Thursday 21 June 2007
[Mr. Mike Hancock in the Chair]
[Relevant documents: Eighth Report from the Constitutional Affairs Committee, Session 2005-06, HC 902, and the Government’s response thereto, Cm 6943. Uncorrected minutes of evidence of 8 May 2007—follow-up, HC 515-i.]
Motion made, and Question proposed, That the sitting be now adjourned.—[Andy Burnham.]
I am pleased that we have been able to secure time this afternoon to debate the findings of the Shipman inquiry, which dealt with a matter of huge significance that has far-reaching ramifications for several Government Departments and which raised matters of great horror for the families who were affected and for the communities that still, to this day, remember the consequences.
To begin, let us remind ourselves of the facts. In January 2000, Harold Shipman, a sole-practice general practitioner in Hyde, Greater Manchester, was convicted at Preston Crown court of murdering 15 of his patients. He committed those murders by injecting his patients with lethal doses of diamorphine, a strong painkiller that is related to heroin. It has legitimate and widespread use in the treatment of the terminal stages of cancer and of other medical conditions. As further information came out during and after the trial, including the results of an audit of Shipman’s mortality data that was commissioned by the Department of Health, it became apparent that those crimes were not isolated but were merely a small sample of an horrific series of murders committed over a period as long as 25 years and spanning virtually the whole of Shipman’s professional life.
The Shipman inquiry was set up in January 2001 and was tasked with investigating the extent of Shipman’s unlawful activities, inquiring into the activities of the statutory authorities and other organisations that were involved, and making recommendations on the steps needed to protect patients in the future.
The inquiry published a total of six reports. The first report addressed the extent of Shipman’s criminal activities as a GP. The second report covered the 1998 investigation by the Greater Manchester police. The third report covered the system of death certification and the coroners system. The fourth report covered the systems for ensuring the safe and appropriate use of controlled drugs. The fifth report covered the arrangements for monitoring and disciplining GPs, including arrangements for the handling of complaints in the national health service, and the sixth report addressed the extent of Shipman’s criminal activities in the early part of his career as a junior hospital doctor. I wish to put on record the conclusion of Dame Janet Smith, now Lady Justice Smith, in paragraph 28 of the summary to the sixth report. It states:
“My overall conclusion, therefore, is that Shipman killed about 250 patients between 1971 and 1998, of whom I have been able positively to identify 218.”
That is the scale of the crimes. We are debating the ramifications as they affect not just the Department of Health but several Departments, and we continue to build a system that will reduce significantly the likelihood of any crimes on that scale ever being repeated.
I welcome this opportunity to debate the findings of the Shipman inquiry and the action programme that the Government have set in place to ensure, as far as we can, that a similar tragedy never happens again. I begin with an obvious but vital point. The overwhelming majority of health professionals and staff working in the NHS are dedicated to providing the best possible care that they can for their patients. They bring to their work skills, professionalism, commitment and empathy for their patients, and we in turn entrust them with crucial aspects of our health and the health of our families. In the vast majority of cases, that trust is well placed. Opinion polls repeatedly tell us that, of all occupations, health professionals such as doctors and nurses are the most trusted.
It is therefore all the more bewildering, as was expressed in the Shipman inquiry’s first report, when that trust is betrayed. Tragically, that is exactly what happened in the case of Harold Shipman. To outward appearances, he was a devoted, caring doctor. In some respects, he was at the leading edge of his profession—for instance, in his approach to clinical audit. It was that outward appearance that enabled him to conceal the evidence of his crimes for so many years and to pull the wool over the eyes of many people who should have been more alert to what was happening.
I believe that I speak for colleagues on both sides of the House when I say that we owe an immense debt of gratitude to the Shipman inquiry, in particular to its chairman, Lady Justice Smith, for the meticulous work that was done in unravelling the story of Shipman’s crimes and the failure of the systems in place at the time to protect patients. Anybody who has reviewed the reports, as I have in preparation for this debate, will be impressed by the extremely detailed analysis of every aspect of the Shipman story. A mere glance at the title pages of the inquiry’s six reports gives an indication of the breadth of the work.
I pay tribute to the skill with which the inquiry sought in its recommendations to balance the need to safeguard the normal processes of patient care with the need to protect the public from the rare cases of professional abuse. It is important to acknowledge at the outset that it is incredibly difficult to get that balance right. It is vital to recognise that the vast majority of health professionals are dedicated to the care of patients and go about their work in an exemplary fashion, doing nothing but good for the communities that they serve.
I welcome the way in which the Minister has introduced the topic. May I explore an issue with him? He maintained that doctors are more trusted than most other groups, and I certainly agree with that. The point that I would like him to address is that they are still the most trusted, even after the Shipman inquiry. There is no sign in polls that they are any less trusted. Therefore, does he agree that policies that the Government wish to put into place following the Shipman and other inquiries must be designed to protect patients and not seek purely to restore or increase faith in the medical profession? That would be a wrong and unnecessary motive, and there is enough work to do if the motive for action is to ensure that patients are protected.
I agree entirely with the hon. Gentleman. The guiding principle of every measure that has been and will be introduced—there is, of course, some considerable way to go before we have done full justice to this hugely significant inquiry—is the protection of patients and the public. All the measures that we take must contribute to that aim, but, in doing so, they can provide further reassurance to the public that their trust in health professionals, and doctors in particular, is not misplaced. As we all know, that trust is not misplaced, but the perception that the systems are transparent and robust is part of ensuring patient safety. The profession has nothing to fear. Indeed, I am hugely grateful for the constructive engagement that we have had with the British Medical Association, the royal colleges and the General Medical Council in getting this complicated package right. As I said when we published our response to the inquiry in February, this has to be a settlement for a generation. It must produce a conclusive and consensual agreement on the right way forward, and that will be done only by working co-operatively and in partnership with the professionals.
I share the gratitude of our colleague, the hon. Member for Oxford, West and Abingdon (Dr. Harris), for the manner in which the Minister is introducing the debate. As we are establishing the principles that we should apply, does he agree that the enormity of what Harold Shipman did and the huge betrayal of trust that occurred, to which the Minister referred, does not invalidate the principle that the medical profession is capable of self-regulation within a statutory framework? Although the balance of professional and lay participation in the process will change, we should start from the presumption that, with the appropriate levels of transparency, doctors are capable and competent enough to regulate themselves.
Yes, I agree. The package of reform that we introduced in February does retain the system of independent self-regulation and suggests a parity between lay and professional representation within the main regulatory bodies and that those appointees should be independently appointed. It is important to ensure that the public have confidence that the regulatory system balances the public interest alongside professional standards. The system that we have proposed would achieve that aim, but there are different views on that and I will continue to discuss the matter with the medical profession. It is not in the interests of any profession for a closed discussion to take place on an issue of such import. As the hon. Member for Oxford, West and Abingdon (Dr. Harris) rightly said, we are discussing matters of patient and public safety and it is important that there is and is seen to be openness, transparency and balance in the way we do so.
I do not want to mention any particular regulator, but I have to be honest and say that I have seen evidence that some professions can become too inward in the discussions that they have about regulatory matters among themselves. At times, they are not sufficiently outward facing in the way in which they consider public safety. I do not want to go into detail, but the hon. Member for South Cambridgeshire (Mr. Lansley) may know to what I am referring. It is important that the professionals’ role in self-regulation is balanced with the voice of the lay representative, but we can discuss those matters further as the debate progresses.
Today's debate is about the Shipman inquiry, but I will mention in passing the work of three other inquiries—the Ayling, Neale, and Kerr/Haslam inquiries—that also deal with the abuse of trust by doctors. The details differ, but the underlying issues are similar: the failure of those in authority in the NHS to take seriously repeated expressions of concern about the actions of trusted health professionals, and to take effective action to protect patients. In responding to the fifth report of the Shipman inquiry, we found it sensible to consider at the same time the related recommendations of the three other inquiries, and I propose to do the same today.
I know that the colleague of the hon. Member for Oxford, West and Abingdon, the hon. Member for Harrogate and Knaresborough (Mr. Willis), who is Chairman of the Select Committee on Science and Technology, has a constituency interest in these matters. Indeed, he wrote to me a few weeks ago and asked whether we could have time for a Government debate on the issue. Unfortunately, it has fallen on a day when I believe he is out of the country, but I put my appreciation of his suggestion of a debate on the record.
I am grateful to the Minister for his comments. I can confirm that my hon. Friend the Member for Harrogate and Knaresborough (Mr. Willis), who Chairs the Science and Technology Committee, is on a Committee trip to Portugal. I would also be there if I was not participating in this debate, but we wished to ensure that at least one of us took part. I know that he is grateful to the Government for finding time for the debate, even though it fell on the wrong day for him.
I am grateful that the hon. Gentleman has put that on the record.
As the Shipman inquiry recognised, the NHS is in many ways very different from the NHS in which Shipman practised. In particular, since the publication of the Government’s quality strategy in 1998, “A first class service”, new structures have been put in place to ensure the quality of care, to focus health care organisations on continuous quality improvement, and to identify and deal with poor professional performance. In the new climate it seems unlikely that abuses such as those perpetrated by Shipman, Kerr and Haslam would have continued for so long without coming to the relevant authorities’ attention. Nevertheless, the list of the weaknesses in earlier systems that were revealed in the four inquiry reports leaves us no room for complacency. We need to learn from the past to ensure that future safeguards are as robust as we can possibly make them.
The inquiry recommendations that we are dealing with today fall into the following broad areas: arrangements for death certification and for critical overview of the information on death certificates; the coroners system; safeguards over the use of controlled drugs; the handling of complaints and concerns in the NHS; routine monitoring of professional performance and conduct; arrangements for professional appraisal and revalidation; and disciplinary processes, including the fitness- to-practise processes of the national professional regulators.
