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House of Lords

Friday, 21st July 1995.

The House met at eleven of the clock: The LORD CHANCELLOR on the Woolsack.

Prayers—Read by the Lord Bishop of St. Albans.

Lord Grantley—Sat first in Parliament after the death of his father.

Medical (Professional Performance) Bill

11.7 a.m.

The Parliamentary Under-Secretary of State, Department of Health (Baroness Cumberlege): My Lords, I beg to move that the House do now resolve itself into Committee on this Bill.

Moved, That the House do now resolve itself into Committee.—(Baroness Cumberlege.)

On Question, Motion agreed to.

House in Committee accordingly.


Clause 1 [Professional Performance]:

Baroness Jay of Paddington moved Amendment No. 1:

Page 1, line 10, after ("deficient") insert ("(measured against published performance standards and key performance criteria)").

The noble Baroness said: The purpose of the amendment is to make the legislation more precise about how professional performance is to be judged. Throughout the deliberations on the Bill in another place and at Second Reading in your Lordships' House, questions were raised about how to define a seriously deficient medical performance—a definition which is clearly central to the functioning of the new procedures.

Ministers in both Houses have acknowledged that the question of definition is difficult and seem to have accepted that establishing practice codes and guidelines will be left entirely to the General Medical Council. In another place, the Minister, Mr. Sackville, reported at the Committee stage that the General Medical Council will soon publish a new version of its so-called Blue Book under the title: Good Medical Practice. It will be the touchstone against which professional performance will be assessed and judged, although he noted that there could be departures which were serious and which were not covered by the GMC guidance.

In this House at Second Reading, the Minister, the noble Baroness, Lady Cumberlege, said that:

    "Serious deficiency in professional performance is a departure from good medical practice, whether it is covered by the GMC guidance or not".—[Official Report, 29/6/95; col. 894.]

The noble Baroness went on to say that she appreciated that what she was giving was "a rather woolly definition"—her words. But she too placed her faith in the publication of the new GMC guidelines, which she hoped would make the issue of standards clearer.

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This does not seem to be a satisfactory situation. My amendment, Amendment No. 1, does not attempt to establish descriptions of good, bad or seriously deficient medical practice. But it seeks to place on the face of the Bill that the performance criteria should be explicit, should explicitly refer to the terms of the Bill and not be part of general guidance to the medical profession left to the GMC. It may be that the kinds of codes which I seek will be included in the new Blue Book, in which case there seems to be no problem about placing them on the face of the Bill. After all, the National Health Service and those who work in it have accepted the need for performance indicators across the whole range of health care. Areas of practice which might in the past have been seen to be solely matters of individual professional judgment are now subject to objective assessment. The introduction of medical audit has made it possible to review performance against agreed consistent standards.

It is true that these changes have sometimes been resisted by traditionalist members of the medical profession, who complained of threats to their clinical freedom. But clinical freedom has sometimes meant doing things as they have always been done and not in accordance with advances in medical science or in the best interests of the patients.

It is exactly that kind of rather blinkered approach that the Bill seeks to prevent. The Bill should also seek to make clear that performance will be judged across key objective criteria and will not be differently judged variously, for example, according to personal prejudice or perhaps on the basis of different local practice.

If the primary legislation does not state categorically that consistent national standards will be published and adhered to, then there will be endless opportunities for argument and debate about what constitutes a serious deficiency in performance. One can see this being any medical practitioner's legal adviser's field-day. It is almost certain that in these circumstances procedures will be delayed and there will be a lack of efficiency in achieving precisely what the Bill sets out to make clearer. This situation cannot be helpful to the overall purpose of the Bill, with which noble Lords on all sides of the Chamber agree and which we all welcome; namely, to improve both medical standards and the confidence of patients. I beg to move.

11.15 a.m.

Lord Walton of Detchant: While I sympathise with the intention underlying this amendment, so ably proposed by the noble Baroness, Lady Jay of Paddington, I believe that to include it in the Bill would in many respects be an error. My reasons for saying so relate to the fact that the purpose behind the Bill is to give additional powers to the General Medical Council—additional to those that it already possesses—to enable it to discipline doctors guilty of serious professional conduct and to take action to rehabilitate or otherwise deal with doctors whose health is sufficiently seriously impaired as to put patients at risk.

