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I am conscious that time is proceeding apace.

Lord Kirkwood of Kirkhope: As the noble Baroness and I are already owed a letter—we did not even get one late, about which we are heartbroken—perhaps one dealing with some of the other points might be possible. If so, that would be perfectly acceptable.

Lord McKenzie of Luton: I am most grateful to the noble Lord and I will do that. I will review the record to make sure that I have covered every point that has been raised.

On Question, Motion agreed to.

Medical Profession (Miscellaneous Amendments) Order 2008

6.50 pm

Baroness Thornton rose to move, That the Grand Committee do report to the House that it has considered the Medical Profession (Miscellaneous Amendments) Order 2008.

The noble Baroness said: This draft order is the third in a series of affirmative resolution orders and is part of the process of implementing the recommendations made in the White Paper, Trust, Assurance and Safety. It makes what are, in effect, three sets of changes to the framework legislation for the regulation of doctors.

The first set of changes relates to medical education. The order will transfer the statutory functions for the oversight of medical education from the Education Committee of the GMC to the council. This will allow the GMC to bring together all four of its interlocking statutory functions under the auspices of the council. In doing so, the GMC will be able to demonstrate that its responsibilities for medical education are central to, and not isolated from, its other regulatory functions. The order will also remove the residual role of the Privy Council in relation to the first year of postgraduate medical education.

The second set of changes relates to the introduction of licences to practise. Amendments were made to the Medical Act in 2002 to create a new system whereby all practising doctors would need not only to be registered with the GMC but also to hold a licence to practise. In due course, doctors will be allowed to keep their licences to practise only if they go through a process known as revalidation, which will be a periodic re-evaluation of a doctor’s fitness to practise. The introduction of licences to practise is therefore an important preparatory step towards revalidation of all doctors.

Plans for the development and introduction of revalidation have been in place for some time now, but none of this has yet been commenced, and thinking

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about how revalidation should take place has now evolved. The order amends some of the provisions already in place to bring them in line with the White Paper.

The White Paper indicated that revalidation is now expected to have two components: relicensing, which will apply to all doctors; and recertification, which will apply to specialist doctors. No provision for recertification was included in the 2002 legislation, and so this order makes the necessary changes that will include it.

Other changes to the licensing system address important issues such as the handling of adverse information about a doctor which is discovered in the course of revalidation and additional powers to ensure that, in all cases where fitness to practise concerns are identified, these can be referred through the GMC’s existing fitness to practise procedures.

The third set of changes relates to specialist registration and will, in due course, have a knock-on effect for recertification. The order enables the GMC to allow senior consultants who did not apply for inclusion in the specialist register between January 1997, when it was established, and September 2005, when the current arrangements for access to the register were introduced, to make a late application for entry. This reinstates the powers that the GMC had prior to September 2005.

The current situation, where some long-standing consultants are not on the specialist register, means that there is the potential for a small number of consultants to avoid recertification. Providing a quick and easy route on to the register is a first step in correcting this anomaly.

These reforms will help to raise standards of medical practice and improve the patient experience. The measures will, in the longer term, help to ensure that doctors meet the very high standards that we and they expect. All the measures are supported by the GMC and I commend them to the Committee. I beg to move.

Moved, That the Grand Committee do report to the House that it has considered the Medical Profession (Miscellaneous Amendments) Order 2008. 28th Report from the Joint Committee on Statutory Instruments.—(Baroness Thornton.)

Earl Howe: The Committee will be grateful to the Minister for introducing the order, to which I have no objection in principle. At the moment, as the Minister made clear, the Education Committee of the GMC has the statutory function of overseeing medical education. I accept the arguments that she outlined for transferring those functions to the council of the GMC.

One question that arises from that is whether, in the process of that transfer, anything of value will be lost. I am sure that the Minister will confidently assure me that the answer to that is no, but, to play devil’s advocate for a moment, one advantage of having a separate committee to oversee medical education and nothing but medical education has been its focus. We have had a group of people who have developed experience and specialist expertise in this important area and, although I accept the argument that the council itself should operate in a way that places education at the centre of its deliberations, it could still have done that without the Education Committee

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being done away with. It is arguable that there may be at least a temporary loss of corporate knowledge and expertise by dint of the transfer and possibly a temporary loss of focus and progress. How is that issue to be dealt with?

