise concerns but are not being heard in their organisation.

In registration, the key thing for us is the English language skills of doctors from elsewhere in the European Economic Area. We have been very proactive over the last two years, having highlighted that the deficiency that prevents us from testing the language skills of doctors from elsewhere in the European Economic Area is in domestic legislation, not in European legislation. We secured the agreement of the Secretary of State in the autumn and he made a statement publicly that the Medical Act will be changed. We are working with the Department to ensure that that happens.

As to fitness to practise, it has been a very big year. We have created a Medical Practitioners Tribunal Service. It started working in June. It is operationally separate from the GMC, with its own offices in Manchester, its own website, logo and email. You will hear more about that in a while. We are also piloting, or consulting on, a number of changes to streamline fitnesstopractise processes. My final comment on fitness to practise is that when we discuss individual cases, sometimes the outcomes can seem very strange, not only to you but to us, too. We did an audit of all the fitnesstopractise determinations over a fiveyear period, ending in December 2011. There were 1,500 outcomes. Of those, under 2% were successfully appealed in the High Court, and only one was successfully appealed because we had been too lenient. All the others were successfully appealed because, in the view of the court, we had been too harsh. It is worth seeing that big picture when we are looking at individual cases.

I have two quick points before I finish. One of the things that we do that is not as widely known as some of the others is that we commission and fund research in areas of interest to us. This year, we published the outcome of our research on the prevalence and causes of prescribing errors in primary care, which some of you are no doubt aware of. We are now working with the relevant authorities to implement the changes that are needed there.

Finance is the last thing to draw to your attention. Both Niall and I over the last two or three years have been determined to make the GMC a very efficient and businesslike organisation. We made savings of just under £8 million a year on a £90 million budget and have passed those savings on in the form of a reduced annual retention fee for doctors.

That is it. It has been quite a busy year for us and those are the headlines, although there is a lot more below that. The health landscape around us, of course, is changing all the time and will continue to change but we too have changed and are well placed to meet all the challenges.

Q3 Chair: Thank you very much. That provides a useful summary of the issues that you have been addressing and I suspect that we will want to follow up some but probably not all of them.

Perhaps we can begin with revalidation, which I know has been a major focus of your work for some time now. Can I be clear that you believe not merely that you are fit to go, but also that you anticipate that the Government are supportive of the revalidation process coming into effect at the end of this year?

Professor Rubin: Yes. We have every reason to believe that. Obviously, we are conscious of all that is going on around us this morning, but we have every reason to believe that the Government are committed. The Government understand that the public would not understand if it was delayed still further.

Q4 Chair: In terms of the implementation, could you be clear with the Committee how you envisage, in practice, its rolling out during the next 12 months to two years? As I understand it, the figure that we have been given is that 20% of licensed doctors will undergo revalidation in the first year. I suppose that raises the question in the minds of individual doctors and everybody else of how you determine which 20% are the lucky ones.

Professor Rubin: I wonder if I could ask Una to come in on that point, please.

Una Lane: Good morning everyone. We have always spoken about revalidation being a shared responsibility between the GMC and the four health departments and healthcare organisations across the UK. Our starting point in terms of scheduling dates for doctors-when we expect to receive their recommendations-was to agree some key principles right across the healthcare sector. In terms of the detail of those principles, the key ones for us are as follows.

Patient safety is paramount. This is not about delaying taking action in relation to an individual doctor until such time as a revalidation recommendation is due, so that is an important principle. We think that in the first year every single healthcare organisation must be involved in making recommendations to us-not only organisations in the NHS but organisations right across the independent sector and locum organisations across the UK so that no particular group of doctors is left behind. We have also agreed with all of the organisations making recommendations to us that the doctors that are recommended in the first year must be representative of the population of doctors as a whole in each individual organisation. With that in mind, each of the four health departments has put together its implementation plans. To give you a flavour, perhaps, of what England has decided to do, the intention is that senior doctors, Sir Bruce Keogh-the Medical Director of the NHS-and the Chief Medical Officer, go first in England.

If the Secretary of State agrees to commence the legislation, we expect to receive recommendations about revalidation in December of this year. This will be followed by the medical directors, responsible officers, in what are currently the strategic health authorities-NHS commissioning boards in the future-and then all other responsible officers right across England in the first quarter of next year. We are now working with individual responsible officers in each of those organisations to determine what the dates for their population of doctors will look like. They are busily completing spreadsheets in line with the principles that we have agreed with them. We are expecting to get those back by 14 September. We will then schedule the dates on the basis of the information they provide for the whole population of doctors.

Q5 Chair: You were careful to say at the beginning that this was not going to be a process that delayed revalidation where it might pose difficult questions. Are you doing the opposite: in other words, identifying a riskbased approach where there is a specific risk with going into the process early?

Una Lane: It has always been important for us to get across to responsible officers and all organisations that revalidation is not a pointintime assessment. The point of revalidation is that it should be a continuing evaluation of a doctor’s practice close to where the doctor provides care in the workplace, in hospital or in primary care organisations or in GP practices. All doctors should now be doing what they need to do in order to be revalidated. They should be participating in appraisal, linking to an organisation that will support them with their revalidation, evaluating the information that is available to them in order to understand where they are and engaging actively in an appraisal process. Organisations should also be ensuring that they are identifying poor performance at an early point in the process and not simply waiting for the point where a revalidation recommendation is due to the GMC. We are very clear with responsible officers in our guidance on that.

Q6 Chair: I understand that, but can I press you on the point? If a responsible officer knew, or ought to have known on the available information, that there was a cause for concern about an individual doctor’s practice measured against those standards, is he expected, in your codes of practice, to bring that to the surface quickly?

Una Lane: Absolutely.

Chair: Thank you.

Q7 Valerie Vaz: It is good to see you all here. I have some general questions, which is why I am coming next before my colleagues hit on specific areas. I congratulate you on the work that you have done to get to this position and obviously His Honour Judge Pearl has an amazing reputation. When I heard that you had appointed him, I thought it was a good appointment and that it would show independence. He has an excellent reputation.

Can I ask a few questions on the report? You did mention, Sir Peter, that you made some efficiency costs. Could I ask where you made those efficiency savings?

Niall Dickson: It was across a range of the businesses. One of the major areas where we have managed to save money has been by pulling some of our legal work inhouse. Instead of spending money on external lawyers in the preparation of cases, we have increasingly built up our own staff. We have seen no diminution-indeed an increase-in the quality of the work as a result of doing that.

Secondly, we have moved our hearing centre to one location, to Manchester. That inevitably meant making some staff redundant in London and moving posts, although staff were offered the opportunity to move up to Manchester. Having a single hearing site will save us considerable sums of money. We have a programme running through the whole business. We operate Lean, which some of you will be aware of, in parts of our business. We are looking at applying Lean into fitness to practise over the coming year and at how we can again make our processes as efficient as they possibly can be. None of this is rocket science. It is looking at every single bit of the business. We recognise that we are a body that receives money. We are not in competition with anybody else. It means that we have constantly to be on our toes, checking that we are providing an efficient service and using the savings that we have made, both, as Peter says, to cut the fee as we did last year-for the first time ever, I think-and also, of course, to expand and do new and more effective things like the helpline or introducing induction, things that will support doctors in their practice.

There is one caveat to all that. We are seeing a remarkable increase in the number of referrals to us. We are like an accident and emergency department. That means that we have to cope with year-on-year increases. In 2010 we saw a 24% increase, in 2011 a 23% increase on top of that and this year we are running at that or a higher level. So we have to expand that fitnesstopractise activity. We want to try to do it smarter, but we also have to recognise is that-and we have done it each time-we have to invest more and employ more staff. It takes time to train them, but we are facing that challenge.

Q8 Valerie Vaz: That was one of my other questions. Clearly, you have a lot to do administratively, so are you taking on more staff? In terms of the savings in costs-which is why I wanted to ask about the savings-is that balanced with taking on more staff?

Niall Dickson: We have increased the number of staff, particularly in the fitnesstopractise area. We have also invested more staff in education and we recognise that. Of course, we took on the Postgraduate Medical Education and Training Board. Because we are a larger organisation, we were able to deliver efficiencies and we handed back money that the Government had allocated to us as part of that merger because we did not need it in order to be able to do the job. But we also recognise the huge challenge of regulating postgraduate medical education. This is 50,000 doctors who are providing frontline care and we have a responsibility for all of them. Having the systems in place to ensure that we know exactly what is going on within postgraduate education will require some more investment.

Professor Rubin: Perhaps I can add to this in the sense of the savings. Niall mentioned something about taking employee lawyers inhouse rather than paying external lawyers by the hour. That saved us just under £3 million a year, so we are talking about huge savings here. So, yes, we have been taking on more staff while making these savings by doing other things.

Q9 Valerie Vaz: Excellent. Can I turn to page A21? You very helpfully list the trustees. What is the tenure of all those trustees? How long are they trustees?

Professor Rubin: These are the council members we are talking about?

Valerie Vaz: Yes, the council members.

Professor Rubin: The tenure is to the end of this calendar year.

Q10 Valerie Vaz: How long have they been in post?

Professor Rubin: It will be four years. We are currently advertising for a new Council, which will be 12 members compared to the 24 that we have at the moment.

Q11 Valerie Vaz: So you are cutting them down.

Professor Rubin: Yes.

Q12 Valerie Vaz: And you balance the lay members?

Professor Rubin: It is 50:50.

Q13 Valerie Vaz: I have one other question. Under the new Health and Social Care Act, clearly doctors are going to have conflicts of interest. That is something that arose. Have you made a risk assessment of how you are going to deal with any referrals in terms of those conflicts?

Niall Dickson: First of all we do not believe that the Health and Social Care Act presents new ethical dilemmas that have never been seen before. What it may do is put doctors who have not previously found themselves in these positions into these positions and they could be sharper, as it were. We have reviewed our guidance in this area. We are publishing a new version of "Good Medical Practice" later this year. That has supplementary guidance attached to it around commercial interests and conflicts of interest. Peter has also written to all doctors and drawn attention to this issue. What we want to do beyond what we have already done is wait until the system is up and running to see what issues arise. There is an issue about raising awareness among doctors about what they need to do. Our guidance is absolutely clear about the need for transparency, declaring where you have a financial issue and recusing yourself or taking yourself out of a situation where there may be a conflict of interest and so forth. So there is an issue about raising awareness. But, of course, it may be that we are required to produce further guidance and help depending on the way the whole thing works out. We want to be helpful to the profession. What we cannot do is answer every single situation before it has arisen. It has to be general guidance which we give. Doctors themselves then have responsibility for interpreting and applying it to their own situation.