The whole objective of the Bill, as the noble Baroness said, is to empower the General Medical Council to take appropriate action in relation to doctors whose

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professional performance falls below an acceptable standard. Having made that point, however, the conduct and health procedures have relied upon definitions which some may regard as being woolly, but which have nevertheless stood the test of time. The problem about attempting to codify professional performance in the precise way that the noble Baroness suggested is one that is far beyond the capability of any body of medical practitioners with the legal and lay advice upon which it is likely to rely at the present time.

The problem is that so many specialties exist in medicine that to attempt to lay down precise published performance standards for each of them and key performance criteria would be an incredibly difficult task. Hence, this amendment—though one which has a worthy intention—is not one that could be carried out in practice. Over many years the profession has had experience in assessing the performance of undergraduate medical students at final examinations in medicine with the advice of experienced external examiners; and the officers of the Royal Medical Colleges have a great deal of experience in assessing performance in postgraduate examinations.

There has also been a major development in the introduction of methods of the audit of professional performance carried out voluntarily by members of the profession. This expertise will be drawn upon by the General Medical Council in its efforts to undertake these performance procedures and to make sure that doctors who are not performing up to an appropriate standard are dealt with appropriately, as set out in the Bill. But to try to lay down these procedures in precise terms in statute would be inappropriate. Such performance criteria would have to be regularly updated and modified according to developments in medicine.

The Blue Book to which the noble Baroness referred is not a code of practice. It is a guide to the medical profession about standards of practice and professional behaviour. It is about to be published as updated. I believe that it will form the cornerstone of the form of professional procedures and assessment procedures upon which this Bill will depend. Therefore, I have to say that I am not able, on the advice that I have received, to support this amendment, despite accepting wholly the intentions underlying its proposal.

The Government agree with the noble Baroness's intent. It is important that a doctor knows the limits within which he should work and the standards that he should meet. It is equally important that the public should have information available so that they know what to expect. The General Medical Council is empowered to issue guidance on standards of conduct and ethics. This Bill will empower it to do the same for standards of professional performance. Of course the guidance will be updated regularly.

However, a doctor cannot be judged on a set of published criteria alone, as the noble Lord, Lord Walton of Detchant, outlined. Such criteria will be constantly changing, and a published document can soon become outdated. To require the Committee on Professional

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Performance to make judgments on published standards alone would constrain it, and may act against the public interest.

Therefore, in order to give the Committee on Professional Performance the ability to carry out its task appropriately and effectively, it is important that published criteria form just one aspect of its reasoning. There is a body of unpublished, but widely acknowledged, standards which also needs to be considered. This must also be taken into account. In the light of these arguments, I hope that the noble Baroness will feel able to withdraw the amendment.

Baroness Jay of Paddington: I am grateful to the Minister for that response, and indeed to the noble Lord, Lord Walton of Detchant, for his very authoritative views on this matter. There is perhaps some confusion about the exact terminology that is to be used. I recall that at Second Reading the Minister said that she hoped there would be greater clarity about this whole area before the Bill left this place.

The distinction between guidance and a code, which the noble Lord, Lord Walton, clearly made, in terms of the General Medical Council's publications, is precisely what concerns me a little. I am still unclear whether the guidance which will be published by the General Medical Council will, as it were, be specific to the standards of professional performance which are to be judged under these new proceedings or whether it consists simply of more general pieces of advice to the medical profession about the general standards that it should maintain. If it is the latter, it seems to me that it will not be sufficiently tight or specific to enable the very well informed and, as the noble Lord, Lord Walton, said, extremely experienced members of the committees involved to make the assessments that will be necessary.

My primary concern is not to establish some kind of false external criteria which have simply to be adhered to, but rather to enable the committee to work effectively and not constantly be tripped up, as I said when I moved the amendment, by an articulate doctor or his even more articulate legal representatives running rings around the concept of serious professional failures.

That was the spirit behind the amendment. Having heard what the Minister said and the authoritative comments of the noble Lord, Lord Walton of Detchant, I beg leave to withdraw the amendment at this stage. However, I hope that, before the Bill finally leaves your Lordships' House, we may be able to obtain some slightly more specific guidance in this matter.

Amendment, by leave, withdrawn.

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