In the time available, I cannot hope to do justice to the wealth of detail in the recommendations in those areas. Instead, I propose first to set out some general principles, and, second, to mention selectively the most important changes that we will introduce. Our action programme is summarised in the paper that we published in February, “Learning from tragedy, keeping patients safe”, and in a series of more detailed papers, all of which have been laid before Parliament. The paper that we published in February provides an overview of all Government activity in response to the Shipman inquiry and will, I believe, provide a document of historical importance and use to people who research these matters as it brings together a vast programme of work.
The Minister for Pensions Reform, my hon. Friend the Member for Stalybridge and Hyde (James Purnell) originally asked the Prime Minister whether the Government would produce such a document. I am pleased to have put the document together at his request and that he has joined us today to hear the proceedings. I pay tribute to him for the assiduous and respectful way in which he has pursued the interests of his constituents in this matter. It will be some time yet until those interests are fully resolved and until we can genuinely say that all of the issues that arose from the Shipman inquiry have been properly dealt with.
I am also pleased that my hon. Friend the Member for Calder Valley (Chris McCafferty) is here. Shipman mainly practised in the constituency of my hon. Friend the Member for Stalybridge and Hyde, but he also practised in her constituency. It is pleasing that they and my hon. Friend the Member for Denton and Reddish (Andrew Gwynne) are here. I believe that he also knows people in his local area who were affected. I thank all three of my hon. Friends for their work on the issue, but I particularly thank my hon. Friend the Member for Stalybridge and Hyde for the measured way in which he has pursued the interests of his constituents. On the record, I give an assurance that we will continue to work through the issues until they are resolved to the satisfaction of him and his constituents.
On the general principles of the matter, our overriding priority has to be the protection of patients and the general public. Secondly, that should be done in a way that minimises any potential impact on the delivery of normal patient care and that affirms and supports health professionals—the overwhelming majority of whom, as I have already noted, aspire to do their best for their patients. Thirdly, any additional safeguards should build on existing processes, in particular on the processes in the NHS for ensuring clinical quality and safety, which are collectively known as clinical governance. Finally, those additional safeguards should apply consistently across all sectors of health care and on a proportionate basis to all health professions, not just to doctors. Shipman was, of course, a doctor in general practice, but it would be deeply irresponsible for us not to consider the further implications for secondary care and for other health professions.
On the detail of the coroners system and, in particular, the proposed changes to that system, generally coroners and coroners officers do a good job in often difficult circumstances, but the inquiry exposed a range of limitations. Proposals for reform of the coroners system were set out in February last year and a draft Bill was published in June. A substantive Bill will be introduced as soon as parliamentary time allows. There was a Westminster Hall debate on the proposals in March this year, so I do not propose to go into great detail, but some of the main proposals are to allow bereaved people a greater opportunity to contribute to coroners’ investigations and to appeal if they are unhappy about decisions taken; to reduce variability in service and spread best practice by introducing national leadership for the service through a new chief coroner’s post and inspection programme; to make investigations more effective by removing some archaic, restrictive legislation and giving coroners additional powers; and to make coroners’ posts whole-time appointments, and to provide them with better medical support and advice.
Death certification is, of course, the basis of the system on which the coroners service operates. It is important to go into that in detail.
I am sorry to interrupt the Minister’s flow, and I do not know if he is coming back to the coroners system, but can he give some idea of the timetable for those reforms, because, as he knows, the Government’s initial draft Bill, although well motivated—a great deal of work went into it—did not meet with wholesale approval, so to speak, when it was scrutinised? It is not clear when that Bill is coming back into what is, I accept, a crowded Government legislative programme. If he can provide some information about Government thinking, it would be useful.
I appreciate the hon. Gentleman’s frustration, perhaps, and the need to make progress. We all feel that. Obviously, I cannot pre-empt future Government decisions on the future legislative programme, but I hope that he accepts that in publishing the draft Bill, we showed good faith in consulting on these important matters. Indeed, we listened to the Select Committee on Constitutional Affairs, which commented in detail on the draft Bill.
In November 2006, the Government responded to the Committee’s report, which was published before that.
I thank the hon. Gentleman for that.
The Committee talked about the importance of the system of death certification, and, because of the interrelationship between the coroners system and that for death certification, to which recommendations 5 and 6 of the report apply, asked the Government to come back to it. Again—I hope that this shows to the hon. Member for Oxford, West and Abingdon that the Government have listened to those concerns—I have taken a personal interest, partly owing to the promptings of my hon. Friend the Member for Stalybridge and Hyde, but more generally because the system is incomplete, in my view, without reform in the system for death certification. I hope that when any Bill for reforming the coroners’ service is introduced, the hon. Gentleman will look at it in tandem with proposals soon to be published for arrangements to improve death certification.
The Shipman inquiry found that existing arrangements for scrutinising death certificates were confusing and inadequate. The main problems are that arrangements are different for burials and cremations, with very little oversight at all for burials; scrutiny in cremation cases is not always sufficiently independent and is not subject to effective quality assurance; and there is no systematic analysis for local clinical governance purposes of the information on death certificates. As Lady Justice Dame Janet Smith pointed out, the system relies heavily on the honesty of the certifying doctor and she felt, partly for that reason, that the system was inadequate. She pointed out also that the doctors involved do not get full access to the medical records so that they can make a careful and detailed judgment, and that it must be integrated with clinical governance arrangements.
As I said, I have looked in detail at that whole area on the prompting of my hon. Friend and others. Parliamentary colleagues will know that this issue has a history, in recent times and before. I refer hon. Members to chapter three of Dame Janet’s third report where she talks in detail about the origins of the existing cremation certification system. In particular, however, she focuses on the more recent attempts to reform that system, beginning essentially with the report of the Brodrick committee in September 1971, which was a major change. It was set up in March 1965 following the British Medical Association paper “Deaths in the Community”, which was published in 1964. In particular, the committee dealt with the suggestion that homicides were passing undetected through the existing certification system. That suggestion was based on the book “The Detection of Secret Homicide” by Dr. John Havard, who was, at that time, assistant secretary of the BMA, and played a prominent part in its dealings with the Home Office over a period of several decades.
It is important for us to remember the history. Dame Janet’s report deals with that history from the publication of the Brodrick committee report, which recommended a fairly detailed overhaul of the system. In paragraph 3.82 of her report, she states:
“Progress towards implementation may depend upon a willingness to take a definite policy decision, regardless of objection from some quarters.”
She says that because she details at length in the following paragraphs the extraordinary exchanges of views between and within Departments, and how eventually they came to a halt in the 1980s. It is a salutary lesson on how, in considering the detail, we sometimes lose the bigger picture. Since the Brodrick committee’s recommendations in 1971, the system has gone unchanged and still dates from the origins of the cremation system in the early 1900s.
In the final paragraph of the third report, Dame Janet concludes:
“As it happens, I do not think that implementation would have prevented the Shipman tragedy. But, in many respects, the systems would have been improved. Today, the systems do not meet the needs of society. There is a groundswell of opinion in favour of change. It is to be hoped that the proposals of the Coroners Review and of this Inquiry do not, as did those of Brodrick, end in stalemate.”
That is a salutary lesson to all of us. Dare I say it, in our recent deliberations on those issues, we have begun to see the mirroring of some of what happened in the 1970s and 1980s. It is difficult to cut through the different perspectives held by different Departments and interests. However, it requires a very definite political decision to reform the system, which I believe is what we now have, following the promptings of my hon. Friend.
I do not want to intrude on the private grief of Departments trying to resolve these matters between themselves, but I have a question. I am not clear about the extent to which some aspects of reform, such as the establishment of medical examiners in primary care trusts, which clearly the Minister and his colleagues favour, can make progress, notwithstanding the fact that Ministers are waiting for the point at which they can introduce legislation. Does the Minister share that view? I imagine that he might. Introducing legislation to reform the regulation of health care professionals alongside reform of death certification and the coroner system would be desirable. Given the current situation, the regulation of health care professions is not something that need be delayed very long beyond the next Session. It feels as though we should have a timetable in mind.
The hon. Gentleman will accept that these matters are extremely complex and of huge import for everybody—for the whole of society. I hope—speaking openly, for once—that we might have a Bill at the end of this process. It would be wrong to call it the Shipman Bill, but it would be the Bill—
It would be the Bill or the two Bills that deal with these matters. I hope that they would be dealt with either in one Bill or in more than one concurrently, so that we could consider them in the round, deal with them from a parliamentary point of view and achieve parliamentary consensus on them. There are different timetables on how quickly that consensus can be gained. The package of proposals that we introduced on professional regulation achieved a measure of consensus earlier this year. I am sure that there are different views on elements of the package, which I may touch on. We are now working through a detailed package relating to death certification.
To give the hon. Gentleman some reassurance, my right hon. Friend the Prime Minister, at my request, made a definite decision in the early part of this year that we should reform death certification and that there should be a unified system covering both burials and cremations, with scrutiny by an independent medical examiner linked to the local clinical governance team in the PCT. That was a definite decision of the Government and, for as long as I hold this job—which, who knows, may be only a few days—I will work to ensure that progress is made on that. However, I believe that progress will now be made, because there is growing consensus about how we can take the proposals forward.
A detailed discussion paper will be introduced soon in a consultation paper. That is at a fairly advanced stage of preparation. I hope that it could lead to legislation —if there is broad agreement about the proposals—at the same time as measures dealing with professional regulation.
I hear what the Minister says and I am grateful to him in so far as he is giving us an understanding of Government thinking, but he did refer to something that might be called the Shipman Bill. May I ask him to reflect on that? There are good reasons why Government legislation should not be too closely linked to a particular tragedy. The danger is that anyone who, for good reason, seeks to oppose any of the measures would have to face the impression being given, perhaps by the media or political opponents, that they are unsympathetic to it. With the Bill that became the Human Tissue Act 2004, which might have been called the Alder Hey hospital Bill, there was a danger that someone expressing real concerns about over-regulation would be perceived as displaying insensitivity or a lack of understanding of what had happened at Alder Hey, which certainly for my part was not the case and was not the case with the Royal College of Pathologists either.