Q14 Valerie Vaz: I have a couple of quick questions. Is the responsible officer always going to be a doctor?

Professor Rubin: Yes. We want responsible officers. The clue is in the name, "responsible". We want somebody that we can nail, quite frankly. We want somebody who is going to be on our register that we can hold accountable for doing it right.

Q15 Valerie Vaz: You mentioned in the survey about revalidation. Have young doctors said to you-because some have said to me-that they need time off to get their appraisals and everything ready? They know the nurses do, but the doctors never get study leave.

Professor Rubin: I will answer that one. We are resorting to a little bit of anecdote here, and there are others around the table who may have views as well. In my wanderings around the country, I have spoken at meetings attended by over 6,500 doctors through the age range. The young doctors are the least concerned about revalidation. The only thing they want is for there to be no paper involved whatsoever-that it is all electronic. The key is to keep what you are doing up to date electronically and then you are not scrabbling around for bits of paper ahead of your appraisal.

Q16 Dr Poulter: Picking up on a couple of points that you made, the Department of Health released figures in March 2012 which said that 73% of doctors had an annual appraisal that meets the basic requirements for revalidation. Which doctors make up that 73%? Are they mostly doctors in training, consultants or GPs?

Professor Rubin: Hopefully Una may be able to answer that.

Una Lane: There is absolutely a mixture of doctors. The 73% is the overall national figure. The Revalidation Support Team, which is funded by the Department, undertook what they call an assessment of readiness of all healthcare organisations in England, and that includes organisations in primary care, secondary care and the independent sector. That 73% is made up of doctors from right across the patch. The percentage of GPs who have an annual appraisal and participate in appraisal is currently higher in England than it is for doctors in secondary care, for consultants and for specialist doctors. The percentage of consultants that have an appraisal in secondary care is higher than those doctors who are in specialist posts. So the 73% figure does cover all doctors right across healthcare organisations, but there are differences between doctors depending on their area of practice.

Q17 Dr Poulter: In all specialities there is an annual appraisal of more junior and middleranking doctors so they can progress to the next year of training, ST3, ST4 or whatever it may be. I am presuming that that in itself-if a doctor has met the requirements for progression in their speciality-is all they need to do, picking up on the point that was made by Valerie about the excessive administrative burden for doctors, which is a very real concern. If they meet the requirements of their speciality, that is good enough for the GMC and they can be revalidated.

Una Lane: That is absolutely right.

Q18 Dr Poulter: That is consistent across all specialities, is it?

Una Lane: Correct.

Q19 Dr Poulter: The other point I want to make, if I may, picking up on the Department of Health figures for this year, is that only 58% of doctors are in designated bodies with a policy for reskilling, rehabilitation and remediation. The point was made earlier that this is not a pointintime assessment; it is a general view about whether a doctor is fit to practise. How are we going to support and help the 42% of doctors who fall outside this category, who do not work in a body that will help them to reskill, rehabilitate and improve areas of practice that are required?

Professor Rubin: Maybe I can begin to answer that and then Niall or Una may want to come in.

Remediation has been a feature of the NHS for all the years that I have been in practice. It is not new. What is new is that one of the successes of revalidation before it even begins is that it has stimulated organisations that do not have effective evaluation and appraisal systems to develop them. That will inevitably start to uncover doctors who are not practising to the high standards that we would all wish to see. So it is bringing a sharp focus on remediation, but it would be wrong to regard remediation or revalidation as inextricably linked because they are not. Remediation is a longterm issue that has been around for a long time. You are quite right that not all organisations have a policy, but I would be astonished if all organisations had not at some stage had to remediate doctors. It has often been done in a very ad hoc way in the past. Organisations are playing catchup to formalise things that have been done very informally over the years. Our view is very clear. The public would not understand it if there were any further delays. We need to start revalidation and those organisations that do not have a formal policy of remediation will need to play catchup quite quickly.

Q20 Dr Poulter: Are you concerned at this stage that 42% of organisations do not have a formalised policy?

Professor Rubin: No, because I would imagine that they have-I cannot give you the figures on this, but just from all my years of practice I would be astonished if these organisations did not have-informal arrangements for remediation. They might not have a written policy, but they would have an informal one.

Q21 Dr Poulter: In the context of the transparency and openness and the fact that other doctors have to go through much more formal processes-particularly doctors in training-do you find it acceptable that these informal arrangements exist?

Professor Rubin: I don’t think that is the way I would view it. There is a difference between what we are talking about-

Q22 Dr Poulter: But do you think it is acceptable that some organisations have a very transparent and open arrangement-where it is very clear how to support doctors in difficulty and doctors who perhaps are not up to standard-and other organisations do not have a formal process? Is that acceptable from a public safety point of view? Is it acceptable and is it a level playing field for doctors themselves?

Professor Rubin: Obviously we would like to see more health organisations have a policy for remediation-of course we would-but what we are saying is that the fact that at the moment not all organisations do should not be a reason not to start revalidation.

Una Lane: I want to add one point about organisations that clearly do not have those policies in place currently. The Revalidation Support Team, again funded by the Department of Health, is working with those organisations to make sure that they have action plans to put those policies in place and to formalise what they may very well currently be doing informally. The responsible officer regulations now place clear responsibilities and duties on organisations to have such policies in place for remediation, rehabilitation and retraining. All organisations must meet those statutory duties and the Revalidation Support Team will be working with those organisations to make sure they put the processes in place very swiftly.

Niall Dickson: We are in a transition period. The first thing is that there has been a remarkable change over the last couple of years, where rates of appraisal have gone up and systems have started to be put in place, but you are capturing a moment when the thing is being finished off, going forward, and it is an indictment of the system. Most of these things-not only the responsible officer regulations which Una has referred to, but the obligation to give doctors appraisals-have been in their contracts for many years. It is interesting that revalidation is acting as a catalyst to put in place basically what we would term clinical governance arrangements that should have been in place some time ago. It is very encouraging. In every inquiry where things have gone wrong you see weaknesses in this kind of clinical governance, and the fact is that the system is strengthening it. I think it will, in a sense, rush to put these last bits in place as the reality of revalidation comes forward over the next few months.

Q23 Dr Poulter: The other group of doctors that are of interest and cause great public concern are locum doctors. This is a point that we will come back to later on, but what is the process in place specifically for locum doctors and are you expecting locum agencies themselves to do revalidation?

Una Lane: Locum doctors should be able to revalidate in the same way as every other licensed doctor. Again, the responsible officer regulations have what they call designated organisations-a whole range of organisations-and have given them statutory duties to support doctors. Over 50 locum agencies in England are designated bodies under the regulations and must support their doctors with appraisal and revalidation.

Q24 Dr Poulter: Given that there have been a lot of concerns expressed by the Royal Colleges, do you think the quality of revalidation and appraisal is going to be the same from a locum agency as it is from a teaching hospital, a DGH or another NHS body?

Una Lane: The part of the appraisal that we are interested in is the focus on good medical practice. We have provided clear guidance for all organisations, including locum organisations, on what they need to do. Our requirements on the information that doctors need to bring to appraisal must look the same for every licensed doctor regardless of the nature of their practice. Every organisation, whether it is a locum agency or a big hospital trust, absolutely has the same duty towards the doctors, to support them through appraisal and to ensure that their appraisal processes are adequate. The Government are playing their part in this. The Department is currently undertaking a tendering process and writing into the contracts of all locum agencies who are preferred suppliers for the NHS to make sure that they have all of these systems in place, not only to support the revalidation of doctors but to make sure that the doctors they are providing as locums to the NHS have the skills and competencies to carry out their assigned roles.

Q25 Dr Poulter: Are you aware of any locum agencies that have the ability to remediate or train doctors, or do they use doctors purely as a work vehicle to make them-the locum agency-money and to fill gaps in the NHS?

Una Lane: Again, in our experience that has absolutely traditionally been the case. The responsible officer regulations that were introduced at the start of last year absolutely changed the role of locum agencies. They are no longer simply providing a service to the NHS in whatever way they see fit. In future, they must correspond to the statutory duties placed upon them in the same way as every other organisation and must make sure that they meet the requirements set out in their contracts.

Q26 Dr Poulter: But you recognise that to close the gap between what they and a hospital will provide as a training environment is a big ask in a very short space of time, as revalidation comes in, to change the whole ethos and approach that the locum agencies come with, which are forprofit organisations providing doctors. There have been safety concerns over the use of some locums in the past and this is a very big challenge. Is that something you feel happy that we can meet in a relatively short space of time as revalidation comes in?

Una Lane: It is a big challenge but we are not beginning from a standing start. We have been working with organisations over the last few years. The Revalidation Support Team is now working with all locum agencies right across England. We need to ensure that we get this off the ground so that the momentum in place to support these doctors and to change some of these organisations continues.

Q27 Dr Poulter: I am quite concerned when you say "get it off the ground", as that is exactly the point I was making in my questioning. We are coming from a standing start here because traditionally-I was registered with locum agencies-they had no concern at all, until very recently, about education. To be acceptable to them, all that mattered was whether I could be employed on a daytoday basis. I am afraid that there is a lot of work to do there and it is from a standing start. Is this an area that you feel needs to be monitored closely? Do you think it is acceptable that locum agencies should be involved in revalidation?

Professor Rubin: This is categorically not from a standing start. We as an organisation have been engaging with the locum agencies for three years now at least. They are very clear as to what their new responsibilities are in this new world. We have known from the very beginning that locums, and particularly peripatetic locums-in Inverness today and Cornwall tomorrow-will be a challenge and that is why we put so much effort into negotiating and engaging with the locum agencies. It is not a standing start.