As we have heard, the amendments to the 2003 order will allow the GMC to provide a mechanism to enable senior consultants who did apply for inclusion in the specialist register at the time it was established to make a late application to the GMC. This will reinstate the powers that the GMC had prior to September 2005. Again this provision appears sensible. However, I have two queries. As I understand the position, if a consultant is not on the register, he or she is not eligible for recertification and can therefore escape that whole process. Once the order comes into force, I do not understand what is to oblige a consultant who is not registered to apply to have their name entered on the register, beyond simply the terms of the consultant’s contract.

Secondly, perhaps the Minister can assure me that there is no suggestion that the changes proposed in this statutory instrument may have the effect of unintentionally slowing down the recertification procedure for consultants. How many consultants are thought to want to avail themselves of the ability to make a late application? Is the GMC resourced properly to meet the likely demand on top of all its other administrative responsibilities?

Baroness Barker: I, too, thank the noble Baroness for introducing the order. I wish to raise only a few questions because I have no great objection to it in principle. First, on the issue of the transfer of statutory oversight of medical education to the GMC, I understand—it has been well debated in the House—that the Government’s intention and that of the GMC is to place medical education at the heart of what the GMC does. However, I echo some of the concerns raised by the noble Earl, Lord Howe. How will this change be evaluated and by whom? What would happen if the quality of medical education were to decline or deteriorate? What would happen if the oversight of the quality of medical education were to decline? Those are the questions which arise from what is, in essence, a technical change to the way in which the GMC conducts its business.

I make no comment of any substance on the proposals for licences to practise simply because this is not about the details of revalidation, which is the primary concern voiced by noble Lords during the passage of the Bill. There is still as yet no detail and to raise questions at this point would be continuing to grapple with shadows. However, I wish to refer to the issue of senior consultants who did not apply for inclusion on the specialists register and the reinstated provision for them to make a late application. I understand why that should be done—it is desirable that all specialist consultants within the NHS should be on the specialist register; I understand from the Explanatory Memorandum and from the GMC briefing how the situation has arisen in which a small number of people have not been included in the specialist register; and I understand from comments

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made by Mr Ben Bradshaw in another place yesterday that we are talking about 200 people or fewer. But no one has explained why these people have not registered when registration of this kind is an essential requirement for an NHS consultant and has been so for over a decade; it is not new.

I would therefore like to know what has caused this other than, I guess, bloody-mindedness on the part of some people. The figure of James Robertson Justice leaps to mind. It is obvious that this is an integral part of the contract that a specialist must have for an NHS consultant’s post—and such a post is a desirable thing to have. I may be being slightly flippant, but I am just intrigued about why this has happened. If it has happened in a situation which has gone on for over a decade, what assurance will there be that that will change as a result of reinstating this concession?

7 pm

Baroness Finlay of Llandaff: I welcome Schedule 2, and thank the noble Baroness. I have to declare an interest: I am one of those doctors. My specialty came into being late and when, having trained in general practice, I contacted the GMC and said, “I’m down on your general practice list. I should be on the consultants’ list”, they said, “Don’t worry. It’s fine—you’re on the register”. I wrote to the GMC and was reassured that I did not need to change anything. So when everything changed and I missed the boat, I spent some time waiting for my contract to be terminated. I am delighted, as are others in my specialty, that the small number of us will be able to rectify this situation in retrospect. It was not wilful; it was simply the way the specialties evolved. I hope that that answers the question—and I hope that the GMC will let me register.

I hope that the GMC will now send out a very simple form to consultants—I presume that it needs to go to the trust as well to verify that they are bona fide and practising as consultants—and that everything happens quite quickly. In that way, there will be 100 per cent recording in the appropriate parts of the register. We are all on the register; we are just in the wrong parts.

I also have a concern about orphan specialties. There are a few with very small numbers, such as breast physicians. The specialty will determine the recertification process, so it will be important that there is enough flexibility and the categories are broad enough to ensure that somebody who is practising in a narrow area gets recertified in that area and is not forced to go through a load of hoops that no longer apply to the way they practise medicine.

I have a warning regarding recertification and revalidation. Attitude is the biggest problem, and it is the hardest to assess. Communication skills can be assessed, but that is a bit fuzzy. My department has been doing it for some years and we have developed a toolkit for when people run into problems. Factual knowledge in isolation is the easiest to assess. The trouble is, it is the synthesis of all aspects—skills, competencies, attitudes, communications, scientific knowledge—that makes a good doctor. It seems from the research that one of the most sensitive ways to

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find out who is a good doctor and who is not is to ask other doctors to rate them and ask whether they would allow themselves or their nearest and dearest to be treated by them. The 360-degree appraisal type of approach is probably the best assessment in the long term, but it has to be meaningful. If it happens too often, it becomes ritualistic and a tick-box exercise. I give that as a slight warning but greatly welcome my personal change in status.