I take the point made by the hon. Member for Oxford, West and Abingdon. It was, perhaps, inadvisable of me to suggest that that label could be applied to the Bill. I was seeking to make a point about the breadth and depth of the reports from Dame Janet Smith’s inquiry and that we are also dealing with the recommendations of other inquiries relating to very serious professional misconduct. I simply wanted to say that it is desirable, in my view, to introduce a package of legislation at the same time, so that the matters could be considered in the round, because that would be helpful for all concerned.
The hon. Member for South Cambridgeshire mentioned the private grief of Departments. That may be the case, but he should read the third chapter of Dame Janet Smith’s third report, to which I referred, because colleagues of his who are still in this place were engaged very deeply in the relevant matters. I am not making a party political point, by the way. It is simply that there is a salutary lesson in that chapter for Governments generally about how such matters can be resolved. They ran aground in the 1980s for precisely the reasons that are set out. I hope that when we finally put the proposals before the House, we do not allow that to happen again.
The Government’s action programme for strengthening the safeguards on controlled drugs was published in December 2004, and action is nearing completion. The fourth report of the Shipman inquiry considered how Shipman could have amassed such a lethal armoury of diamorphine, and the recommendations are intended to deal with that very point. I shall set out the key elements of the programme which have been introduced. First, the new governance arrangements introduced in the Health Act 2006 build on existing NHS clinical governance processes by requiring all health organisations to appoint an “accountable officer” with specific responsibility for controlled drugs to share information and to collaborate in action needed to protect the public.
The second key element is restrictions on prescribing controlled drugs, placing on all health care professionals a clear requirement to prescribe only within their professional competence. The third element is strengthening the audit trail for controlled drugs, for instance by capturing information on the private prescribing of controlled drugs and developing and implementing an audit trail for controlled drugs requisitioned for internal use by GP practices.
The fourth element is improving information for patients on the therapeutic uses and special status of controlled drugs. Fifthly, we are working closely with professional bodies to improve the education of health professionals in the appropriate use of controlled drugs and in the special precautions needed.
On the issues raised by the Shipman inquiry’s fifth report and the reports of the Ayling, Neale and Kerr/ Haslam inquiries, the crucial first step is the initial identification of causes for concern. In Shipman’s case, despite the ingenuity with which he attempted to cover his tracks, potential clues were missed. In the case of Clifford Ayling, that was compounded by the failure of different NHS organisations to combine the information that each held.
Health care organisations need to work with information of two types. The first is routine indicators of clinical processes and outcomes, which, taken together, give a broad view of the clinical performance of clinical teams and individual clinicians. The second is information derived from complaints from patients and carers and from concerns raised by other professionals or organisations. Clearly, information of that type needs to be used sensitively and with appropriate safeguards to ensure that the reputations of health care professionals are not unfairly impugned. The Government will work with professional, NHS and patient organisations to develop further the use of routine quality indicators and to agree guidance on the appropriate use of softer forms of intelligence, in particular on the safeguards that should apply to the sharing of such information between organisations.
Complaints and concerns are potentially a vital source of information that may indicate poor professional performance or abuse. However, patients, carers and professional colleagues need clear signposting so that they know where to register their concerns. They may need support and help in articulating concerns, and reassurance that they will be taken seriously. In particular, they will want reassurance from those responsible, including senior managers, that action will be taken to ensure that there will be no recurrence of the incidents that caused concerns and that organisations take on board the concerns as part of their ongoing service improvement.
This week, the Government launched a consultation proposing comprehensive reform of the complaints system for health and social care. Key features relevant to the debate are proposals for a right for patients with complaints against a GP to go directly to the PCT, rather than to the practice itself; closer collaboration between organisations receiving complaints to ensure that complaints are speedily routed, where necessary, to the most appropriate body; developing good practice on keeping complainants informed about the progress of their complaint; placing a responsibility on PCTs to maintain an overview of complaints against GPs; and working with the NHS to build capacity and skills for investigating more serious allegations.
I have always believed that the NHS needs to adopt a more open culture in handling complaints from the public. Too often in the past, the tendency has been to allow the shutters to come down and to push complainants towards the legal process. There needs to be a learning culture at the very bottom of the NHS so that complaints are received and acted on. In the vast majority of cases, patients’ motivation in bringing complaints, including to Members of Parliament, is to prevent what happened to them from happening to somebody else; it is not to seek financial redress or to take the NHS to the cleaners. It is important that the NHS understands that and works with it.
Where local information indicates a potential issue over professional performance, health organisations have a responsibility to take whatever action is needed to protect patients and, where possible, support and help the professional to get their career back on track. Experience shows that intervening early—before problems have become ingrained—is far more likely to be effective, and that is a major theme of the White Paper on professional regulation, “Trust, Assurance and Safety”, which we published in February.
In recent years, the Department has agreed new arrangements with the professions to clarify and strengthen such processes in primary and secondary care. The new arrangements incorporate important safeguards, including the separation of the investigation of concerns from the formal decision-making process. Despite those reforms, the Shipman inquiry considered that primary care trusts did not have adequate powers to protect patients in the case of poor performance by GPs. The Government agree and will this year carry out a review of the operation of the performers list system, relating it to the proposals for reform of professional regulation, to which I will now turn.
The Shipman inquiry’s fifth report was critical of many aspects of the regulation of the medical profession, particularly the lack of clear standards for judging fitness to practise, the lack of demonstrable independence in the adjudication of the most serious fitness-to-practise cases and the way in which earlier proposals for the revalidation of doctors had been implemented.
Given the radical and, in places, controversial nature of the inquiry’s recommendations on those points, the Government decided in early 2005 to set up a review of medical regulation under the chief medical officer and a separate review of non-medical regulation under the then NHS director of human resources, Andrew Foster. Those reviews reported in July 2006, and, following a period of consultation, our final proposals were published in the White Paper on professional regulation, which I mentioned.
Our proposals include inviting the professional regulatory bodies and specialist organisations such as the royal medical colleges to develop clear standards to determine whether health professionals remain fit to practise. We also propose improving co-ordination between local NHS employers and national regulators—in the case of doctors, through a network of General Medical Council affiliates. That system was proposed by the chief medical officer to close what he termed the regulatory gap—a situation in which a professional’s behaviour may be causing local people concern, but there is insufficient evidence to take a complaint all the way to the national regulator.
I am prompted to intervene by the Minister’s remark about the relationship between professional regulation and clinical governance among NHS employers. If I recall correctly—I do not have the quotation to hand—Dame Janet Smith was clear about the desirability of ensuring that we did not rely excessively on NHS clinical governance structures where those who were providing the medical services were not necessarily in NHS employment structures. Does the Minister agree that clinical governance is of great importance not only for the NHS but for health care providers that happen not to be NHS organisations? We should create a structure that is robust in both those circumstances.
I agree entirely that that is what we need to create. The systems that we are describing should transcend all organisational boundaries and apply right across the piece. Different organisations will seek to achieve the same ends in different ways, but the principles should transcend organisational boundaries and apply equally to the private sector and the NHS. In that respect, the GMC affiliates could play quite an interesting role. Originally, it was proposed that that should happen at trust or local community level, but following discussion with various stakeholders, the regional or sub-regional level would seem to be the right one. We therefore want to take the proposals forward carefully to ensure that they do what we hope they will, and I hope that they will achieve some of the aims that the hon. Gentleman has alluded to.
The Government’s proposals also include setting up an independent body to adjudicate the final stages of the fitness-to-practise process. That will initially apply to doctors, but the other regulatory bodies will be invited to establish a similar separation between their adjudication and other functions. In addition, we propose to strengthen the current system of appraisal for doctors so that it can become an adequate basis on which to carry out the periodic revalidation of their generic fitness to practise, with separate arrangements for specialist recertification overseen by the appropriate royal medical colleges. Finally, for other professions, we propose that revalidation should be carried out by employers or other appropriate means.
When we leave this issue, as I told the hon. Gentleman, we need to put in place a system that will stand the test of time and which constitutes a generational settlement on these issues. In this day and age, it is not enough to tell the public that we have done the job; the system that we put in place must be seen to be transparent and to uphold the public interest. That is why there should be parity between the professional and lay appointees to each of the regulators.
We can, however, deal with that issue in the parliamentary debate that follows our proposals. Although it is important that we hear all the views on the issue, it would surprise me if parliamentarians of all parties did not agree that upholding, and being seen to uphold, the public interest was crucial; indeed, it is in the interests of professional self-regulation, because it will strengthen the image of self-regulation in the mind of the public. We should remember that we are not talking about Government regulation, because those appointed to the regulatory bodies would all be independent.
I have spoken for a considerable time, but I appreciate that I have given only a superficial summary of the action programme that the Government have set in hand to address the many thoughtful recommendations of the Shipman, Ayling, Neale and Kerr/Haslam inquiries. Some of those actions are already in hand, and we are working closely with regulatory bodies and patient, NHS and professional groups to implement the remainder.
Unfortunately, we can never give an absolute assurance regarding criminal behaviour of the kind perpetrated by a Shipman. However, the action that we are setting in hand will make it highly unlikely that any future criminal could go on for as long without being detected. We can achieve that without disrupting the excellent care that the vast majority of our health professionals give their patients day in, day out.
Let me conclude by thanking those hon. Members who are here for the debate for their interest in the issue. I cannot stress enough how important the determination of those hon. Members who represent constituencies in which Harold Shipman practised for so many years has been in ensuring that these matters are adequately concluded. The Government will eventually bring the issue to the right conclusion so that my hon. Friends’ constituents can—this is very important—draw this awful chapter in the history of their towns to a close, and that applies particularly to Hyde. We have some way to go yet, but we are making clear progress towards our goal.
I thank the Minister for that thoughtful presentation; before I call the hon. Member for Calder Valley (Chris McCafferty), may I explain for the record and for the benefit of any of his constituents who may be in the Public Gallery that, although the hon. Member for Stalybridge and Hyde (James Purnell) is present for the debate as a constituency MP, under a convention of the House, because he also happens to be a Minister, he is restricted as to his participation in the debate.