Q28 Chair: Can I be clear on one thing? Una Lane stressed the fact that the change in the role of the locum agency is reflected in the conditionality on the appointment of responsible officers. Is that a decision for the GMC or for the employing organisation, the Department of Health? Who recognises, and by implication can therefore refuse recognition to, the responsible officer?

Niall Dickson: The designated bodies are determined by the Department of Health, not by the GMC. There are two wider points to be made. The first is-whether you call it a standing start or whatever-that the answer is yes, of course, this is a transformation in what locum agencies have been to what we want them to be. It is not only what we want them to be but what the service wants them to be and what the Government expect them to be, hence the reprocurement of approved locum agencies that the Department of Health is going through now. We will have to see how it works in practice. But the other side, of course, is the obligation on employers of doctors, not just the agencies. Locum agencies do have responsibilities and they have new responsibilities, as Una has made clear, with their responsible officers, and their responsible officers are accountable to us in the sense of being doctors and of providing recommendations to us and they must base that on proper evidence. But there is also an obligation on employers when they are working with locums-and it has been recognised by NHS Employers that employers do not do enough to feed back to locum agencies about what has happened-to provide them with access to information that enables them to build on their practice. There is a series of things that employers need to do and obligations on employers taking on locums as well as on locum agencies themselves.

Q29 Chair: But there is also, isn’t there, by implication a responsibility on the GMC, accepting that the responsible officer is appointed by the Department of Health, to express concerns, if it feels concerns are appropriate, about the rigour and effectiveness of the transformation that Una Lane referred to?

Niall Dickson: And we will do that, absolutely.

Q30 Andrew George: Una Lane, you mentioned earlier that revalidation is a shared responsibility and one of the bodies or structures you share that responsibility with are the PCTs. You want to crack on with revalidation at a time of organisational turmoil. Because time is pressing, I will wrap a number of questions into one. You have already said, I think, that you want to nail the responsible officer. I think that is what you said, Sir Peter. That is very clear. At this moment, when there is a lot of uncertainty about what the CCGs are going to look like, are you satisfied that, in their present form, they will be ready to take on responsibility when it is clearly not going to be their primary focus at the moment? Are you satisfied that, during this turmoil, you are not going to lose ground in terms of working with the organisations that should be your eyes and ears?

Una Lane: There is no point in pretending that the changes and restructuring in the NHS-in England, of course, not in Wales, Scotland and Northern Ireland-are not a complicating factor. We have been working very closely with the Medical Director of the NHS in England, and indeed all responsible officers, including those in primary care, to make sure that we can make that transition as smoothly as we possibly can. I appreciate your point that revalidation might not be at the top of their agenda. We believe that quality of care to patients is something that should always be at the top of the agenda of those involved in the care of patients. We see revalidation, appraisals for doctors, as absolutely intrinsic to ensuring that, ultimately, patients receive good care from their doctors.

We have a whole range of operational processes in place to make sure that the transition works for us. All GPs are currently linked to primary care trusts. In the future, the proposal is that they should link to responsible officers in the NHS Commissioning Board and we are putting systems in place to ensure that that transition works effectively from 1 April next year.

Q31 Andrew George: So the line of communication is with the NHS Commissioning Board, with a single body rather than a plethora of PCTs?

Una Lane: That is currently the Department’s proposal.

Q32 Andrew George: Are you engaged at all in any discussions with the emerging CCGs? Is that not a line of conversation and communication that you have formally established with those bodies?

Una Lane: We have certainly established relationships with all responsible officers in primary care, regardless of where they are based. We have established a responsible officer reference group that enables us to understand much better what is happening on the ground. But, again, our understanding from the recent Department consultation is that responsible officers in the new structure will not sit at CCG level but will sit almost certainly in local area teams of their NHS Commissioning Board. That is currently the Department’s proposal.

Q33 Andrew George: Have you any concerns that those responsible officers, and indeed the NHS Commissioning Board in its devolved structure, are still going to be too remote from the front line, from the grass roots, where services are delivered?

Una Lane: The Department has not published its final decisions as to exactly where responsible officers will be or how many there will be, so it is difficult to answer that question on remoteness. We know there will be local area teams of the NHS Commissioning Board. The Department has not yet published its decision on how many local area teams there will be or how many responsible officers there will be in those local area teams. But I think you are absolutely right that there is a balance to be had.

Q34 Andrew George: But you are waiting on the Department to tell you what it is going to put in place. Don’t you have a view on what you think is most ideal?

Niall Dickson: We have a view in the sense that we believe that responsible officers need to have sufficient support and a good team about them-in a way, it doesn’t matter where the responsible officer figure is, providing they have that. Certainly, in relation to general practice, we would want the responsible officer and his or her team to know who the doctors are. So having, say, responsibility for 10,000 GPs would be completely unacceptable. We would want to see arrangements in place whereby the responsible officer was able to exercise those powers, possibly with assistance if it was a slightly larger group, so that a proper system was in place, and that he or she had an understanding of the range of performance among the doctors on their list.

Q35 Andrew George: You said not 10,000, but do you have a figure in mind?

Niall Dickson: We do not have a particular figure in mind. It is not necessarily the number; it is about what the support is. We are conscious at the moment, for example, that there has been some clustering of PCTs, so you have a single medical director. In some cases, those medical directors still have the other medical directors working alongside them so they have sufficient resource to be able to do the job. If you had a situation where you were putting in one person to do a job that five people were doing before, then obviously we would be concerned. I am sure the Government are not proposing such a structure, but it is important that the investment is put in place because the responsible officer bit is only one part of the role that medical directors at this level would be expected to fulfil. But from our point of view it is an extremely important role. There are new and quite difficult responsibilities which these individuals face and they need to have the resource to be able to do the job effectively.

Q36 Dr Wollaston: Can I ask at what point the GMC will be involved if an annual appraisal or revalidation highlights particular concerns about a doctor’s practice? You have already indicated that it is not going to be a pointoftime assessment process every five years but a rolling process. When you identify that a doctor is in difficulties, will you require a formal fitnesstopractise hearing to take action against seriously underperforming doctors?

Una Lane: As far as emerging concerns about performance go, we would expect them to be dealt with locally in healthcare organisations, as they are currently. What we have put in place, though, is support for responsible officers in dealing with those relatively lowlevel concerns. We have now in place a group of employer liaison advisers-16 in total-right across the UK. The purpose of this role is to support responsible officers in dealing with emerging concerns about doctors and in providing advice on when the GMC absolutely needs to engage where the concerns are significant and there is a role for the GMC in terms of taking action on the doctor’s registration.

Q37 Dr Wollaston: Will those responsible officers be absolutely clear at which point a case has to progress to a GMC hearing? Will that be universal across the country or are we going to see different responsible officers taking a different view?

Una Lane: The purpose of the employer liaison is exactly that-to provide clear and consistent advice to all responsible officers about the point at which they need to refer concerns to us, the threshold for investigating concerns about doctors and the threshold for us taking action in relation to individual doctors where the concerns are serious and patients are put at risk.

Niall Dickson: Those thresholds have not changed. Revalidation does not change this. They are the same thresholds as medical directors have had until now. What we are now doing, as Una says, is providing more support to help people who have to make these decisions.

Q38 Dr Wollaston: Coming back to the issue of locum agencies, there could be a concern that locum agencies might perhaps apply criteria different from responsible officers, and we would all recognise that that is a particular concern.

Niall Dickson: That is where the employment liaison adviser will come in to support the locum agency’s responsible officer.

Dr Wollaston: Thank you.

Q39 Chair: There is a little bit of tension, isn’t there, between the message that nothing has changed and the message that the GMC is taking more seriously its commitment to maintain and improve standards?

Niall Dickson: That is a fair point. The point about not changing is that a lot of doctors talk about failing revalidation as if some new test has been created. You cannot fail revalidation. The point is, as Una has made clear, that it is not a point in time; it is putting you into a process. The process may well identify concerns that were not identified before and the thresholds are the same as they are now. But the world changes and I think the world changes very significantly. All this is not an overnight panacea, but we believe that we are putting in place something that really will help to drive up the quality of medical practice in this country.

Q40 Valerie Vaz: Who will pay for the remediation and retraining if that is necessary?

Professor Rubin: This is an NHS or health organisation responsibility, not a GMC responsibility.

Q41 Chair: Or, in some circumstances, presumably, it is the individual’s responsibility. It is a matter between the individual doctor and their employer and nothing to do with the GMC, isn’t it?

Professor Rubin: There will be independent contractors, of course, involved in this. It is a very complex area, but the responsibilities are out there at the front line, not with the GMC.

Q42 Barbara Keeley: You touched a couple of times on the issue of locum GPs. Taking that group of doctors and other nonmainstream doctors, can you clarify for us how the revalidation process will handle them? Particularly, do you think the process provides sufficient protection for the public? Clearly, locums are an area where there have been issues and we have seen an increasing problem.

Una Lane: As I mentioned previously, our very strong view is that revalidation should look the same for all doctors regardless of the nature of their practice or where they practise in the UK. All doctors-locum doctors or doctors working in the independent sector-have a connection with a healthcare organisation, usually the one that employs them or that they contract with. Those organisations have duties to provide appraisal for all their doctors, including locum agencies. Doctors, in turn, have duties to collect the relevant supporting information, engage meaningfully in appraisal and to reflect on their practice. That is as true for a locum as it is for any doctor working in an employment context and secondary care. So the process should look the same for all doctors. The kinds of supporting information that individual doctors might bring will vary depending on the nature of their practice or the specialty in which they work.

Q43 Barbara Keeley: Clearly, we have seen cases of locums coming in from European countries, perhaps having excessive travel time before they start their working day, issues of language and perhaps not understanding or making themselves understood, resulting in errors. The focus of my question was not only the process. Is there sufficient protection for the public in that we are seeing a lot more doctors flying in and out, almost, to practise? Isn’t it the case that now, in a number of fields, people are coming from other countries, practising for short periods of time and going back again?

Professor Rubin: It is the case and it is probably appropriate to draw a distinction between fit to practise and fit for purpose. A doctor may well be fit to practise, having kept up with their continuing medical education, etc., but they may not be fit for purpose for a particular role at a particular time. It may be because they have not had any sleep for 24 hours or it may be because their experience in another EU country is not relevant to primary care in this country, which is a recurring issue. We are the gatekeeper with regard to being on the register, having a licence and being fit to practise in a chosen specialty or primary care, but employers have a big responsibility to say, "Does this individual doctor meet our purposes for this role at this time?"