Baroness Thornton: I thank noble Lords for their brief and thoughtful contributions. The aim of the reforms is to enhance confidence in the system of professional regulation.

The noble Earl, Lord Howe, and the noble Baroness, Lady Barker, both asked whether we need a separate committee for medical education. As I said in my opening remarks, we want this to be core to the GMC’s other statutory functions. Removing the Education Committee as a separate statutory committee does not signal a diminution of the importance of education; instead, it highlights its crucial importance in all the regulatory functions carried out by the GMC.

The GMC is proposing a three-board model to improve co-ordination of medical education and training—a graduate board, a postgraduate board and a continuing professional education board. While the Education Committee will no longer be a separate statutory committee, the council will have three boards to provide advice on all stages of medical education.

That brings me to the other point that noble Lords raised concerning continuing expertise and the potential loss of expertise. It seems very likely that many of those who have served on, and been involved with, the Education Committee will move on to the new committees and therefore their expertise will not be lost.

I turn to the subject of specialist consultants. Again, I thank the noble Baroness, Lady Finlay, for informing the Committee and answering questions for me. I am always very grateful for her interventions. The vast majority of the 200 consultants are long-established and, for one reason or another, have not registered. However, we hope that the carrot of free registration will encourage those who have not done so to register. In future, those who do not do so may find recertification difficult if they do not co-operate. We hope that this carrot means that a stick will not have to be used at this point.

Finally, I turn to the point made by the noble Baroness, Lady Finlay, in relation to standards and orphan specialties. We intend that standards will be developed for each area of specialist recertification by the appropriate medical royal college or specialist association. We expect the academy and individual colleges to work closely together to develop these standards. Therefore, although there are differences in practice, we have to ensure that there are consistent standards but with the flexibility that the noble Baroness mentioned.

If I have missed any points, I shall pick them up and write to noble Lords.

On Question, Motion agreed to.



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Civil Contingencies Act 2004 (Amendment of List of Responders) Order 2008

7.07 pm

Baroness Thornton rose to move, That the Grand Committee do report to the House that it has considered the Civil Contingencies Act 2004 (Amendment of List of Responders) Order 2008.

The noble Baroness said: This order amends the Civil Contingencies Act 2004 to ensure that NHS trusts that provide ambulance services remain as category 1 responders if they attain NHS foundation trust status.

As noble Lords will be aware, the Civil Contingencies Act imposes a series of duties on local bodies, such as the police, fire brigades and local authorities, which are known as category 1 responders. Schedule 1 to the Act classifies NHS trusts as category 1 responders if they provide ambulance services, hospital accommodation and services in relation to accidents and emergencies, or public health services in Wales.

NHS foundation trusts, first established in England in 2004, have a status that is different from that of NHS trusts. Established as independent public benefit corporations, they are free from central government control and accountable to their local population. The Act classifies NHS foundation trusts as category 1 responders only if they provide,

It does not take account of the potential for foundation trusts to provide ambulance services.

In June 2007, my predecessor announced that NHS trusts that provide ambulance services would be able to apply for foundation trust status from April 2009. In other words, none is in existence at the moment. Therefore, an amendment to Schedule 1 is required. This order serves to maintain the status quo should an ambulance trust become a foundation trust, ensuring that it will continue to be subject to the duties and responsibilities of category 1 responders.

As I am sure the Committee can appreciate, failing to amend the Act could, in the event of ambulance trusts attaining foundation trust status, result in these trusts no longer being legally responsible for the duties set out in the Civil Contingencies Act, and this, in turn, could have serious implications for patient safety and, indeed, the nation’s ability to respond to a national emergency. As such, I commend the order to the Committee. I beg to move.

Moved, That the Grand Committee do report to the House that it has considered the Civil Contingencies Act 2004 (Amendment of List of Responders) Order 2008. 30th Report from the Joint Committee on Statutory Instruments.—(Baroness Thornton.)

Earl Howe: I thank the Minister for introducing the order, which is straightforward in its purpose and content. In broad terms, I take no issue with it. However, a few questions arise. Two of the defining features of a foundation trust are the greater degree of autonomy that it enjoys, as compared with a non-foundation trust, and the fact that it is not performance-managed

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by a strategic health authority. Given that these features apply, I am not clear about what drivers will exist to ensure that the care of patients who have been looked after by an ambulance foundation trust and then passed across to the A&E department of an acute NHS trust will be seamless and of a uniformly high standard.