I am grateful for the opportunity to speak on behalf of my constituents in Calder Valley and those of the Minister for Pensions Reform, my hon. Friend the Member for Stalybridge and Hyde (James Purnell), who, as you pointed out, Mr. Hancock, is in the Chamber but may not speak because of his ministerial responsibilities.
I thank the Minister for outlining the proposals which, I stress, are historic and wide ranging. He is correct that we would not have reached the stage that we are now at without huge political will. The proposals will set out for the first time a national framework for the work of coroners, who will become full-time professionals, with a chief coroner heading the service. The proposals will empower bereaved families by giving them, for the first time, a proper legal standing. They will have the right to a second opinion, and the ability to challenge coroners’ rulings. Those changes will be welcomed by families who have had a relative die a violent or sudden death, but especially by families who were patients of Harold Shipman, such as my constituents in Todmorden in the Calder Valley and, of course, many constituents of my hon. Friend the Member for Stalybridge and Hyde. We should never forget the extent of the tragedy, especially for the hundreds of families in Hyde and Tameside who lost loved ones.
The extent and magnitude of Harold Shipman’s crimes were such that they were hard to encompass, unless one was personally involved and touched by the tragedy. Of course, by killing himself and going to his grave, Harold Shipman robbed all those families of the one thing that he could have given them: the truth—the right to know what happened and perhaps to help to put an end to what for most of the people concerned is a continuing horror story. The Government can help by making sure that the lessons of what happened in the Harold Shipman case are learned. That case gives rise to today’s debate and is probably the case of the greatest magnitude, but there are other instances in which GPs and medical and health professionals have not only gone beyond the bounds of their duty, but have behaved in a wholly inappropriate way, in relation to the life and death of their patients. The reforms are definitely necessary.
I hope that the reforms will ensure that a tragedy like the Shipman case can never happen again. My hon. Friend has had regular contact with the bereaved families in his constituency, and he has told me that he never ceases to be impressed by their resilience and their commitment to ensuring that reforms are made. They have met Ministers several times and have helped to develop the new proposals. My own constituents in Todmorden believe that Dame Janet Smith has done a remarkable job in very difficult circumstances. Of course, in the case of my constituents the events happened at the beginning of Harold Shipman’s time in practice. It was very difficult for those families when the bodies were exhumed, because the deaths were so long ago that there was little if any medical evidence to be assessed. That did not make things any easier. Families in Hyde have always made their respect for Dame Janet and her team, and their commitment to the implementation of her findings, very clear. I want to express my own gratitude for the dedication that all Ministers concerned have shown to introducing good and relevant legislation, for the spirit in which the Government have approached all the reforms, and for today’s debate.
My biggest concern, which is central to the debate, is the proposed reform of the coroners system by the draft Coroners Bill, and the reform of the regulation of the medical profession initiated by the chief medical officer. It is widely known that Dame Janet has concerns about some of the proposals in the Bill, particularly the way in which death certificates are to be checked. I know that the Minister has examined the proposals carefully and that, as has already been said, it is intended that there will now be a single process for both cremation and burial certificates, operated through local primary care trusts. That is a very welcome development.
There has always been widespread concern among patients—certainly among my constituents in Todmorden— about the fact that Shipman could write any name he fancied on medical certificates and it would not make a scrap of difference; they would still be accepted, and not detected as fraudulent. I should be grateful if my hon. Friend assured me that the new system will deal with those concerns. In addition—I know that other hon. Members have already asked about this—will he try to clarify the time scale for the introduction of the reforms? I am particularly interested to know whether the reforms will be extraterritorial. Will the family of someone who has died abroad, perhaps in suspicious circumstances, be able to contribute to the coroner’s investigation or challenge the verdict? Will the Government implement the suggestion that a simple information leaflet should be provided to bereaved families, setting out their rights? When does my hon. Friend expect the draft Bill to be presented to Parliament?
Another key question, which I think all the families have asked, particularly in Todmorden, given that Harold Shipman practised there for a period before going to Hyde, is why the medical system could not identify him earlier. When he practised in Todmorden he was found to be abusing drugs. That was brought to light by an eagle-eyed medical practitioner who was his colleague. Shipman was subsequently investigated and suspended from the Todmorden medical practice, and convicted in the Halifax court of misuse of drugs and prescription fraud. However, he was then able to go down the road and carry on practising in Hyde, with no monitoring at all. In both Todmorden and Hyde, his prescription and death rates were off the Richter scale, but he was never detected.
How does the Minister think the new system will ensure that that cannot happen again? Does he have confidence that we are now reforming the system overall? Are all the pieces of the jigsaw falling into place? Joined-up thinking and the interconnectedness of the reforms are important considerations, which, as the Minister pointed out, have caused some delays in implementation—and he is right that the reforms need to stand the test of time. I expect he understands the frustration of Members of Parliament whose constituents have been affected by Harold Shipman, and of the general public, who feel great anxiety about whether they will be protected in the future. Only a very small minority of medical practitioners abuse their powers, and the vast majority of GPs and health professionals are in that business because they want to help people, but the affair has left a very bad taste in many people’s mouths, as well as a lot of fear. The general public are anxious for the reforms to be implemented. Given all that I have said, and given our understanding of the need for interconnectedness, joined-up thinking and transparency, and the fact that it is important to get the reforms right for the 21st century, perhaps the Minister will tell us when he expects the reforms to be fully and finally implemented.
It is a privilege to follow my hon. Friend the Member for Calder Valley (Chris McCafferty). She and the Minister for Pensions Reform, my hon. Friend the Member for Stalybridge and Hyde (James Purnell), have been at the forefront of the campaign for justice for Dr. Harold Shipman’s victims. I echo all of the views that she expressed.
As one of the three Members of Parliament for the metropolitan borough of Tameside, I am grateful to be allowed to contribute briefly to the debate. I know that my hon. Friend the Member for Stalybridge and Hyde would have liked to contribute as well, because the Shipman tragedy so directly affected his constituency, as it did mine, to a much smaller extent, but, as has been explained, he is not able to take part due to ministerial protocol.
I welcome the Minister’s thoughtful comments, the details in the various reports before us and the work of the Select Committee on Constitutional Affairs. We should never forget the extent of the tragedy, in which hundreds of families in Tameside lost their loved ones. The extent of Dr. Shipman’s crimes are such that it is hard for anyone who was not involved or from the affected communities to understand just how deep the wounds are and, in some cases, will be for some time. Despite that, the communities of Tameside, particularly the town of Hyde and the parts of Denton that were covered by Dr. Shipman’s surgery, have not let him win. The borough has pulled together to make sure that we are defined not by that tragedy, but by our successes. Tameside officially has the best council in the north-west of England, and the area is growing rapidly and becoming increasingly prosperous as a result of massive inward investment. We should focus on those positives in Hyde, Denton and Tameside.
I strongly agree with my hon. Friend the Member for Calder Valley that by ending his life, Harold Shipman took the one thing that he could and should have given the affected families: access to the truth and the full story, and information about the full implications of his actions. What the Government can do, however, is ensure that such a situation can never happen again. I was reassured, as, I am sure, were my hon. Friends, by the Minister’s positive and forward-looking opening remarks.
I know that my hon. Friend for Stalybridge and Hyde has had regular contact with the families, and that they have met Ministers several times. The Minister of State, Ministry of Justice, my right hon. and learned Friend the Member for Camberwell and Peckham (Ms Harman), and the Under-Secretary of State for Northern Ireland, my hon. Friend the Member for Wythenshawe and Sale, East (Paul Goggins), both visited Tameside in their official capacities to discuss the proposals while—this is the important point—they were being developed.
The families in Tameside welcomed the inquiry of Lady Justice Janet Smith and her team, and they are as committed as we all are to ensuring that the Government implement the inquiry’s findings. The onus is on us to ensure that that happens, so I welcome the spirit in which the Government have approached this issue and I reiterate that the Minister’s remarks were very positive. It is also positive that we have been allowed to air our views on this matter again in the debate.
Reform of the coroners system and the need for tighter regulation of the medical profession are central issues. In its inquiry, the Select Committee thoroughly examined many issues regarding the reform of the coroners system, and its report and findings are to be welcomed, taken alongside what the Government have been doing. However, I wish to raise a small number of issues with the Minister, which follow my hon. Friend’s comments almost directly.
The first issue that I want to address is death certification. The Select Committee report rightly highlighted concerns about death certification and the Government’s approach to it. Lady Justice Janet Smith also highlighted a number of concerns about the proposals for changes to the coroners system, particularly how death certificates will be checked and monitored. The Minister has considered the proposals, and he told us that a single process will be operated through local primary care trusts. I hope that that means that there will be a single process for both cremation and burial certificates.
Patients have always been concerned that Dr. Shipman could have written almost anything on certificates—that he could have written “Donald Duck” or “Mickey Mouse” and it would have gone almost unchecked. That is a real worry for the families concerned. Will the Minister reassure us that the changes to the system that he proposes will address that worry, because people are very concerned that some of those practices went unnoticed for so long? He has assured us that a Bill will be introduced when there is parliamentary time. I understand the pressures that exist and that he might not be able to give firm commitments, but it is important, certainly for the families involved, that there is some degree of certainty about when the changes will be introduced. I understand that he cannot give absolute time scales, because of the programming of future legislation, but what are the general time scales in which we can expect some of the measures to be introduced?
The families also made a key point about medical regulation. I agree with my hon. Friend the Member for Calder Valley that the system should have flagged up what Dr. Shipman was doing a long time before it did. Of course, hindsight is a wonderful thing, but we know that he had a record of drug use and that he had been investigated and suspended in his previous post in her constituency. His death and prescription rates were considerably higher than they should have been, and should therefore have been detected, but they were not, so there are those issues to address. How will the system work differently to ensure that something similar could not happen? That is an important point.