Q44 Barbara Keeley: How can the new processes achieve protection for the public that we have not had in the past? How can you ensure that employers go through the same procedures with doctors that fly in and out as they do with others on their books?

Professor Rubin: We will have a very important role to play in terms of the integrity of the register, making sure that only doctors who are up to date and fit to practise have a licence to practise. But there remains for the employers a huge responsibility to ensure that they only employ doctors who are fit for the intended purpose. Each party has a role here: the GMC as the gatekeeper but the employer with regard to intended purpose.

Niall Dickson: We have beefed up the employer side with the responsible officers. The responsible officers are the new army of people who are doctors working at a local level. They are accountable to us as doctors for how they perform their duties. They and the designated bodies that they work for are now subject to a series of regulations which require them to make sure that the doctors they are taking on are both fit to practise and fit for purpose. One of the changes that we are proposing, and working with the Department on at the moment, in relation to the language testing of doctors is to put a new explicit responsibility within the responsible officer regulations for making sure that responsible officers check and test, if required, the language competence of doctors they are taking on to their list. So for the first time, these responsible officers have a list-we have them now and Una and her team were gathering these lists from every responsible officer-of all the doctors for whom they have these responsibilities, and it formalises the system. I don’t think we are saying this will be a perfect system, but it is an awful lot tighter and builds up that arm of the two stages that Peter was talking about in terms of national regulator and local employer. It means that the local employer bit is much more integrated into our process and I think has the potential to be a lot more robust.

Professor Rubin: That, again, is why we want the responsible officers to be doctors that are on our register because we can then set the rules.

Q45 Barbara Keeley: In terms of the administrative requirements of the appraisal and revalidation procedures, what feedback have you been receiving and do you think that they risk placing excessive burdens on licensed doctors? I think we touched on this earlier.

Una Lane: We have done a huge amount of work in the last two years. Members who were on the Committee in late 2010 will remember an inquiry into revalidation and a discussion on revalidation. The concerns raised by doctors, and indeed healthcare organisations, were that the process was too cumbersome, overly burdensome and disproportionate. We have done a significant amount of work in the last two years to streamline the process. We now feel that we have the support of all parties, including the BMA, for the process that hopefully will begin later this year. We think it is robust but proportionate and we want to ensure that there is not an administrative burden on doctors that takes them away from frontline care with patients. We have moved quite some considerable way in the last two years since we were last before the Committee discussing this issue. All parties, right across healthcare, feel that the process is now workable and not overly burdensome to individual doctors.

Q46 Barbara Keeley: How do you plan to monitor doctors who, as a consequence of the process, change path, retire, move to other countries or fail revalidation? There seems to be a need to keep track of that if the process follows through. There have been instances, I think, of doctors who have had issues in other countries appearing here, haven’t there?

Una Lane: Sure, and it is very important for us that we have data that enable us to track all of the developments in relation to individual doctors. Once revalidation is introduced, we will have a whole raft of data as to doctors who will be validated and doctors who haven’t engaged in the process. We will have data on doctors who decided to relinquish their licence, doctors who decided to take voluntary erasure and the reasons for that. We are putting a process in place where the UKwide Revalidation Programme Board, which has existed for a number of years now and has been leading on overseeing the implementation of revalidation, will continue into the future and monitor what is happening as a result of revalidation, what is happening with individual doctors, what the data are telling us, what they are showing and whether there are things that we may need to do to be fast enough in responding to some of the issues that this new process will inevitably throw up.

Q47 Barbara Keeley: The Royal College of Radiologists is concerned that revalidation is being introduced without clear systems in place for remediation or retraining of doctors requiring that support. Do you share that concern?

Professor Rubin: Again, it is worth emphasising that remediation has been a feature of the NHS since the NHS started. There are two aspects. One is that as a doctor, I and all doctors have a responsibility to keep ourselves up to date and fit to practise and not to get into that position in the first place. It is very important, as a doctor, that I say that this morning. Where, for whatever reason, a doctor is found to need remediation, there have always been, over all my years in practice in the NHS, ways of achieving that. There is a difference, as we were saying earlier, between organisations that have a written policy and those that do not yet have one. But we have no reason to think that revalidation should be further delayed while waiting for organisations to have their written policy. We need to get moving and others can then be encouraged to catch up.

Q48 Mr Sharma: We have briefly touched on language proficiency testing. In the past, there was a case where somebody was misdiagnosed because of a language problem and because of the tiredness of the individual doctor who came and had not slept for many hours. Do you have any data on how many doctors failed the test in the last year?

Niall Dickson: At the moment we test, for example, doctors coming from outside the European Union. We are not able-as the GMC, it is forbidden by UK law for us-to test all doctors coming from the European Union. There are circumstances, I have to say, where our staff are simply aware that the doctor is not communicating effectively and we have a discussion with them and often find that they do not pursue their application. But in relation to doctors from other countries overseas, we ask them to sit the IELTS test, which is the International English Language Testing System test. I don’t know how many of them fail, because they sit the test independently and then come along to us with their certificate. We have recently increased the level that we require of doctors in terms of passing the IELTS test. We then also subject those doctors to a twopart exam-called the PLAB exam-one part of which is multiple choice and the second part of which is a series of little clinical tests, which they have to undergo. Obviously, as part of that, their communication skills are assessed, often by a senior doctor who will be in the room and who will watch them deal with an actor or an actress who is putting them into a particular clinical situation. So we do have that process as well. The pass rates for PLAB do vary a lot. It depends on the particular cohort of doctors that has applied.

Q49 Mr Sharma: To follow up on that, I am quite aware of what is happening outside the EU under the immigration rules. Language testing is a very hot issue at the moment. How do you overcome the problem within the EU, even though under the British rules you are not allowed to do that? How do you overcome that problem, because that is also a major problem, whether we realise it or not?

Niall Dickson: There are three areas that we are trying to work on and on all of them, I am glad to say, we are making a degree of progress, probably at different rates.

The first is, as I explained a while ago, that UK legislation prevents the GMC from doing any form of testing. The Government have made it clear that they will amend the Medical Act. That will involve a section 60 order. We hope that it will be passed by the end of next year. It does take time to go through your processes. I would do it tomorrow if I could, but the processes are there. That is the first thing. That will, in a way, expose us to European law, because we will not be constrained by UK law.

Secondly, European law does not enable us, as far as we can see, to universally test anybody who comes to us, but we will, in circumstances where we have some doubt about a doctor being able to fulfil criteria, apply a test. We don’t think that is sufficient, so we are doing two things. We are pursuing it at the European level because there are now proposals to change the directive and we are pushing for amendments that will give more authority to competent authorities like us throughout Europe. We have support from other competent authorities in Europe for us to be able to do more than is currently allowed under the current directive.

Thirdly, we are using the responsible officer network, this army of people at local level. Medical directors have always had responsibilities, but these people have written regulations. They have clear responsibilities about what they can and cannot do. We will work with the authorities in Scotland, Wales and Northern Ireland to get to the same result, possibly by different routes, but the idea in England is to put a duty on responsible officers when they take in a doctor to make absolutely sure that they have tested the language competence of that doctor, unless they are convinced it is all right. So they have both a duty in terms of the language competence and indeed the clinical competence and the fitness for purpose of that doctor. Those all sit with the responsible officer.

We think that in those three areas we will have created a much more robust system. I am not saying it is a perfect system, but it will be a much more robust system than we have at the moment. Some of these things, as I say, like the Medical Act, we should be able to change by the end of next year. We hope to try and get the responsible officer regulations in for next year.

As far as European legislation is concerned, probably your guess is better than mine, but it will take some time to get through. In all areas, I think we are making some progress and trying to close a hole in our regulatory guard which has been quite considerable and has caused us some concern.

Q50 Dr Wollaston: Can I go further on that issue of responsible officers, the third arm, if you like? How are they going to apply that? Is it going to be a matter of personal judgment whether they think a doctor has adequate language communication skills or are they going to be able to find and apply a test that would give us consistency across the country?

Niall Dickson: They have to apply it to the job that they are appointing the doctor to, in theory, but the answer is that when they are interviewing-it won’t necessarily be the responsible officers-they would have to have a system in place for that organisation to ensure that they had a process by which they were assured that the doctor had sufficient command of the English language to undertake the job. That would be the test. They can do that in a number of different ways. They may well ask them to sit an IELTS test and if that were the area-

Q51 Dr Wollaston: So they could.

Niall Dickson: Yes, absolutely.

Q52 Dr Wollaston: Basically, if a locum agency wanted to give reassurance, they could standardise things by saying that anyone who comes on to the locum agency has to sit that test and they would not be in breach of the law.

Niall Dickson: No, they wouldn’t be. We could not require that test under current European law but, at local level, they can require that test and they can make it universal.

Q53 Dr Wollaston: There is going to be a whole network of people making these judgments, not necessarily through a formalised test. If everybody is responsible, we come back to the problem that nobody is responsible. Who is the GMC going to hold to account for making sure that that happens, because the public are deeply concerned about this issue?

Professor Rubin: It comes back to the responsible officers being doctors on our register. If we imagine a hypothetical case where a doctor flies in from somewhere for a week or a weekend locum shift and something goes badly wrong as a consequence of language skills, we the GMC would hold the responsible officer accountable for not having systems in place to ensure that that doctor had adequate language skills. That is the extreme circumstance.

Q54 Dr Wollaston: But those systems could be whatever they judge them to be, because at the moment, as you say, you cannot require them to have a formalised language test.

Professor Rubin: Indeed. There are two aspects. One is that it is, in our view, for the NHS and health organisations to start working on this to get some coherence, but our view has always been that we should be the gatekeeper when it comes to fitness to practise and we need to communicate with patients to be fit to practise. That is why we continue to lobby in Brussels to make a change that we think is long overdue in the European directive, which is that all medical regulators across Europe should test for language skills.

