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Lord Patel: My Lords, I support the order. I shall try to be brief. I declare my interest. I am a fully registered doctor and a member of the council of the General Medical Council. For the past four years I have been a member of its education and professional conduct committee and I have also been a member of the interim orders committee.
The medical profession supports the order and the amendment to the Act, which will introduce a streamlined structure reducing the size of the council. It will also introduce revalidation for a doctor's licence to practise medicine and streamline the current fitness-to-practise procedure, including the separation of investigation and adjudication.
All the changes proposed have been discussed and discussed. I remember the many hours and days that we spent doing that. They have gone through an extensive consultation process. The medical profession is keen to have a system of professionally laid regulations that command the confidence of patients and doctors.
I will conclude by quoting the GMC president, Professor Sir Graeme Catto, who said:
- "This order is an important milestone in the GMC reforms. We are on schedule to deliver the changes that we have proposed".
The current officers and the council are well aware of the need to deliver all the changes on time. I have no doubt that the changes required to registration and recognition of training and experience of overseas doctors will be addressed by the GMC in the light of the changes proposed in the order.
It is not my role to answer many of the questions raised, but I assure your Lordships that most, if not all, have been discussed by the GMC and it will deliver them.
Baroness Emerton: My Lords, I speak as a former lay member of the General Medical Council. I served for a five-year term and was present at the beginning of the discussions on the reform of the council. I fully support the order and congratulate the GMC, the Minister and the Government on it.
Reform of the council was long overdue. Decision-making was tortuous, because of the time taken by having over 100 people present. The reduction in size will assist in the speed of decision-making. The increase in lay membership is also important.
Will the Minister clarify that the lay membership does not exclude other health professionals participating? Healthcare practice today is a team process. There is value in having other health professionals participating on bodies. Just as the nurses and midwives council has other health professionals present, I hope that the presence of lay members on the new council will include some healthcare professionals, although not many, because it is important that the lay representation covers the wide public interest.
The provisions in the order for the revalidation of doctors will benefit the practitioner, the patient and the public. That is crucial in any regulatory body. Fitness to practise is the key with the regulatory system. The order sets that out. There is much still to be done on regulation, but it is a miracle that we have got to this stage. I support the order.
Baroness Finlay of Llandaff: My Lords, I, too, support the order. I declare an interest, as I am also registered with the General Medical Council as a practising doctor. I commend the Government on their open approach to consultation in drawing up the order. It has been not just consultation, but reconsultation with open channels of communication, resulting in the whole profession understanding why the changes are happening. These changes are being introduced remarkably peacefully and with a wide degree of understanding. They are also being welcomed by the profession.
I reiterate the request from the noble Lord, Lord Clement-Jones, that this open process of consultation should be built on and used when other changes, such as those relating to education, are being looked at. The smooth transition that we have seen has much to commend it and will bring about the necessary changes to raise standards across the board.
The revalidation processes are a major step forward and are recognised as necessary within the profession. They have to be done with sensitivity and with sense so that clinical time is not eroded. Those women—two thirds of our graduates are now women—who wish to should be able to have time out to raise a family for one, two or three years and then re-enter the
profession. Those who wish to pursue other educational avenues should be able to broaden their horizons and then continue with their clinical practice.All the evidence that we have seen over many years is that those who take time out and then return to clinical practice do so with their clinical practice enhanced. The practitioners who have caused concern are those who have not taken time out from clinical practice, but have continued to practise without updating themselves and without auditing their own practice. Flexibility will be very important to maintain a vibrant workforce.
There are some exciting examples of appraisal already occurring—not simply straightforward appraisal, but 360 degree appraisal and team appraisal, with input gained from all members of the team. The flexibility to allow that innovation and creativity is important.
It is also important to reflect the wide range of duties and responsibilities that exist within the enormous envelope called medical practice. It goes from very high tech and complex practice right through to broad, generic, front-line practice, as one sees in some areas, particularly in the community. It would be impossible to transpose one set of practice into another where there are very highly specialised areas of scientific practice, particularly those doctors who work in specialised areas of laboratory medicine.
To conclude, I commend the processes that have gone on behind the order and I support it. There is one small area that I should like the Minister to clarify, because it may not be as clear as might be helpful. Article 6(2) concerns full registration of EEA nationals by virtue of overseas primary qualifications. Will the Minister confirm that the General Medical Council will not be obliged to grant full registration in every case and that the order gives the council discretion in deciding whether it thinks fit to grant registration to the applicant, to ensure that the process of registration is truly based around fitness to practise?
Lord Hunt of Kings Heath: My Lords, I welcome all noble Lords who have contributed to this interesting debate. I echo the comments of the noble Baroness, Lady Noakes, and the noble Lord, Lord Clement-Jones, that there is broad support for the proposals in Parliament and among the medical profession, as the noble Baroness, Lady Finlay, has indicated. I again pay tribute to the GMC, to the work of the noble Lord, Lord Patel, who has played a positive role, and to members of the GMC past and present. The noble Baroness, Lady Emerton, has played a distinguished role.