On a more general level, the Select Committee emphasised the importance of medical regulation and scrutiny. Is the Minister confident that we are reforming the overall system, particularly in relation to medical regulation? That is crucial and is at the root of the problem.
Finally, it is worth recognising that the draft Coroners Bill was the first to be scrutinised in Westminster by families with recent experience of the inquest system. That is why it is so crucial that we get things right and why the Select Committee was absolutely right to highlight further areas in which work is required. The Minister has gone some way towards clarifying the Government’s intentions. Getting things right will not erase the pain brought about by Dr. Shipman’s activities, but it will make it more difficult for a similar episode to occur. That will offer some comfort and a sense of positive closure to the families concerned. I thank the Minister for his positive and thoughtful approach so far, and I am sure that my hon. Friend the Member for Stalybridge and Hyde and the communities that we represent look forward to hearing his response.
I was shocked that you had even made a mistake, Mr. Hancock, such is your reputation for accuracy. I certainly did not take it personally. I hope that you do not mind me not taking it personally if you misaddress me, because I know that you are a perfectionist in all matters.
The Liberal Democrats welcome the debate and the opportunity to discuss these issues with the Minister in this sort of atmosphere. Several statements on the subject have been made in the House, but there is a limited scope for inquiry with statements. It has been extremely helpful to have a clear exposition of the background and the proposals from the Minister, and to hear from the hon. Members for Calder Valley (Chris McCafferty) and for Denton and Reddish (Andrew Gwynne). They spoke very well and with clarity and sensitivity on behalf of their constituents, and they showed how much they have thought about this matter as a result of the representations made to them and because of their need to represent their constituents. They have added value to the debate and to the discussion of the matter in this House. I understand that everyone involved could speak for a long time, so I was grateful to hear them summarise the remaining questions that they have for the Minister and the points that they wanted to make.
Given that there is an opportunity for a direct exchange, it would not be appropriate for me to comment in detail on what the hon. Members for Calder Valley and for Denton and Reddish said. I merely say that, for the most part, I agreed with their points and the importance that they attached to some of them. I want to raise a couple of points in response on which I do not completely share their perspective. I hope that they will allow me the opportunity to do so, even though I recognise the importance, relevance and accuracy of almost everything that they said.
I should like to put on the record my condolences to the families of the victims of Harold Shipman, the biggest mass murderer in British history. It is appropriate to say that now, because the pain never goes. I imagine that every day, relatives of those whose lives were lost are reminded of what happened, the fact that people are no longer with us and that the manner of the deaths was evil, rather than natural, although many of the victims were in old age. I cannot imagine what it must feel like, particularly given the media coverage that followed and the references to that man.
I am a doctor. I qualified in 1991, but have not practised direct clinical medicine since 1994 and have only been called on to use my medical training on an occasional basis since. I am still on the medical register, so I ought to declare an interest in that I am potentially liable to be referred to the General Medical Council and to be subject to its revalidation procedures, if they ever happen—I hope that they do as soon as possible. I fully anticipate not being able to take part in those because of my lack of recent clinical practice and, at an appropriate point, expect to come off the register.
I am also a member of the BMA’s medical ethics committee, and attend the BMA annual representative meeting as a member from the Oxford division. I do so mainly to discuss medical ethics matters. I shall refer to some of the BMA’s concerns, although I do not agree with them all. In the case of those to which I do refer, I shall be asking questions on the BMA’s behalf, and I shall indicate where my party—not me personally—agrees that there are relevant questions to answer.
A couple of premises need to be stated and some myths need to be abolished. I am interested to know the Minister’s view on a couple of important themes that run through what I am about to say. Does he accept the principle that doctors are more likely to be tougher on the underperformance, poor performance or criminal behaviour of other doctors than patients and the public? A strong argument can be made that doctors attach such significance to their responsibilities and greatly recognise the privilege that they have in practising medicine with the consent of their patients—they are able to do things to patients that people would not be able to do without the qualification—that they have a much lower level of tolerance for medical misfeasance and malpractice than the average member of the public. That is my experience. When dealing with my casework, I get visibly angry in my surgeries when I hear of allegations that appear to have some substance of poor practice or, especially, of attempts by management—this usually involves them but it can include some doctors—to cover up or unreasonably seek to excuse the behaviour of their close colleagues and other colleagues.
My general point is that the profession has a huge vested interest in having zero tolerance for doctors who behave in bad faith in a way that damages patients and, in doing so, damages the reputation of the profession. I invite the Minister to agree with that view, because it goes to the question of whether general professional self-regulation, rather than doctors judging doctors whom they know, is in any way weaker than the alternative that the Government appear to be proposing of Government regulation. They also have vested interests.
It is important that I say that I do not agree with the point that Government regulation is being proposed. We are proposing to maintain the system of professional self-regulation. It is as a result of the counsel of the regulators that we are proposing parity between the professional and lay interests. The hon. Gentleman will know that that is very different from the panels that hear fitness-to-practise inquiries. The GMC proposed bringing forward the parity proposal, which is as good as we can get in terms of a system of independent self-regulation where we enshrine and are clear about the public interest.
I accept what the Minister says. There is a debate to be had about terminology and I did not mean to caricature the Government’s position, but the feeling exists that the alternative to professional self-regulation is some form of regulation by those appointed. One can have an independent appointments system, but there is no doubt that if a number of council members are elected by their profession to uphold its integrity and proper functioning, that will, by degree, represent greater professional self-regulation than a system of appointed medical members combined with an equal number of appointed lay members.
I hope that the Minister will accept that there has been a change or, at least, that a change has been proposed, in terms of moving away from professional self-regulation. When the measures come forward in statute, we will take a view on whether we think that the case has been made. A case needs to be made, because there is a danger that non-members of the medical profession may well take a more lenient view—in my experience, that argument can be made. If anything, we must ensure that there is less of a willingness to believe that the doctor is right. In the doctor-patient relationship, too much respect is sometimes shown by the patient for the doctor. The relationship needs to be more one of equals.
I was grateful that the Minister responded to my first point. My second general concern is the most important one regarding regulation and the health profession. Even with the best audit trails and the most empowered patients in the world, episodes of poor or impaired practice, malfeasance or malpractice are much more likely to be identified by doctors themselves or their close colleagues. I am sure that the best way of getting the most reports of poor or bad practice by doctors is by relying on people on the inside who can see what is going on and are prepared to report it.
Therefore, a test of any new regulatory proposals is whether doctors will be prepared to report their colleagues. If doctors do not think that their colleagues will get a fair hearing or if they think that their colleagues will be abused in the media, as they have been, with little protection and no ability to answer back on the basis of patient confidentiality or legal process, that will be a huge deterrent to people reporting their colleagues.
The treatment of doctors such as Professor Southall and Roy Meadow by the media, which continue to report the Meadow case as if he had been struck off or found guilty of serious professional misconduct, is extremely damaging not just to the individual concerned, but to doctors. Doctors say that if this is the way the GMC behaves, by getting it so wrong, as the appeal found, or if this is the way that the media behaves, by, in the case of Professor Meadow, hounding and decrying a man who has made a significant contribution to child protection, there will be a diminution in the ability to pick up real cases of poor practice, because doctors will not report themselves or their colleagues. It is a difficult problem, and I want the Minister to accept that it is real. Individual doctors—not the profession generally—must know that they not only have a duty to report, but that it must be unabridged in any way by a fear of lack of due process.
It is appropriate to speak about the standard of proof. Recommendation 81 of the Shipman inquiry’s fifth report states:
“The GMC should reopen its debate about the standard of proof to be applied by”
fitness to practise
“panels. It should consider introducing a rule that the civil standard of proof should apply unless the doctor faces an allegation of misconduct which also amounts to a serious criminal offence”—
I emphasise “serious criminal offence”. It goes on to say:
“In that limited class of case, the criminal standard of proof may well be appropriate.”
The Government’s response was:
“The Government has decided that all health professions regulators should follow the civil standard of proof. It should be flexibly applied to take into account the circumstances and gravity of individual cases.”
The civil standard of proof is not the balance of probabilities, but a sliding scale that can go beyond reasonable doubt in a criminal case.
There is a misunderstanding in the recommendation that only when the charge is of a serious criminal offence should the criminal standard of proof apply. I think—I cannot be certain because the Joint Committee on Human Rights, on which I sit, has not looked into this, but no doubt it will—that there is a real risk of non-compliance with the Human Rights Act 1998 if something equivalent to a criminal charge is to be tested on less than the criminal standard of proof. That does not mean that the wording is not right, because the civil standard of proof can come up to that level, but it is a matter of concern. If we want to have the profession’s confidence without the perception of a witch hunt, we must deal with that, and there is no doubt that it would have interfered with any GMC approach to cases such as Shipman or anything close to it.
I intend to speak about this matter, but I want to be clear about the point that the hon. Gentleman is making. He was talking about circumstances that amount to the equivalent of a serious criminal charge, but the essence, as I understand it, of the application of the criminal standard of proof beyond a reasonable doubt is not simply that a criminal charge has been brought but that it entails criminal penalties. To put it another way, there is a difference of substance between, on the one hand, the risk of being deprived of one’s livelihood as a result of adjudication and, on the other, the risk of being deprived of one’s liberty by a criminal court. That distinction must be retained.
The hon. Gentleman makes a fair point, but there are two ways of looking at the matter. Loss of livelihood, particularly for someone who has spent years training, should probably not apply, but that would happen if someone were struck off on the balance of probabilities. That is not proportionate or right, and I would be interested to know the Minister’s view. I do not understand why or on what basis the higher standard of proof should apply to a serious criminal offence, and I should like to know who should define what is serious on that scale, even if my point is not accepted that the loss of livelihood is such a serious penalty that it would be unreasonable to apply it to cases determined on the balance of probabilities?