Q55 Dr Wollaston: Of course, that is in an ideal world, but that sort of move is going to be at a glacial pace. Are you concerned that this is going to be rather woolly if there is not enough clarity and consistency in the way that responsible officers are operating?

Professor Rubin: It will take a while to get going well. But this is a step improvement in what is going on at the moment. It will take a while. We are there with our employment liaison officers to advise, of course, and we can be a coordinator-a conductor of the orchestra-to make sure that there is as much coherence as we can achieve.

Q56 Dr Wollaston: Although you cannot require them to, will you be informally advising them that in order to cover themselves they should ask locums to sit an English language test?

Niall Dickson: My guess is that we will be working-this is a developing relationship-with responsible officers. Una mentioned earlier that we are already establishing a close relationship, and we have our own reference group. We will be building in every area of the country a personal relationship with every responsible officer. I foresee a situation where we would be talking with responsible officers about the kind of things that they might do in order to make sure that they were-

Chair: And at the same time reminding them of the consequences for them if it goes wrong.

Q57 Valerie Vaz: What are the consequences for the responsible officers?

Niall Dickson: In the most extreme case, which Peter has described, obviously if a responsible officer had not put systems in place, and that resulted in the death of a patient, we would be investigating vigorously.

Q58 David Tredinnick: With your permission, Chairman, I would like to stay with the line of questioning of my two previous colleagues because I am concerned about what I have heard. I do not feel there is any consistency of approach here. You are saying that these responsible officers will be responsible but I do not see any national footprint, any national plan. I can see all sorts of oddities occurring across the country. I feel in the way that you have answered these questions that this has not been fully fleshed out, despite the problems you have with Brussels, and I am not sure that I hear in your answer the extreme anger and concern that we face from constituents who are deeply troubled by the idea that they are being treated by doctors-I know this is very rare-who do not understand their language. I think this needs a very clear focus. Even if you don’t have statutory powers to tell responsible officers what to do, you should have a very clear template of advice that you put out in a consistent way.

Professor Rubin: Can I say that we share that anger and concern? It is because of it that we were very proactive and fought many battles within Whitehall to get where we have got to now, which is an agreement with the Secretary of State that the Medical Act will be changed. That was not an easy path. We were very determined that we were going to get a change in the law because we knew how strongly the public felt, so we share your anger.

With regard to responsible officers, this is a big new development and we are very aware that throughout the UK-and we are UKwide-there are many different health organisations. What we are doing now is saying to responsible officers, "The clue is in the name. You are responsible. You have to make sure. It is your organisation. Whatever works for you, you have to make sure it works and make sure that the doctors who practise in your organisation can speak English."

Q59 David Tredinnick: Forgive me for interrupting, Professor, but it puts the onus on them. Surely you should give direction and say, "This is what we feel very strongly should be the way that you handle this situation."

Professor Rubin: That message has come out from us pretty clearly.

Niall Dickson: The reason we are slightly nuanced in this is that if it were seen by Europe that the GMC was in effect imposing a single test on the system, it would cause problems. What we will ensure in our discussions with responsible officers-we were at the very early stages and the regulations have not been passed yet-is that the responsibility has been put at local level for them to make sure. It could not be clearer that the doctors they take on must be able to speak English effectively in order to practise. That is a clear responsibility on those organisations. Of course we will work closely with the responsible officers-as I have described, we are now having a relationship with them-in a way that we did not with medical directors. We have people out there on the ground working alongside them. Of course we will be talking to them about the arrangements that they are putting in place to make sure that this happens, but the law is such that we do not have the power to direct them, to say, "You will impose this test or that test." We do not have that legal power. I do not believe the UK Government would give us that power and I don’t know that they would regard it as consistent with European law.

Q60 David Tredinnick: I would have thought that consistent advice would certainly be a very good start.

I want to move on to talk about patients’ rights. What rights do patients have to be informed about the outcome of appraisal and revalidation processes?

Una Lane: As far as revalidation is concerned, all the information we hold about individual doctors is open and transparent. Where we take action in relation to a doctor’s registration through our fitness-to-practise procedure, all those decisions are published on our website and linked to the individual doctor’s entry on our register online. Similarly, where we withdraw the doctor’s licence through the revalidation process, that information will be publicly available. Where doctors decide to relinquish their licence, again that information is publicly available online via our website.

As far as appraisal is concerned, local healthcare organisations run an appraisal process. For most of us who have an appraisal, the output looks like a professional development plan for the following 12 months. The issue I think is probably more about organisations that are investigating concerns about doctors locally and whether that information should be made available to patients. That is probably a balancing act between the rights of doctors and the rights of patients.

Q61 David Tredinnick: So you put it online, but do you take steps to make sure that local newspapers are aware? They should be trawling, of course, for this information, but are you proactive in trying to get the information out there? Secondly, do you take a particularly proactive approach when the findings against a doctor are negative?

Una Lane: Shall I take this?

Professor Rubin: If we have understood your question correctly, and if we have not you can try again-

Q62 David Tredinnick: My question is simply this. When you have made an appraisal or when you have gone through the process and you have found in favour or against a particular practitioner, what steps do you take to make sure this is in the public domain and the patients have that information, particularly when it comes down to those few doctors who have fallen foul of the system and are clearly not up to scratch?

Professor Rubin: I can honestly say that the GMC is the most transparent medical regulator in the world. Where we find a doctor’s practice is impaired, that information and the reasons why we came to that conclusion are in the public domain. You can go on to our website and see this information. We have a very effective media team and they communicate with the press on a daily basis. The information is there and is well known to be there.

Q63 David Tredinnick: Moving on, formal patient feedback as part of the revalidation process is to be collected once every five years. Are you sure that this is adequate to allow the views of patients to be captured by your system?

Una Lane: The first thing to say is that it will be a big win for all of us and for patients if we can ensure that every doctor seeks feedback from patients periodically about their view of their care and the quality of care that is provided. We know that this happens in many GP practices currently, and in fact in many good hospitals, but it absolutely does not happen universally and it is not something that every licensed doctor is currently engaged in. We think it is a big prize, a big step forward and that revalidation will drive doctors to ensure that they seek such feedback from patients. Is once in every five years sufficient? I think the question goes back to some points that were made earlier by some of your colleagues around the Committee. We need to get the balance right in terms of introducing revalidation. We want to ensure that doctors seek feedback from patients and that they reflect on that feedback. But we do not want to introduce a system that is overly burdensome. We want to ensure, and will require, that doctors gather together and bring to appraisal patient concerns, complaints or indeed compliments. So it is not a onceineveryfiveyear opportunity. There are other opportunities to consider patient feedback.

Q64 David Tredinnick: Fine, so it is something that you are continually evaluating. What do you think the next steps are on patient and colleague input development? Do you have a vision as to where you would like to go with this?

Una Lane: Yes. As far as all of our requirements on revalidation are concerned and all of our supporting information requirements, we have always said that where we begin is not where we intend to end up in five or 10 years’ time. As soon as we begin revalidation, we will be looking at all these areas, including patient feedback. We have been having discussions with patient groups and patient representatives to see where we might go from here. What we have said is that we want to be ambitious about this. So simply saying we will move to ask doctors, to seek feedback, twice in every five years as opposed to once in every five years does not appear to us to be particularly ambitious. We need to understand the wider developments, including perhaps patientreported outcome measures or a whole range of ways in which patients can properly engage in providing feedback about the quality of care they receive from their doctor. We want to keep this under review and we want to be ambitious about the future.

Q65 Andrew George: In view of the objectives of the GMC to "raise standards" and enhance patient safety and also to command confidence, clearly your role is not just one of maintaining technical, medical, standards but of addressing issues of medical ethics as well. In the light of that, while we understand that of course there are resource constraints, sometimes clinical decisions might be compromised by financial incentives. For example, there are two areas of medical ethics where I want to find out whether the GMC feels that it has a role in intervening or commenting.

One is in relation to the kind of report that came out from the new chair of the BMA, Dr Mark Porter, suggesting that there were financial incentives for doctors to avoid directing patients for either treatment or tests. The other is that of whistleblowers and their role. While you have produced guidance in that regard, I notice in our evidence that Doctors4Justice, for example-who are clearly not one of your greatest advocates-have indicated that they are not persuaded that you are sufficiently robust in defending doctors where they are, one might argue, properly raising a concern, not one that will undermine patient confidentiality, but about medical and patient safety. In those areas, do you feel that you have a role or do you think it is beyond your remit?

Professor Rubin: I will kick off and then hand over to Niall, if I may. First of all, as to the financial incentives for a doctor to do or not do something, Niall said earlier that I have written to every doctor in the UK on that subject-about the conflict of interest issue in the new world. I was unambiguously clear in what I said: "Your patient comes first." Clearly, there will be highlevel rationing issues, as there always have been since 1948. But for individual patients, financial incentive for the individual doctor or for individual patient is unacceptable and I have made that very clear in writing to every doctor in the country. We will act if we have evidence that that is not being followed.

With regard to whistleblowing, the very term implies something about the culture of the organisation in which that doctor is working. Open organisations, learning organisations, do not need whistleblowers because the organisation wants to know what went wrong and to do something about it. So you are dealing with an organisation that has the wrong culture, a culture of bullying and suppression. We understand how difficult that is. If I can hand over to Niall, he will describe some of the steps we are taking to try to address that.

Niall Dickson: We mentioned in our evidence that, for the first time, this year we produced guidance that we sent to every single doctor. Guidance is guidance, but I think that that first of all did raise awareness of the issue. Our perception-I do not know whether the doctors on the Committee agree with this, but certainly it is our view-is that the willingness of doctors to see themselves as their brother’s or their sister’s keeper is infinitely more advanced than it was 20 or 30 years ago. So we are on a journey in this process. That does not mean that we do not recognise that there are barriers, not least, for example, for doctors in training who may be in a place of work for a short period of time before they move off. If it is a specialty they do not particularly want to go into, do they want to draw attention to themselves and so forth? We have made it very clear on the one hand how important it is that doctors do raise this wider concern. We were conscious of it in relation to the Mid Staffordshire inquiry. There was certainly an element of people perhaps being aware of our guidance but it not being so much to the forefront of their mind that they felt it was their obligation to raise issues even if the concerns were not about medical colleagues but about other aspects of care. We are on a journey with this. We have produced the guidance and we need to work with the Royal Colleges, with the BMA and with other organisations who also share leadership in this space about how we engage with the profession, how we make guidance very relevant and easy to access, and how we have a dialogue and discussion with the professions.