I appreciate that foundation trusts have a duty of co-operation with the wider NHS, but that does not seem to be sufficient to guarantee that the interaction between an ambulance foundation trust and an acute trust will make the quality of the whole patient journey something that the ambulance trust makes one of its specific priorities. What matters to a foundation trust in terms of demonstrating that it has performed well is that it has met certain benchmarks relating to the care that it delivers. Whether or not it has facilitated good care delivered by another provider is not central to its mission.

On the other hand, what matters to a badly injured patient is not just the length of initial response time by the ambulance, or whether he is well looked after en route to A&E, but how long it takes him to access high-dependency care in hospital. Not for a minute do I wish to sound critical of ambulance crews, whose professionalism and dedication are not in question. I am just a little concerned that the systems and structures that we are setting up may not always work to the maximum extent possible in favour of good patient care, and that the greater insularity of an ambulance foundation trust may, in practice, not be wholly conducive to the delivery of optimum patient care along the entire patient pathway.

On a different issue, one of the other distinguishing features of foundation trusts is that they are fully subject to the tariff system. What progress is being made to apply a workable and credible tariff system to ambulance trusts, and how will this operate? Is it anticipated that there will be any change in target response times for ambulances, if and when ambulance trusts are overseen by Monitor? On a factual point, I should be glad to know how many ambulance trusts have indicated a wish to apply for foundation status.

Reverting to the content of the order, what steps are being taken to ensure that disaster preparedness training is being extended to these trusts, so that staff remain fully briefed and prepared for the worst? Will these civil contingencies duties be built into the functions of ambulance foundation trusts?

Baroness Barker: I thank the Minister for introducing the order and I, too, wish to home in on some of the same concerns as those expressed by the noble Earl, Lord Howe. I, too, am concerned about the fractured nature of the planning and management of emergency response that might arise from the granting of foundation trust status. For that reason, I want to ask the Minister the following question. It is right and sensible that foundation trusts and ambulance trusts should be an integral part of civil contingencies. Will this function be a factor upon which an application by an ambulance trust to be a foundation trust is assessed? Whether it is or not, will the preparedness and performance of an

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ambulance trust in the event of a disaster be part of the ongoing evaluation and maintenance of its trust status?

7.15 pm

Baroness Thornton: I thank both noble Lords for their questions, some of which I had anticipated. We spent a considerable amount of the early part of this year discussing the work of Monitor and the CQC. We commended Monitor for the admirable way in which it goes about its business and the way in which it ensures that foundation trusts carry out the job that they are supposed to do. That is what it and the CQC would do for ambulance foundation trusts. They would be under the same regulatory regime as other foundation trusts.

The noble Earl asked about payment for results. Payment for results in the sector is not a pre-requisite for the introduction of foundation trust status. On civil contingencies, that will be part of their terms and conditions of authorisation. It will be monitored and will be part of the granting of foundation trust status. They all intend to apply. Only one or two are on the stocks for early application.

On Question, Motion agreed to.

The Deputy Chairman of Committees (Lord Colwyn): There is a Division in the House. The Committee will adjourn for 10 minutes.

[The Sitting was suspended for a Division in the House from 7.16to 7.25 pm.]

Armed Forces (Alignment of Service Discipline Acts) (No. 2) Order 2008

Lord Tunnicliffe rose to move, That the Grand Committee do report to the House that it has considered the Armed Forces (Alignment of Service Discipline Acts) (No. 2) Order 2008.

The noble Lord said: The order has a simple purpose, which is to amend the service discipline Acts—the Army Act 1955, the Air Force Act 1955 and the Naval Discipline Act 1957—to remove the constraint that the prosecuting authority for each service must be an officer of that service. Rather than an officer, the amendment permits a person to be appointed to be the prosecuting authority in the future. This amendment will allow Her Majesty the Queen to appoint Bruce Houlder QC, the current Director of Service Prosecutions, or DSP as he is more usually known, to be the prosecuting authority for each of the three services.

Our intention is that his appointment should take effect from 1 January 2009. I am pleased to say that this date is consistent with the original target we set for the DSP to begin work as the single prosecutor for all three Armed Forces. It is the date that was discussed with Bruce Houlder when he was appointed to be the DSP, and I know that he is keen to take up his duties as a prosecutor on the date that was originally planned.



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