I am not competent to explain what “serious” means in this context, so I shall not even attempt to do so. However, the hon. Gentleman has slightly slipped back into saying that it is a case either of “beyond reasonable doubt” or “on the balance of probabilities”. The whole point is that deprivation of livelihood, particularly in the case of a doctor, is a very serious penalty, and I do not dispute that for a moment. However, on adjudication by the GMC, the penalties are not confined to being struck off the register. Depending on the proof of misconduct and the severity of the misconduct, various penalties are possible. That is the whole point of a sliding standard.
I understand that, and I think the hon. Gentleman is making the point that it is perhaps the severity of the penalty rather than the severity of the charge that dictates the matter. However, the inquiry’s recommendations do not mention the severity of the penalty, so perhaps it is an unfortunate misunderstanding on my part, or ambiguity in some of the language in the report and in the Government’s response.
Could I inject a note of caution, as it is important not to lose sight of the bigger picture? The proposal was recommended by both Dame Janet Smith and the chief medical officer to address the hesitancy or reluctance to bring cases because of the difficulty of proving them. My advice from the Department is that there is clear legal authority so that in cases of sufficient gravity—that might be a matter for debate or clarification—the flexibly applied civil standard is virtually indistinguishable from the criminal standard. I also point out that six of the health regulatory bodies already use the civil standard of proof, including the General Dental Council.
I am grateful for the Minister’s explanation. I want to reinforce my point about the motivation for the Minister’s proposed changes, many of which we support. The fact is that public trust of doctors is still high, so it is important not to have the wrong motive. It is better to make policies to protect patients and to improve the practice of medicine, rather than to require doctors to restore a loss of public confidence, because the latter would mean that we, as parliamentarians and legislators, were passing our responsibilities on to the media, who create—sometimes rightly, sometimes wrongly—concerns and worries, and we would be legislating on the basis of opinion polls, which is something that is notoriously difficult.
I am reassured by much of what the Minister said: there is good evidence that each proposal will improve the safety of patients and reduce the risk of something like Shipman ever happening again, and the measure is not, even in part, an exercise to restore an alleged loss of trust in the medical profession. If it were, we might overreact or react wrongly, and that would not be of service to the public or the profession.
I want to put on record my admiration for Dame Janet Smith’s work in her detailed reports. She went a long way in the scope of her recommendations, which show a huge amount of work and application. She has made sure that public policy-makers are not in a position to forget the views that she expressed. That is laudable, but as parliamentarians we must ensure that we do not—we all risk doing this, and I may have done so myself—simply make up our minds on the basis of the thinking of the person who ran the inquiry, whether it is the Alder Hey or Bristol inquiry. We have a responsibility to look at the generalities, perhaps even more so than individuals appointed to do a particular job. They are experts, and we should value their views and recommendations, but we should not abrogate or delegate our responsibilities to them.
The hon. Member for Calder Valley said that the general public are keen to see the reforms implemented. I would agree if she meant that they are keen for reforms to be implemented to ensure that the risk is reduced, but I am not entirely sure that the public are aware of the details of the specific reforms. I agree that there is an appetite to ensure that lessons are learned and that processes are put in place. I want to reinforce a point I made earlier, because the Minister misunderstood it. I did not complain about his use of the term, “Shipman Bill”, which he immediately corrected and explained; I understand entirely his correction. However, if the Government propose something in legislation and refer to the Shipman case, we should be careful to avoid a situation in which people who have serious concerns about the legislation are regarded as unsympathetic or as having failed to learn the lessons. There is a genuine difference of opinion. During the passage of the Human Tissue Bill after the Alder Hey case, one sometimes formed the impression that if one really cared about what happened at Alder Hey hospital, one had to show it by backing measures that were quite restrictive. That situation was not right, and it may have been counter-productive in the end.
I do not want to dwell on the question of the coroner system, because we debated it in the Chamber some time ago. My right hon. Friend the Member for Berwick-upon-Tweed (Mr. Beith), who chairs the Select Committee on Constitutional Affairs, expressed his concerns very well, and other people, including the Minister, have commented on the need to make more progress. I accept that the Minister cannot give a clearer timetable, but there are serious concerns about the support for coroners’ offices, not least in my county of Oxfordshire, which has had to deal with a number of cases, and about the need to ensure a uniform and professional standard for the coroner system.
I support the Government’s proposals for death certification, and I want them to be introduced. The medical profession rightly drew attention to the inadequacies of the death certification system years ago. I remember when I was a junior doctor being invited by the bereavement office to sign the cremation form for a patient whom I had not seen recently, although I was the treating doctor, and effectively signing off the judged cause of death in the medical notes, which then went to a part 2 completion. In retrospect, neither my colleagues nor I took the situation seriously. As it was one of the few things for which one received a separate fee, it was laughably known as “ash cash”. In retrospect, it was a disrespectful way of treating the whole exercise, but black humour is fashionable in the medical profession. The main problem was that it was done without any confidence that either signing doctor would pick up any foul play or negligence.
If that applies to cremation forms, where there is a higher level of foul play or negligence, the same should apply to death certificates. There are concerns, as featured in a recent television programme, that it is still difficult for the patient’s relatives to challenge the cause of death on the death certificate, so we must ensure that the process becomes a learning experience for the health profession, and indeed, patients. We must learn lessons, too, about patients who have died from natural causes, as the sad decline in hospital post mortems is deeply damaging to the education and training of current and future health professionals. We have failed to ensure that death certificates are as accurate as possible, if for no other purpose than audit.
The Minister rightly said that clues were missed during the Shipman case, and that information was not adequately combined during the Ayling case. We need a more coherent system of complaint gathering. I find it difficult to blame the GMC for the Shipman case, because it dealt with his drug use in the usual way, which was not to deprive someone of their livelihood indefinitely in the case of drug dependency, but to seek to manage it. If a mass murderer has previously encountered the prison and court systems, it does not mean that the court system is negligent in failing to spot continuing homicides. There is no doubt that the system of medical checks and audit failed Shipman’s victims, and there is no good reason for failing to identify a better audit trail on the use of controlled drugs and the GPs’ death rates. When I say “no good reason”, I accept that the health service has other priorities, but we must ensure that we protect health service auditing. There are so many targets, emergencies and patient needs that sometimes things like auditing, which do not attract bespoke research money, are the poor relation. It is critical to improve medical practice, as well as to pick up on poor practice.
We must ensure that in any procedure that makes complaints easier, we avoid the problem of racial bias, which, for reasons that are not clearly known, sometimes occurs in complaints against doctors. We must ensure that doctors who are the subject of complaints are treated fairly, as I have said. On the issue of complaints metrics, the Minister rightly said that it is important that patients and the public can complain about doctors. However, I am worried that if hospitals or other employers—not individual doctors—are measured on the basis of the number of complaints, we will create perverse incentives. There is a strong argument that, all things being equal, units against which there are more recorded complaints are probably doing a better job by allowing complaints to be made, but one could take a view of the quality of care based only on the number of valid complaints. I should be grateful if the Minister assured me that performance monitoring will not mark hospitals, NHS units or PCTs down on the number of complaints. If anything, a significant number of complaints may represent the good practice of enabling complaints to be made. Without complaints, we would miss a real opportunity.
The Government are right to tackle controlled drugs as they propose. I strongly support their approach, but the Minister knows that patients can be poisoned, and that doctors can poison their patients deliberately or inadvertently, with all sorts of drugs, not just controlled drugs. The lessons that we have learned in controlled drugs cases must apply to other drugs, too, because doctors’ prescribing practice is an area in which there is a great deal of room for improvement. The question is about best care, not just about criminal liability. I have a couple of questions about regulation, which the BMA, too, has raised. It would like to know the details of the timetable and the national advisory group on professional regulation, which has supposedly been set up to advise the Department and the devolved Administrations on the detailed implementation of the proposals.
Does the Minister believe that the proposals for doctors to appeal against adverse findings by the regulator in the new system will be adequate and accessible without too great a legal cost? Another concern is that the appeal process is expensive, and when we are dealing with the health service and the needs of its employees, it is money that might otherwise be spent on health care. We need a system that is not just thorough but efficient. I welcome the Government’s general approach. My concerns about the proposed speed and extent of coroner reform, and the proposed medical regulation, should not be taken as a general criticism either of their approach or, in particular, the Minister’s openness and his ability to engage with the professions, the public and the Opposition on these matters. I look forward to his response.
I join others in thanking the Minister for securing us this opportunity to debate the issues, not least because the way in which he introduced the debate has, apart from anything else, allowed us all to raise some of the issues in interventions, which has been helpful in exposing some of the issues for future resolution, and saved me from having to explain many of the things that I otherwise might have.
I also share the Minister’s appreciation of the contributions that the hon. Members for Stalybridge and Hyde (James Purnell), for Denton and Reddish (Andrew Gwynne) and for Calder Valley (Chris McCafferty) have made in representing their constituents. As constituency Members of Parliament, we can barely comprehend the scale of the distress and grief that Harold Shipman’s evil caused. However, it must be of comfort to the families and the communities that those hon. Members represent that their Members of Parliament have been active in representing them and are here today, ensuring that the issue does not become unfinished business. I entirely accept the point that the Minister made. We must all learn from the past and ensure that they we do not allow the deficiencies of reform in the past to prevent us from taking the necessary steps today.
I am therefore all the more grateful that Ministers tackled the question of controlled drugs in the Health Act 2006, in part 3, which we generally welcomed. There will be the question of what the role of the inspectorate of the Royal Pharmaceutical Society of Great Britain may be in helping to buttress accountable officers and how the two might interact with one another. We do not want any duplication between the two, so it will be helpful to consider that as time goes on, particularly as the RPSGB will, for professional regulatory reasons, be separated from the proposed general pharmaceutical council. That gives even greater confidence that the RPSGB will be a proper vehicle for exercising greater professional scrutiny.