Secondly, we are about to introduce a helpline. There are other helplines around, so we are not saying we are the first to do this or anything else, but we feel, as the regulator, the owner and producer of the standards, that it is very important that doctors feel they can phone us if they have a concern and say, "This is what I am proposing to do," or, "What should I do in this particular situation?" Clearly, if we have cases where we think patients are at immediate risk, we will act as a result of that. But we believe that that is another way in which we can be supportive to doctors. We believe that being supportive is probably the key rather than emphasising our big stick. We do have the big stick, of course. If people fail, for example in management positions, to report and deal with concerns or fail to answer concerns that are brought to them, that is potentially a fitnesstopractise issue. But we believe the big change is about driving forward a culture to create the kind of organisations that Peter talks about, which do exist within the Health Service, where people feel able to raise concerns even in what may seem quite a hierarchical system and say, "We have worries."

The third area, which I think was touched on earlier and Peter mentioned it in his opening comments, is that in the national trainee survey this year we asked a question about patient safety. We got a very large number of responses from young doctors who were raising concerns about patient safety and we are following up all those concerns, making sure that deaneries contact the NHS organisation. We did know about a lot of them already, but there were doctors who said that they would find it difficult to raise some of these concerns. So there is still an awful lot of work to do in this area. We think we know what our part is and we recognise that it is only a part, but it is about changing culture within organisations and empowering doctors and other professionals to feel that they can raise concerns, and putting out the message, whether it is to groups like Doctors4Justice or others, that we are open for business. These things are not easy to judge. Of course there are examples where people say "I am a whistleblower" when they are not, when it is a fight between colleagues. There are all sorts of complexities and it does not mean that we will immediately take the side of the socalled whistleblower in every case that is brought to us, but we will absolutely investigate any case that is brought to us with an open mind, and we want to support doctors in every way we can to raise concerns.

Q66 Andrew George: You mentioned a "big stick". The only big stick I understand-as perhaps a oneclub golfing machine-is to strike off doctors who fail. Presumably some of those in management are not, of course, GMC registrants.

Niall Dickson: If they are not doctors, they are beyond our ken, but I would not underestimate that a lot of doctors are fearful, as it were, and don’t like the idea of getting a letter from the GMC and so on. The message that we are giving has to be a supportive one to the profession saying, "We want to help you to raise concerns" rather than "We will be down on you like a ton of bricks if you don’t do it." It is a complex message. It is not saying "you are negligent", particularly if you are in a more senior position and you do not raise concerns. So we have to get that balanced message across. That is all I am saying.

Chair: There was a very specific application of this issue that the Committee looked at earlier this year in the context of breast enhancement surgery. Barbara, would you like to pursue that point?

Q67 Barbara Keeley: Indeed. There are still a great number of outstanding issues relating to the way that breast enhancement surgery is reported to us, and generally patients have been treated in private clinics when they go for all types of cosmetic surgery. We looked at PIP breast implants because of the issues with that particular implant. We heard examples of-and have more recently taken evidence from members of the public directly-surgeons who did not see the patient and that it was all marketing until the day of the operation. There was hardly any followup; there was no tracking and records were not kept, so that when the information had to go out that the implants were faulty and should be checked, and that people should have scans and things, there were months of delay, which caused great fear and concern among the people involved. A lot of those issues have not gone away; there are still various inquiries and there will be more done and said on that.

One of the concerns we ended up with is that there is a real issue with the way that some surgeons are operating and the way that some clinics are working with them. Tens of thousands-40,000-women felt very seriously let down by that and many of them have still not had their issues sorted out. They are trickling through in small numbers to the NHS. Given that it is an ongoing issue, is that something you feel that the GMC could and should be addressing? Do you have plans to deal with that? Anecdotally, a lot of women contacted me and sent me emails as a member of the Health Select Committee, and I heard reports of surgeons running away from patients in clinics, disappearing when they had an appointment, going away and leaving them high and dry with no advice and information. It was clear to us that there was very little followup, no intention of following up on surgery, no advice given about followup and that people were having these procedures without any knowledge of what they were doing; they did not understand that it was quite a serious piece of surgery.

Chair: If I could add to that-I do not want to spend too long on this-the implication was that because they were commercial rather than NHS, somehow the normal doctor’s obligation to patients was softer or maybe, in extreme cases, suspended. These are all, of course, surgeons who are on your register.

Niall Dickson: The first point is that in particular cases we should and would investigate anything that was brought to us in terms of the kind of absence of proper patient care. Those are serious breaches of good medical practice that you have alluded to.

On the wider issue, we are first of all conscious that the cosmetic industry has expanded by leaps and bounds over a relatively short period of time. We have had some conversations with the plastic surgeons at what I call the very serious end of the market about their concerns in relation to this. The Government, of course, have an inquiry under way and we will be cooperating with, and trying to learn from, that.

I have a wider point about how we go about our job. Traditionally, regulators like us have tended to wait until a problem came and then dealt with it, often in an individual doctor sense. We are starting to look at areas where there are higher risks on our register and how we respond to them, and there are quite a few areas, I have to say. We are about to produce a report on the state of medical education and practice. You may have seen last year’s version, which was the first time that we had properly started to analyse our data, as Una was saying, and reflect that back. In the next edition, we are going to be looking at different points in a doctor’s career and different areas of practice that may raise areas of concern where we want to have a dialogue with the profession but also to see if there are particular interventions that we can make. We need to respond in that way. We certainly want to respond to, and participate in, the inquiry into this area that Sir Bruce Keogh is heading. So we are conscious of it.

Q68 Chair: I would like to ask one question. In our report after this session last year, we referred to the role that we thought the GMC could perform in what we described as professional leadership. To some degree, what we had in mind, I think, was encouraging the kind of culture change that you have been talking about in the last half hour. The evidence we have had from the CHRE says they do not think professional leadership is a responsibility of a regulator and I wondered whether you agreed with the Committee or with the CHRE in that debate.

Professor Rubin: Perhaps I could begin to answer that question. I am slightly surprised by the CHRE’s view. I would be intrigued to know what problem they are trying to solve if they think we should not be providing leadership. Over the years, particularly over the last three decades or so, the GMC has achieved international recognition for our professional leadership in a number of areas. When I appeared before your counterparts in Washington 10 years ago, they heaped praise on our leadership in undergraduate medical education in that we were the first country to introduce explicit professionalism into the undergraduate curriculum. That was led by the GMC. Our guidance on professional standards "Good Medical Practice" has been translated into many languages and to our certain knowledge has formed the basis of guidance for professional practice in medicine in 15 countries worldwide. We are very proud of that. I am therefore puzzled that the CHRE should feel that we should not be doing work that is internationally acclaimed. So we need to understand more about where the CHRE is coming from on this one. My answer will probably give you a flavour of where we are coming from.

Niall Dickson: We have very good relationships with the CHRE and I think the answer is that in every conversation we have had, including the report, which you will have seen, that they wrote about us, they commended us for our professional leadership and our work on standards and so forth. I think it may have been in relation to other matters that they were-

Q69 Chair: It is not for me to write the Committee’s report in an open session like this, but if we were to reinforce our view that the GMC has a role in creating the right culture in the profession, that is not something you would resist?

Professor Rubin: We would bow to that.

Chair: Good. Thank you.

Q70 Dr Poulter: We touched in some detail-we are not going to reopen this-on the issue of overseas doctors, doctors from the European Union and the difficulties with locum agencies. A specific concern has been raised by the Royal College of Radiologists as to the increasing use of telemedicine, which is something the NHS is going to be embracing as time goes on. Radiology in particular often does not need to have a radiologist on site to check a CT scan. You can have them offsite. The point is that that "offsite" potentially could be in France, Germany or elsewhere. How does the GMC regard the fact that those doctors may not be GMC registered and that potentially hospitals may have arrangements with doctors overseas to provide NHS services when they are not necessarily accredited as UK doctors?

Professor Rubin: Indeed. This I think is also relevant in some areas of pathology where things are happening offshore, as it were. We can regulate only those doctors who are on our register. We have no jurisdiction over doctors who are operating from another country. We do, however, have jurisdiction over medical directors-this comes back to issues about responsible officers being on our register-who are in the organisations that may be commissioning these services from overseas and we would expect them to have done the due diligence to ensure that the services they are purchasing, from whichever country, are up to the standard that patients in the NHS have a right to expect.

Q71 Dr Poulter: If there was a concern, the fact that you obviously would not have any jurisdiction over the medical professional involved in providing the medical expertise-the advice on a CT head scan or pathology-means you would directly hold the medical director of a hospital trust, for example, to account as a part of their GMC responsibilities as a good doctor for the fact that they had endorsed the appointment of potentially poor quality services?

Professor Rubin: If the medical director, clinical director or any other doctor in the management system had been party to commissioning services that were found to have been substandard, and due inquiries had not been made and so on, yes, of course, we would hold them accountable.

Q72 Chair: Presumably if any doctor using the result of a pathology test or a radiology scan could or should have had concerns and did not raise them, they themselves would be falling foul of another aspect of their obligations.

Professor Rubin: Yes, indeed, although I think our focus would be on those in the management tree primarily. This is going to be an increasing issue as telemedicine and the internet come into play more and more. But our jurisdiction is defined in law, defined by Parliament. Our jurisdiction is what it is.

Niall Dickson: What I do not think we can do, which is perhaps what the College would like us to do, is start demanding the registration of doctors all over the world. It is simply not a practical proposition.

Q73 Dr Poulter: No, indeed. Take, for example, multidisciplinary conferences about patients. On quite a regular basis, there will be some guy across the river from here-right now, I am sure-discussing histopathology or radiology. At the moment, there may well be Vidilinks to a consultant pathologist or a consultant radiologist who will contribute from offsite. If, shall we say, it was potentially the case that the doctor offsite was not directly registered by the GMC, how would the clinical and medical responsibilities of the other doctors be affected if they were involved in a multidisciplinary meeting, for example, that then contributed to patient care based on the wrong advice of a doctor that you could not accredit?