There is clearly support for the concept of professional self-regulation to ensure public confidence. The Government also support that wholeheartedly.
I apologise to the noble Lord, Lord Clement-Jones, about the drafting issues that he raised. I agree that this is a lengthy and complicated order, because of the way that it has been done, through amending the Medical Act. I hope that the broad thrust of our proposals comes through clearly.
The noble Baroness, Lady Noakes, thought that a committee of 35 was too much. Indeed, I believe she considered a committee of 23 too much. Sometimes a committee of two is too much. Clearly, there is a delicate balance to be drawn between enabling us to have enough lay people to carry the profession with us and having some people nominated from the medical education world. Inevitably, one arrives at a figure higher than might be desirable. I agree with the noble Lord, Lord Clement-Jones, that one size does not fit all. In picking up the point raised by the noble Baroness as to why the GMC has only 40 per cent lay members while the NMC and HBC have 49 per cent, I believe that there are two points to be made. The key change is that the GMC will have a substantial and much increased lay voice. The exact arithmetic would matter only if regulators took decisions by votes which divided along lay versus professional lines. Experience shows that that does not occur.
The main reason why the GMC's proportion of lay members differs from the NMC and HBC is that, unlike them, it has separate places reserved for educators. In view of the discussions we have had over the past 12 months about the importance of medical schools, I believe that noble Lords will agree that it is right that it should have places. But we wanted also to ensure a majority on the council for elected medical members in order to preserve the principle of professional self regulation. It is for that reason that we have reached a figure of 40 per cent of lay members.
The question of the electoral base was raised by the noble Lord, Lord Clement-Jones. I understand that the Liberal Democrats are obsessive in their interest in the minutiae of electoral matters. Indeed, I am reliably informed that it is considered that the GMC took a rather Liberal Democrat approach to the proposals it is making for its electoral system.
Lord Clement-Jones: My Lords, it is much more like an old-fashioned gerrymander to me.
Lord Hunt of Kings Heath: My Lords, noble Lords would know more about that than I. The point is that the body has arrived at a system of five election areas in England based on postal districts. That is because it is taking the postal codes of every member of the GMC. It was divided up into five areas and that is why there are some quirks with Coventry and Warwickshire not appearing in the same electoral division.
But that surely is matter for the GMC rather than we politicians. I believe it is best left to it. One of the reasons it followed the route of regional election constituencies is that at the last election I believe over 300 candidates stood and all electors were given a list of over 300 candidates. That proved to be somewhat trying for the electorate. This system will be much easier. For the noble Lord's interest, they are multi-member constituencies using the single transferable vote system.
I say to the noble Baroness, Lady Emerton, that as regards a definition of lay membership, it has always been possible—and remains so—that other members
of other professions could be nominated as lay members of the GMC. The balance of views which we have received in the consultation is that the nomination of lay members should be for those who speak up best for the public and patients. But that in no way rules out the possibility of a nurse being appointed. No doubt that will be very carefully considered.As regards the question of restructuring, I was quite surprised by the noble Baroness, Lady Noakes, wishing us to review urgently and perhaps restructure again. Usually, she accuses me of restructuring far too many times. But the point to be made about that and her comments about fitness to practise is that it is one of the joys of a Section 60 approach. It does allow for changes to be made in the light of experience without having to go for primary legislation. I assure her, and I have been assured, that all these matters will be kept under review by the GMC. The noble Baroness is absolutely right in that these matters need to be reviewed in the light of practice. If the GMC comes forward to the Government and indicates that more changes need to be made, we shall listen to that very carefully indeed.
The noble Baroness, Lady Noakes, asked about appraisal and revalidation. I very much agree with her. The appraisal of all doctors and the revalidation process is a mammoth task. I would not underestimate the challenge facing the GMC, individual members of the profession, as the noble Baroness, Lady Finlay, has indicated, and the NHS itself. Clearly, we have to do all we can to make sure that this system is bedded down as effectively as possible.
The GMC is planning to issue instructions, information and guidance about the new arrangements in April 2003. I can give the noble Baroness the assurance she requires that the GMC is required to consult professional bodies representing the medical professions. In addition, it has given a clear indication that it will consult more widely, as it has done already in developing the proposals in this order. I certainly agree that the amount of time spent on appraisal and revalidation is important. I am told that the actual time for appraisals differs from individual to individual. But anecdotal evidence suggests that the average time commitment for appraisal is a minimum of four-and-a-half hours up to six-and-a-half hours. That includes between two and four hours for preparation. We recognise that there will be a learning curve and that the time commitment in the first year of appraisal may be higher as trusts and individual doctors adapt to the new system. But all of us who have been involved in appraisal will recognise that it does take time and probably ought to do so, and that the benefits are there both for the individual and the organisation provided that it is done effectively.