We debated the timetable for coroners reform, so it was a surprise, given the availability of draft legislation, that Ministers did not introduce legislation in this parliamentary Session. That was only a matter of surprise, however. It would be a matter of disappointment, which would be shared throughout the House, were Ministers not able to bring anything forward in the next Session. It is not that every issue is resolved, but with the consensus that exists, I cannot but feel that the coroners system is ready for reform. The basis of that reform must be a greater assurance that investigation of suspicious deaths will take place to uncover wrongdoing. Perhaps most important, we must ensure that the system is not so rigid, for reasons to do with historic legal structures, that it fails to be as sensitive and supportive as it should be to the relatives of those who have died. They must be assured that the issues will be fully investigated.
I do not represent that part of our Front Bench that will be responsible for the structure of coroners reform, so now is not the moment for me to address it. However, I am sure that we shall want to consider carefully the relationship between medical examiners, in the context of the NHS, medical assessors—a recommendation of the Luce review—and coroners, and whether, if we do not take up that recommendation, medical examiners will in practice be able to give coroners the necessary support. I hope that they can.
It must be right that consideration of the process of death certification and coroners reform should proceed alongside one another. I have seen that Ministers wish to embed medical examiners in primary care trusts. I think that that is the right thing to do, as it will put medical examiners in a position where they can link their role into performance management of primary care providers and commissioners. Although the Select Committee on Constitutional Affairs was worried about the risk of a conflict of interest, we do not need to go down the policy line too far with the Minister to recognise that, in terms of corporate and clinical governance, primary care trusts will at the very least separate their commissioning and provider functions. The role of a medical examiner in those circumstances forms part of that core PCT commissioning responsibility, so that whether providers are community-based providers or hospital-based providers, a medical examiner could clearly be independent and have no conflict of interest.
I should like to talk for a few moments about the regulation of the medical profession. Let me put the matter in context. The Minister quite rightly said that the medical profession continued to command a very high level of confidence among the public. The system of regulation of the medical profession also continues to command confidence. However, when one considers the issues that we are dealing with and the responsibilities of the medical profession, the system of regulation and the level of confidence enjoyed must be exemplary. For example, if one says, as is true, that three quarters of the public are fairly or very confident in the system of regulation of the medical profession, we submit that that is good, but not good enough. If one in four patients do not feel confident that their complaint or their belief that something has been done wrong will be properly investigated, that is too many people. We need to minimise any lack of confidence in regulation of the medical profession.
Although it is sometimes tempting to say that the enormity of what Harold Shipman did was so exceptional that one could not extrapolate from that lessons about regulation of the medical profession as a whole, the principle that we are dealing with is a risk-based system of regulation. One calculates risk by calculating the probability of an event and looking at the severity of its consequences. One has to contemplate only for a moment the enormity of what Harold Shipman did to understand that even a tiny probability of such an event occurring means that one must, taking a risk-based view of proportionate regulation, have a very robust system of regulation in place.
I subscribe to the view that we should have a risk-based system. Dame Janet Smith seemed, on my reading, to set out in a very competent and comprehensive way to examine what had happened and to expose how, if people had acted on the information that was available to the respective parts of the system in place, it would have been possible, in a better system, to identify wrongdoing and risk, and to deal with it. However, because Dame Janet considered many aspects of the regulation of the medical profession and identified deficiencies in it, she has made wide-ranging recommendations geared to the reform of the system as a whole. On any reading, those recommendations go beyond what is necessary to identify and deal with—I hope far more effectively—someone who is behaving even remotely in the way Harold Shipman behaved.
To bring that back to specifics, she recommended that revalidation should be conducted not on the basis of concerns about somebody’s fitness to practise but on the basis of a positive effort to secure revalidation.
Exactly—that is indeed what the Minister is proposing. However, we are dealing, in that sense, with two different things. They are not alternatives. In order to combat the risk of any eventuality arising in which a medical practitioner’s responsibility for malfeasance, wrongdoing, malice or incompetence was such that we needed to act on the basis of risk, we must have a very robust system for acting on concerns.
We must be very clear that we are trying to ensure that practitioners are fit to practise; that part of the system has to be robust but proportionate. It is for us to work out how much effort and time and how many resources need to be put into revalidation to make it work in a way that commands the confidence of the medical profession and the public. Enormous amounts of resources are going to be involved.
I do not want to anticipate the Second Reading debate of a future health professions Bill. However, as the Government published their White Paper in February, it would be useful to air some issues; if, in the next parliamentary Session, we can secure legislation that commands consensus across the House and creates a stable system for the long term, it will be the better for that. I am content for us to move towards a structure of governance for the GMC that is balanced in respect of its representation of the professions and of lay people. We just need to talk a bit more about how confident we are of what “independent appointment” means in practice.
I know that the Government are clear that they have to set out the specifications and criteria for appointments and that things will be conducted through the Appointments Commission, which is independent, but we are placing a large amount of confidence in the ability of the commission to secure the right candidates for posts. I am not yet clear about how confident we can be about that; we should go further.
I turn to revalidation. As I said, I have questions about the risk that, by putting in place a rigid structure, we will not only incur large costs and a diversion of effort, but may end up with something that becomes routine rather than proactive. If we looked, as we must, at where the real deficiencies lie, we would find that clinical governance in the hospitals—the secondary sector—has developed enormously in recent years. From my vicarious experience, it is far stronger now than it was many years ago.
I do not want to underestimate the efforts that those working in primary care put into continuing professional development. However, I do not think that the sector’s process of clinical governance as a whole—particularly the effort put into audit of outcomes, adverse events and risks—is anything like as strong or systematic as that of the hospital sector. That is why the medical examiner should not only be concerned with assuring people about the certification of deaths, but should be integral to securing that quality of audit trail through primary care. We need to be confident that we are creating structures in primary care, for GPs in particular, that are at least as strong as those in the secondary sector.
There are many single-handed general practitioners, and I do not disparage them in any sense. However, we must be aware that large numbers of doctors practise in the community in a highly professional independent way. When we debate the pay and remuneration of GPs, we often forget how independent and responsible they are. With that responsibility must go an equal level of audit and clinical governance.
I turn to some questions for the future, if not for today. I am not clear about how far we are, literally, going to maintain a self-regulated professional structure and how far we are shifting from a statutory framework to Government regulation. I listened with interest to what the hon. Member for Oxford, West and Abingdon (Dr. Harris) said. He accused the Government of imposing Government regulation, but I am not sure whether the Government are proposing that. However, there is a difficulty: if we go too far and the statutory framework becomes too intrusive and prescriptive, it will become, in effect, the same thing. What is intended is professional self-regulation that secures a high level of confidence and good results, within a statutory framework that gives us powers of intervention.
That will be an area of debate on the legislation, but can I be clear that the hon. Gentleman accepts—I think he does—that there has always been an element of hybridity about medical regulation? A parliamentary process lays down the framework through which self-regulation happens. By definition, there will be some prescription in the legislation of the basic structure of that self-regulation. Perhaps I did not say it clearly enough to the hon. Gentleman, but that is exactly what is being developed. There will be no diminution of professional self-regulation.
Yes, I am sure that that is a shared intention. However, let me give two relevant examples that will illustrate the nature of my concern. We have already gone down a certain path. In medical education and training, responsibility for undergraduates and continuing professional development are with the GMC, but responsibility for postgraduate education and training is with the Postgraduate Medical Education and Training Board, which, from the profession’s point of view, has been substantially nationalised. I do not understand why one bit in the middle of that spectrum—from undergraduate to specialist and continuing professional education and training—has been taken out and is something on which the profession does not lead.
I come back to the GMC. I have never understood why the profession and the GMC will lead on revalidation and fitness to practise, yet if somebody’s practice has a difficulty that does not get to the point of their fitness to practise being investigated, that will be the responsibility of the National Clinical Assessment Service, which is effectively part of a Government agency. I get rather confused by that; perhaps it is my ignorance, although I suspect that it is not entirely that. There seems to be a discontinuity in the spectrum of support for professional competence. I would rather that it were a professionally-led and professionally-delivered structure that commanded confidence in the profession.
I shall not go all the way with the hon. Member for Oxford, West and Abingdon in respect of how much the profession is concerned about the issue, but we certainly need professional confidence, as well as public confidence, in the structure. If we give the profession the responsibility and a proper structure, we shall be able, as the hon. Gentleman said, to rely on the medical profession to be sufficiently well informed, concerned and responsible to identify and root out problems at least as well as any group of lay people.
I am grateful for the intelligent way in which the hon. Gentleman is going about this discussion. However, the issue is not only about professional confidence. I did not give this example in my earlier remarks, but let us say that a doctor is accused of not meeting Government targets because he thinks that they are not right for his patients. I think that the profession would think that other doctors —independently of that doctor—would be more likely than lay people and those appointed indirectly through a Government-organised process to uphold the importance of putting patient care above the need to meet Government targets. The profession is concerned about that sort of example.
I understand; the hon. Gentleman slightly tempts me, but I shall not go too far along that line. The moment that the hon. Gentleman mentions Government targets, one has to embrace the thought that the medical profession will be able to deliver the kind of professional self-regulation that we are discussing in circumstances in which responsibility for the care of patients is exercised by clinicians on the basis of their professional judgment. The chief medical officer, in his conclusions to his document “Good doctors, safer patients”, which was published last year, said:
“The quality and safety of the care received by patients is not yet central to the goals, culture and day-to-day activities of every organisation and every clinical team delivering care to NHS patients. Financial and activity targets often have a higher priority.”
That comes back to the point made by the hon. Gentleman. If we are looking for professional regulation, it has to be in a structure within which professionals understand that the structural framework and the organisational framework are entirely consistent with the care and priority that they give to the care of patients.
The next sentence in the report from Sir Liam Donaldson stated:
“It is misguided to think that these considerations are mutually exclusive. In the best healthcare organisations in the world, the ‘business plan’ and the ‘quality plan’ are one and the same.”
To be fair to the chief medical officer, we know exactly what he is aiming at, and I hope that we would see it in policy terms. Professionals would not find a conflict between Government targets or the objectives of an organisation and their professional responsibility, because they all point in the same direction. That is what we are aiming for.