Professor Rubin: Under those circumstances, as the Chairman was saying, all doctors have a responsibility to raise concerns if they have doubts. You can imagine the kind of thing that could happen, that you have this new arrangement whereby your imaging is done offshore, you get a dodgy CT scan and you think, "That’s a one off and maybe it’s only one." Then the following week you get another one. That is the point at which you say, "Hang on a minute. What is going on with the reporting? This is not right." I would expect all good doctors to raise those concerns very early on. If we found that doctors had repeatedly not been raising concerns when there was obviously a pattern of deficiency, we would be very concerned.

Chair: David Pearl has sat now for an hour and three quarters in total silence. We want to make better use of your time, if we may. Valerie.

Q74 Valerie Vaz: I have one or two general questions before I move on to you, Your Honour. The GMC reports to the Privy Council. You are accountable to the Privy Council, and the Law Commission is looking at your accountability mechanisms. What was the evidence you gave in relation to whether you should still be accountable to the Privy Council?

Niall Dickson: Our view was that-and I think we are still in a debating situation around this-our line of accountability should be to Parliament rather than to the state. To the extent that the Privy Council represents-it was once described as-a posh post box to the Department of Health, we would prefer to have accountability to Parliament, rather than to the Privy Council. I have to say, as to the way that that operates at the moment, that the Privy Council does not interfere in our daytoday work. But our view would be that a clear line of accountability to Parliament is the right model. Peter is always asked by doctors, "What do we buy when we pay for you?" He rightly says, "Our independence." Our independence is very important, our ability-this is not simply theoretical-to eyeball an NHS trust, which is part of a state mechanism, and say, "This is not acceptable. You must put additional support into this emergency department and you must do it within 24 hours, otherwise we will be withdrawing the trainees from this situation."

Professor Rubin: We have done that in the last year, incidentally.

Niall Dickson: Having hard conversations with the system requires you to have that degree of independence without-I am not saying this happens in other spheres-the phone being picked up and the Minister saying, "What are you doing interfering, doing that kind of stuff?" So our independence is very important. However it is worked out, we have to be accountable in some way, shape or form. Other than the accountability, obviously, that I have to Peter and to the Council, the organisation as a whole does need a line of accountability and it seems to me that Parliament is the right place, if we can get the mechanism right.

Q75 Valerie Vaz: When you see all these references to fitness to practise and you realise that in a certain section you need more education and training-for example, you need more radiologists-do you have a mechanism into the Secretary of State? I must say it is Jeremy Hunt.

Professor Rubin: Thank you for that information.

Q76 Valerie Vaz: Would you have a mechanism to get to the Secretary of State to say, "I think you should look at recruiting more radiologists", for example, because we have had lots of, say, poor overseas-

Professor Rubin: The answer is, indirectly, yes. The mechanism will be to Health Education England in England and NES in Scotland, and so on. We have already established very good relationships with HEE. It helps that the Chair and Chief Executive of HEE are well known to the GMC, for very good reasons, and already chairs stuff for us, for example. So the relationship will be at HEE level. We will soon be the custodians of the most complete information about doctors and their training that anyone has and we must use that information in a constructive way.

Q77 Valerie Vaz: Thank you. Your Honour, turning to you now, I have the geeky questions, being a lawyer. It is quite interesting that complaints have gone up by 23%. What would be quite nice, for the record, is if you could set out exactly how you set up the tribunal, also touching on how you deal with the complaints, how you have these two case officers. What I am interested in is, are they a fresh pair of eyes for each of the cases, the kind of cases that are being referred to? Your evidence talked about consistent decision making. Was that because there was not consistent decision making before? Do you have a complete set of rules and procedures? Are you abiding by the Civil Procedure Rules? Basically, how did the whole thing get set up?

David Pearl: That is a large number of questions and I will try to handle them in the short time we have left. The first thing to say is that obviously the MPTS has now been in existence for two and a half months, so it is early days. We have a governance committee, which is a committee of three, myself and two nonexecutive members. It is a very proactive committee. It has already sat, discussed and dealt with a number of issues, some of which were high policy issues. It has also been involved in some of the matters of procedure. That is the way in which, if you like, the general framework of the MPTS is going to operate, and has started to operate, now and in the future.

I have, obviously, also initiated and built upon much of the work that has been done by the GMC over the last couple of years in, for example, some of the rule changes we are hoping will be introduced in the next year or year and a half, primarily looking at case management. The key to, or the driver for, much of the reforms that we hope will be introduced in our hearings is case management. I am not saying that there has not been case management in the past, but it has been perhaps sporadic and confined to some of the more highprofile cases, and the cases that are likely to last a longer time. It is my view, and a view that is shared by many, that all cases require case management-all of them. Indeed, I have been involved myself already in one or two telephone case management conferences to get the parties together and to agree on procedural issues in advance of the hearing, so that when day one of the hearing starts in a fitnesstopractise case the evidence can be presented right at the beginning rather than days being lost on procedural wrangles that, frankly, should have been sorted out in advance of the hearing. So we are doing that.

You talked about consistency of decision making, and it clearly is important to ensure that we look at, and performance-manage, all of our decisions. That again is, if you like, one of our key priorities. We have set up a quality assurance group, which I chair. It meets every month. We have met now on two occasions, July and in fact just last week, looking at almost all of the decisions, both fitness to practise and the interim order panel decisions as well, where we have to make interim decisions in relation to cases that are sent to us by the GMC. That involves, as I say, looking at all of our cases. In some cases, feeling perhaps that the reasons for a decision are not entirely clear, I have taken it upon myself to address in letters to all three members of the panel the concerns that we have, as a learning tool, in order to ask the panel to reflect on the fact that reasons are so very important. Whatever the decision of the panel, it needs to give reasons that can be understood by, obviously, the doctor, the GMC, the patients and the patients’ relatives, anybody who reads the decision and, obviously, if the matter goes to a higher court, by the higher court.

In addition to picking on those sorts of cases, again going back to your point on consistency, it is my view that it is very important to get best practice. The good decisions should be distributed around our panel members so that they can see how decisions should be written and how reasons can be given, improving the performance of our panel members. So we are addressing consistency.

In addition, I should briefly mention the importance of introducing appraisal schemes for our panel members and mentoring for our new panel members. We are at the moment in the process of introducing new medical members to our panels. We are in a recruitment process now. We will have, from the end of this year to the beginning of next year, another 80 medical members on our panels. I think that they require not only training, of course, but also a continuing mentoring of their work on the panels.

Q78 Valerie Vaz: Thank you, Sir. Because this is really a new system, could you start from the complaints side? I don’t know whether you should go first and then the others take it up, but could you set out how it starts and why it does or does not get to a hearing?

David Pearl: As to the complaints side-and this is a very important point to make-the MPTS is a separate body that is dealing with adjudication. We only come in when a case is referred to us for adjudication. The investigation remains very much a matter for the GMC, so it is a matter that perhaps Niall ought to deal with.

Niall Dickson: We have seen this continuing rise in the number of cases. We have done some research with that, not least talking to-or getting research from-medical directors, trying to understand their numbers. Numbers of complaints from patients have gone up very considerably. You can see it in other regulators as well, so it is not necessarily something that is peculiar about doctors, though the rate of complaints even within the NHS about doctors tends to be higher. I suspect it is because patients believe that doctors have overall responsibility for their care, or the kinds of decisions they make are more crucial in some cases. So we are seeing this rise. Of the cases that we get in, quite a considerable number are not really for us. They do not reach our thresholds or they may not even be about a doctor. There is a whole series of stuff we have to get rid of at that stage.

When we look at the other cases, there are cases where we think it is better handled at local level, so we refer those cases and send them back to what will be the responsible officer in future and say, "This instance has arisen. On its own, this would not be enough for us to do a fullscale investigation, but if it is part of a pattern we need to know about it." That is the point when we would have a dialogue, and it will be a much closer dialogue in future because we have these teams of people working with responsible officers. So that deals with another section.

The remaining ones are where we believe there is at least a chance that it represents a serious or persistent breach of our guidance and then we have what is called a "stream 1 investigation", a full investigation, into that case. At the end of that process, the case may be referred to a panel. Under certain circumstances, if the doctor agrees to conditions themselves, we can do that at that point or we can issue a warning, which is sort of like a slap on the wrist for five years, or we can give them advice, which is a private letter in which we are basically saying, "I don’t think that was very good. Can you sort it out?" So there are a range of things that we can do at that stage.

The reform programme we are considering at this stage, as opposed to the reforms that David has described-they are both equally important-is trying to get the system streamlined and more effective. There is the idea of introducing meetings with both complainants-so that we start talking to them and listening to them, rather than only exchanging letters, as it were-and then also having meetings with doctors. Our hope is-and we are going to pilot it later this year-that we will start to pilot these procedures in what won’t be the most serious cases because we have to send those to the panel under the current rules. Our idea is that we would have meetings with doctors at which we would encourage them and their lawyers to be more frank and open about what the situation is. If we can come to an agreement about what the right sanction is in terms of protecting the public, then there would be no need to go to a panel. If that worked, we would look at applying it to more serious cases as well. This would not be a secret process. It would be a public process and the outcome would be absolutely clear and, of course, for the first time we would also be involving patients in terms of having two meetings with them, one at the start of the process so we understand the nature of their complaint and they understand our processes, and one at the end of the process so that they understand what we have been attempting to do.

Q79 Valerie Vaz: The more serious cases you refer to the panel?

Niall Dickson: Yes.

Q80 Valerie Vaz: You have asked for a right of appeal from a panel’s decision. Who would you want that appeal to go to-an independent judge?

Niall Dickson: As of now, there is an appeal mechanism that the CHRE operates on behalf of regulators, so regulators do not do it themselves. But we have had from the Department of Health an indication that, in principle, they support the idea that the GMC would also have a right of appeal as well as the CHRE. I think it is important that the CHRE retains its right of appeal. If the GMC failed to appeal a case or, for example, it was under prosecution by the GMC, and the CHRE regarded that as inappropriate, it would be fine if we did not take it. I also think it is very important to demonstrate the separation of functions, David’s autonomy and the tribunal system’s autonomy, and the fact that we can appeal cases. There are cases and there have been cases where we believe that the sanctions that have been imposed by panels have not been, in our view, what we would like in terms of protecting the public.