I do not have all the information that the noble Lord, Lord Clement-Jones, asked for such as the number of doctors in the pilot schemes. I shall try to get that information. Perhaps I may ask the GMC to write to the noble Lord directly in relation to revalidation. I am told that the pilot schemes have
been very valuable and that the GMC is still considering some of the results. I shall seek to find as much information as I can on that matter.I agree with the noble Lord on the issue of duplication. In my opening remarks I referred to the need for the GMC to pick up the most serious cases, but we must hope that NHS trusts will be able to take a more vigorous approach at local level to sorting out some of the issues that would not be classed as serious but nevertheless can become a running sore.
I know that noble Lords have been concerned for a long time about the number of doctors suspended. The establishment of the NCAA is an important process of trying to turn that around. I am convinced that it is to the benefit of the NHS and doctors to try and nip some of the problems in the bud at an early stage.
The noble Baroness, Lady Noakes, asked what would happen to a doctor whose revalidation was delayed through no fault of his own. I am advised that the doctor would retain the licence to practise unless it had been withdrawn if the doctor had been referred to a fitness-to-practise panel. The licence does not expire; it is not time limited. It is clear that the intention is that revalidation should take place on a five-year basis, starting in 2005.
The cost to the GMC of operating revalidation is estimated at approximately £8 million per year. The cost to individual doctors is a matter to be decided. As your Lordships would expect, when it comes to fee structure the GMC will be seeking doctors' views. I have no doubt that there will be a healthy response.
In response to the noble Baroness, Lady Finlay, I confirm that the GMC has discretion in the matter. That discretion must be exercised reasonably, but it is clear that the GMC must have regard to its responsibility to protect the public interest by ensuring that only those doctors fit to practise are allowed to do so.
The noble Lord, Lord Clement-Jones, asked about admission to the register. The practice in the UK is that a doctor needs to be placed on the medical register by the GMC. That can be through the UK primary medical qualification, plus a satisfactory pre-registration house officer year. For a person with a primary medical qualification from outside the European Economic Area, the GMC is required by law to satisfy itself that he has the necessary knowledge and interest. That is normally done by requiring such doctors to pass the International English Language Testing Scheme examination.
EC law prevents us from applying such a requirement to people qualifying in the EEA, but employers have a responsibility to ensure that anyone they appoint knows enough English to do their job properly. I can reassure noble Lords that the GMC has begun a fundamental review of registration, due to report in May 2003, which will lead to consultation on any changes recommended. I can also assure the House that if the law needs to change, the Government would consult on a draft of any new provision under the Section 60 order procedure.
I know that there is concern about the 22 Commonwealth medical schools, graduates of which up to now have had privileged access to the UK as if they were graduates of UK medical schools. I am aware of some of the issues and problems that that policy entails. It has discriminated against all other medical graduates from the Commonwealth, from Canada, Nigeria, or Pakistan, and against doctors from anywhere else in the world. It has often amounted to indirect racial discrimination. There has never been objective evidence that those 22 medical degrees were better than one, say, from Harvard. In future, all doctors from outside the EEA will have to provide the same objective evidence of competence at the point of entry to the register.
The noble Lord, Lord Clement-Jones, referred to St George's University School of Medicine. That issue has been raised with the department before. I will chase up the matter and respond to him directly, as it is important.
I was asked about delays in registration. I understand that noble Lords want to be assured that some of the problems that the NMC inherited from the UKCC, which I am glad to say are now being tackled with vigour, do not arise in the case of the GMC. I have two points to make. There is no doubt that currently in proceedings against doctors there have been long delays within the GMC. Our hope is that the restructuring brought about by the order will enable many of those delays to be tackled.
I am assured that if a doctor's paper is in order, registration from the UK or the EEA can be accomplished by the GMC within a fortnight. The problem seems to lie with doctors outwith, who are having to prove their specialism, which can cause delays. No doubt the matter will be looked at by the GMC and other regulatory bodies. Not only the GMC is involved in those cases.
I very much welcome the spirit of consultation which noble Lords have commended, and for which I thank noble Lords. There is a suggestion that this spirit should be applied to the Postgraduate Medical and Training Board. I do not quite understand why noble Lords should think that the Government's spirit of openness and consultation has not applied to discussions on the Postgraduate Medical and Training Board. I reassure noble Lords that there is a joint working group with at least six royal college presidents in membership. We shall be working very hard through the joint working group to ensure that, when we bring the relevant order before your Lordships, it will have been thoroughly tested and consulted upon.
The noble Lord, Lord Clement-Jones, raised an issue which the noble Baroness, Lady Finlay, has raised before—the issue of mutual recognition. I did not quite understand the noble Lord's suggestion that the Government have been slow to act. As I said when this issue was raised previously in your Lordships' House, we have concerns which we are raising in Europe.
I hope that I have covered most of the points raised. This is a very good order, and I thank noble Lords for their support.
On Question, Motion agreed to.
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