Q81 Valerie Vaz: Who would you appeal to?

Niall Dickson: The High Court.

Q82 Valerie Vaz: Can I get back to you, Sir? Some people have argued that the NICE guidelines are not firmly law as such. When you are looking at the weight of evidence, what sort of weight would you give to the NICE guidelines when you are making a decision as a panel?

David Pearl: The evidence that is presented is presented by both parties, as in any case, and the panel in a performance case-because obviously when you talk about the NICE guidance it is a performance issue-has to form a view, both in terms of the findings of fact and then subsequently on whether there is or is not impairment. They would have to form a view as to whether in fact the doctor concerned, or what happened in that particular case, fell below the guidelines, and the "Good Medical Practice" guidelines are the ones that they would obviously follow.

Q83 Valerie Vaz: So you would give it quite a bit of weight, wouldn’t you?

David Pearl: There would be weight given, but it would depend on the facts of the particular case. In some cases, there would be more weight given and in other cases perhaps a little less weight.

Q84 Valerie Vaz: Generally-I am clearly unaware of this and how it occurs-when the litigation kicks in, when someone has issued a claim, what happens in terms of referring to a fitness panel? Do you stop as soon as litigation starts?

David Pearl: Are we talking about a civil case?

Q85 Valerie Vaz: A civil case, yes.

David Pearl: The only way I can answer that is to say that if the GMC, as a result of its investigation, refers a case to the panel, to the MPTS, the MPTS is apprised of the matter and it will be for the individual panel to decide whether to proceed with that case or to await a decision taken by another court. I think good practice may well be that we proceed with the case because, frankly, we are primarily concerned with public protection.

Niall Dickson: We would pursue the case. There are circumstances, not where we would stop an investigation-we would always take action through an interim orders panel to restrict a doctor’s practice if we believed there was any patient safety issue-but where, for example, a public inquiry is going on, we would decide not to close the case while that is going on. Likewise, if there are criminal cases going on, again we may not close the case or refer to the panel. We may suspend the doctor, or whatever, pending the outcome of that so that the information can come in. The key point is that we ensure that we protect patients even if the system takes a bit longer, and other proceedings going on is one of the reasons why things take a bit longer sometimes.

Q86 Valerie Vaz: I have a final question. Clearly, you are going to be quite busy with the Mid Staffordshire inquiry coming out. What are you doing to support the doctors that may or may not be involved?

Niall Dickson: That is an interesting verb, "support". We have taken action in relation to some of the doctors that have been referred to us as a result of Mid Staffordshire. So there is a fitness-to-practise issue and there are still ongoing cases, not least with doctors who have been involved in management, who will be appearing before hearings early next year. Alongside that, the wider issue, which we have raised in the Committee before, is about the cultural change we think Mid Staffordshire highlighted and the importance of us making sure that our guidance is real and that the profession across all organisations is engaged with it. That is incumbent upon us, but, as I say, I think it is also incumbent upon other organisations to work with us to achieve that.

Valerie Vaz: Thank you.

Q87 Chair: Can I explore a bit further this concept that you may investigate a doctor and then reach agreement without having to take the case to a panel hearing? Is that something relatively new? How established is it? What proportion of cases achieve that outcome at the moment?

Niall Dickson: We are at the start.

Q88 Chair: At this moment it is 0%, is it?

Niall Dickson: We are at 0%. At the moment, under our current rules, if it is of a certain level of seriousness, we can give undertakings. That is like conditions we can put on a practice. We cannot suspend the doctor without it going to a hearing. We cannot strike off a doctor without it going to a hearing. We are exploring the idea, and we are using it within existing rules to see if these meetings within our existing system help the way in which we approach these cases with a view to, if this works, then seeking to change the legislation to enable us to do it in more serious cases whereby we could speed up the process and reduce the number of hearings, or at least stop the growth in the number of hearings. We do not know how many cases there would be. Certainly, the medical defence organisations believe that a significant number of cases could be resolved if we all went about it a different way. I think it would require a cultural change in our building, but it also requires cultural change within the medical defence organisations. But I think we all recognise we are on a learning curve. For us, the paramountcy of all this is patient protection. We have to protect patients. We are not about punishing doctors but we are about protecting patients. Obviously, if the doctor does not accept the sanction that we offer, they can choose to go to the panel.

Q89 Chair: Particularly in serious cases, have you thought about whether you may wish to get to a world where you have the opportunity of agreeing a sanction with a doctor, but in the serious case it might be ad referendum to a panel to ensure that what you agree with a doctor actually corresponds with a panel view, or have you not got to that point?

Niall Dickson: If we go ahead with this process, we need to have a system by which our decisions are reviewed externally, for example by the CHRE checking our decisions and checking that they correspond to the seriousness of the case. Obviously, we do not want people saying, "You have only agreed that with the doctor so that they do not have to face a hearing and you are not protecting the public sufficiently." So we need to keep that measure. We are also hoping to get a change in the legislation whereby for some cases we would not even need to have meetings with doctors. We would simply be able to remove the doctor from the register without reference to the panel. There are certain things that we think are simply incompatible with being a doctor. For example, if a doctor is convicted of rape, why do we need to go through a process of putting him through a panel? We should be able to strike them off. Of course, they would have a right of appeal to the High Court or whatever, but it should be a decision that we can make without putting everybody through that process.

Q90 Chair: On a completely different subject, there was one question I wanted to come back to that Sir Peter mentioned at the very beginning; it was your reference to the development of the education role of the GMC in which you used the word "interventionist". I think I am right in saying that you said you were becoming more interventionist. I wondered if you could enlarge a little bit on what that meant.

Professor Rubin: I am not sure I said we are becoming more so, but I said we have been in this year, as in previous years. Niall gave an example in answer to one of the other questions about us saying to a training environment, in this case an A and E department, "You really do have 24 hours to give us your answer to this and say how you are going to resolve these staffing issues." We have been doing this around the UK when issues are brought to our attention either through the national training survey or through our routine quality assurance processes. We will continue to do so. I have little doubt that there will be challenging times ahead when we are commenting on some maybe smaller health organisations, smaller hospitals in rural areas and the suitability of a training environment. I think there will be some interesting times ahead, which I would be surprised if we did not find ourselves debating in this forum a year or two from now.

Niall Dickson: One of the things we certainly want to try and do more is understand from the concerns we are getting where there are patterns. If we got patterns of safety concerns which were, for example, doctors working in split sites or doctors who were under particular kind of pressures in certain kinds of departments and we could not solve these problems systemically across the system, we could expose those problems and feed that back to the system. That is exactly what we will-

Q91 Chair: Is your principal driver here the safety of the patient being treated in the training environment or the quality of the training being given to the doctor?

Professor Rubin: Our driver, because of the statute, in these specific examples will be the training environment for the doctor. However, the two are inextricably linked. That is the reality. Where we find that there is an environment where young doctors are not getting the support or supervision and training that they should get, almost invariably, we will find that there are patient safety issues as well.

Q92 Chair: But there are other forms of concern about the quality of training that is being provided that might not be related specifically to that type of patient safety calculation.

Professor Rubin: There can be, and not all our interventions are quite as draconian as the example that Niall gave and I repeated earlier. The reason I made that point is that a lot of what we do in the GMC is very public, and fitness to practise and the start of the MPTS now is all over the newspapers. We do an awful lot behind the scenes that does not get us much publicity but is very important with regard to the quality of tomorrow’s doctors and, as a consequence, often it is very important in terms of patient safety in the here and now.

Q93 Chair: What you are signalling could be interpreted as the GMC positioning itself to do perhaps more what the Royal Colleges used to do, which is the withdrawal of training recognition on grounds of quality being provided in a particular environment.

Professor Rubin: I think we are heading in that direction. We would certainly not do what the Colleges sometimes did, which was, on the basis of sometimes virtually anecdotal information, precipitately take action which would have a huge impact on the service. However, on the other hand, we will not shrink from saying things that need to be said and come back with action plans, with timelines. If those timelines are not met, we will act. As I said when I gave evidence to your education inquiry, the combination of the Working Time Regulations, "The New Deal" and everything else, I think will mean that we are going to be making some tough choices about where doctors should be trained and where they should not be trained.

Chair: Perhaps now is not the time. I suspect we could launch off on another half hour on the subject. Does anyone want to follow it up or maybe come back to it on another day?

Q94 Dr Wollaston: There are issues here. Take, for example, F2 doctors in general practice in situations where sometimes they feel they are being treated as if they were much more senior registrars and feeling very undersupervised. They have genuine concerns about the impacts on them in raising those concerns for their future career. Were they to contact the GMC through a helpline, how confident could they be that you would investigate and take action against the organisation rather than taking action that could penalise or identify them individually in raising those concerns?

Professor Rubin: We would always act in a way that would support the doctor who had raised the concern. When you are dealing with such a local issue as a doctor in a practice, there is no way that the postgraduate dean can sort it without involving the practice and the doctor obviously, but the whole point of how you deal with it is that it should be done in a constructive way, finding a solution and not getting into a blame game. We are passionately committed to highquality education and training and will do whatever we need to achieve that.

Niall Dickson: It is a difficult balance, this business about identifying and so forth. In the trainee survey I mentioned, we basically said to the trainees, "If you fill this out, it is confidential but not absolute because there may be circumstances where there are patient safety issues and we have to raise this and you may be identified." So they knew that and yet 5% of them raised patient safety issues. As I say, many of those were known about but some were not. I think that has helped, and we will see that they are all followed up.

Professor Rubin: Could I give you a quick example of what we are doing that is different? We now have a small group of experienced doctors who are ready to move into an area to investigate it at very short notice, so if there are concerns about the training environment at a particular hospital or whatever, we can send people out very quickly to feed back to us information on what the position is and what needs be to be done to put it right.

Chair: That promises to be a subject for future hearings, I suspect. I think we have covered a wide range of issues and I am grateful for your attendance. Thank you very much.

Prepared 3rd December 2012