I managed to raise most of the points that I wanted to make in my interventions. One was about the standard of proof in particular. It is right to proceed on the basis of a civil standard of proof, flexibly applied. The point that I made in my intervention was that flexibility must be carefully applied in determining the severity of penalties that might ensue from accusations. I hope that that will be understood in the medical profession. As the Minister rightly said, most doctors are worried about the standard of proof that would be applied to deprive them of their livelihood and bring them in to public disrepute. That sanction would be applied only where there was evidence to support the accusation beyond reasonable doubt. A range of penalties are available that do not have quite the same impact and do not require a “beyond reasonable doubt” standard of proof. That seems logical to me, but everything that I read suggests that we have not yet got that message across to the medical profession. We need to have that debate, even if it is in the few months before we discuss the legislation.
Is there not a problem? I have to say that I have not investigated the matter fully, so these are initial thoughts, but the hon. Gentleman is implying that the person who makes the decision about guilt has the sentence in mind when deciding the burden of proof that is to be required. That might be possible, but it might break down if an appeal is made only on the sentence, as can be done through the Council for Healthcare Regulatory Excellence. It might increase the sentence without a commensurate increase in the level of the burden of proof required.
Yes. I am not a lawyer, so such a subject trespasses slightly outside my expertise. The hon. Gentleman is not a lawyer, either, but he clearly has great expertise, not least because of his participation in discussions on the subject at the BMA. As I understand it, it is impossible not to have in mind the nature of the penalty that might ensue from the accusation. It does not mean that the person has to have the penalty in mind. There is an interplay between the nature of the charges and the nature of the penalty. My point, however, is that one should start from an understanding of the extent of the penalty that might ensue from an accusation.
The hon. Gentleman makes a fair point, given the nature of an appeal process that might change the penalty. One has to think about that, too. However, unless I am much mistaken, in considering on appeal what should be the penalty, any responsible tribunal would bear in mind the standard of proof that had been achieved.
I said that I was going to conclude, so I should. I wanted to make one point about what lies at the heart of the matter—happily, I know that such subjects are at the forefront of thinking among doctors. I was with the Association of Surgeons in Training in Belfast back in late March, and listened to a number of presentations. There was a fascinating presentation by someone whose name I forget, who had suffered the loss of his wife. Clinical negligence had not taken place, but mistakes had been made during the course of her operation. He had devoted an enormous amount of effort to communicating with doctors about how to achieve quality and safety. He was qualified to do so because he was an airline pilot. One can stretch the analogy only so far, but it is an important one. In the airline industry, it is well understood that people make mistakes. If someone makes a mistake in the airline industry, they are held to blame or penalised not for making the mistake, but for not reporting the mistake, since reporting the mistake allows the problems to be eradicated.
If we are confident that we do not have a culture in which we try to escape blame, pass blame or cover things up, and that we have one in which all adverse events are brought out, not only will we disclose mistakes and deal with them but we will make it harder for all those who are guilty of wrongdoing or behaving with malice to carry on and to hope that the things that they do will be dealt with on the inside rather than exposed and dealt with through the system of regulation that we all hope to achieve. I hope that we can be confident that we will achieve that culture.
I echo the last remark of the hon. Member for South Cambridgeshire (Mr. Lansley). If we can create such a culture, we will have done something truly valuable for the country for many years to come.
I am grateful for the way in which all hon. Members contributed to the debate. If we can continue our deliberations on these matters in the same vein, we will do politics, our parties and Parliament a service in trying to get the right settlement for the future.
When my hon. Friend the Member for Denton and Reddish (Andrew Gwynne) spoke about the effect on the borough of Tameside, it got me thinking. The borough does not want to be remembered for those terrible events—nor should it be, because it is a fantastic part of Greater Manchester, which I represent, too. In some ways, I hope that my hon. Friend’s constituents and those of my hon. Friend the Member for Stalybridge and Hyde (James Purnell) will see some of the positive legacy of the improvements to Tameside general hospital that we hope to implement quite soon through the substantial redevelopment scheme under the private finance initiative.
It is a matter of some coincidence that tomorrow I shall open a new practice in the fine borough of Tameside, near the constituency of my hon. Friend the Member of Stalybridge and Hyde—Dr. Kailash Chand’s practice at the Stamford House surgery. In many ways, what matters is not raking over the coals but bringing forward positive progress to the borough of Tameside that shows that the health service can take a stride forward and do something significantly better than before. That is the challenge that faces us all.
I shall answer the questions that colleagues have asked, although I do not intend to speak for a long time, as we have had a full debate. My hon. Friend the Member for Calder Valley (Chris McCafferty) eloquently asked how it was possible for Shipman to continue his criminal activities for so long without being detected and how the system could not have been adequate to pick up the clues and warnings and protect patients. That is the key question that I have asked myself in considering the right response to the matter, and it was why I re-examined the issue of death certification when I was asked to do so.
The hon. Gentleman is correct to say that the matter should sit within the clinical governance function of PCTs, so that information is used for commissioning and public health purposes, for general good governance in a locality and to detect any patterns of disease or illness. That would make it part of an integrated system, working with a reformed coroners system and system of professional medical regulation to do precisely what my hon. Friend said. That is a crucial piece in the jigsaw of creating systems that give us the satisfaction that we want.
My hon. Friend asked whether we could create systems to ensure that such a thing never happens again. I am not sure whether we can ever be so arrogant as to say that any piece of legislation could do that, but we can work to close the cracks and limit as much as we can the weaknesses and the likelihood of it happening again. That is my objective in bringing forward our package of proposals. If the system is to work it is crucial that PCTs examine the whole range of indicators of clinical quality, including death rates, analyse information from death certificates and have an overview of complaints. They must use all that information to inform the strengthened system of scrutiny and accountability.
My hon. Friend and others asked about the timetable for the implementation of the system. We propose to publish a consultation document on death certification shortly—that is not Department of Health-speak “shortly”; it does mean shortly. The timetable for implementation is still to be determined, because it will be subject to legislation. One of the problems, and the reason why I referred to Dame Janet’s third chapter of the third report, is that there is legislation controlled by and relating to different bodies such as the Ministry of Justice and the Office for National Statistics, and the Home Office has a considerable interest in some of the issues that we are debating. The matter is complicated and subject to legislation, but it makes sense to consider a timetable for putting the reforms together.
The earliest that we can hope for the coroner reforms to be fully implemented—the hon. Member for Oxford, West and Abingdon (Dr. Harris) asked me about that—is 2010. That is not unreasonable at this stage. I recognise the frustration that some people feel about the pace of progress, but I cannot make decisions on future legislative programmes. We need to ensure that the hon. Member for South Cambridgeshire’s frustration does not turn to disappointment, and we do not want momentum to be lost.
My hon. Friend the Member for Calder Valley asked me about deaths abroad. When a death takes place overseas, the body is brought back to England and Wales and the coroner investigates the circumstances, as he would if the death took place in this country. That will remain the same. Families in those circumstances will get the same powers as others under the new Bill to challenge coroners’ decisions, although the death certification process is not the same.
My hon. Friend the Member for Denton and Reddish raised important points about medical regulation and GMC affiliates. It is important to say how we envisage those affiliates working. I agree with the hon. Member for South Cambridgeshire that the system being developed is, in many ways, not punitive. As the chief medical officer made clear in his document, “Good doctors, safer patients”, the idea is to create a supportive system whereby doctors exhibiting signs of difficulty, perhaps through alcohol or drug misuse, are supported, referred to bodies such as the National Clinical Assessment Service and offered help and support to get their careers back on track.
The revalidation process will contribute to that. GMC affiliates will have a key role in placing recorded concerns on file so that there is a record of things brought to their attention. Even if they are not felt worthy of being taken to the GMC, they should nevertheless be recorded as concerns. That will build the more detailed system that my hon. Friend was looking for. We will close the regulatory gap between the GMC, which is at the end of a long process in many cases, and examples of practice that give rise to concern at a local level. I hope that he appreciates that.
I wish briefly to touch on an issue that we have not mentioned. As well as the reform of the death certification system, the Government are considering adding to the draft Coroners Bill a provision recommended by the Constitutional Affairs Committee to place a statutory duty on doctors to report to coroners particular types of deaths, such as those that are in unnatural circumstances or are violent and fit certain characteristics. We will set out our proposals on that in a consultation paper, which is currently being considered in draft form. The hon. Member for Oxford, West and Abingdon referred to that and I hope that he will be reassured.
On death certification, I was pleased to hear the hon. Member for South Cambridgeshire say that having the medical examiner within the PCT was the right thing to do and that he did not feel it should give rise to concerns about conflicts of interest. However, that is a legitimate point to consider.
It is important to say that if we create a unified system of death certification it will apply to burials as well as cremations. At the moment the charging structure falls heavily on people whose relatives are cremated, and any new system will have to create a unified charging structure. It is important that that is done carefully and sensitively when the details are considered.
The role of the medical examiner receives a lot of criticism, but it will be hugely strengthened by Connecting for Health and the national programme for IT. An examiner sitting at a PCT will be able to call up the necessary documentation, have immediate access to records and speak to family members if it is deemed necessary. It will be an easy, streamlined process. The system has the potential to be neither costly nor bureaucratic and will do the job that Dame Janet envisaged for the coroners service.
The hon. Member for Oxford, West and Abingdon spoke about doctors’ lower tolerance towards poor practice and the importance of their not being hounded. They are important points and the two need to be balanced. He often talks about Government targets as though they were inherently antithetical to good patient care. I hope he understands that our targets are about the generality of the population getting access to basic standards of care. It is not enough for the system just to deal with the patient before it. Obviously, any health care system must consider how it is meeting the needs of everybody, not just those who come into the system because it is their turn in the queue. I wish sometimes that he would temper his description of targets. They are designed to improve the system for everybody, not to work against the interests of patient care. I believe that the hon. Member for South Cambridgeshire made that very point. I would not want doctors to be hounded as a result of the new system. It is crucial that professionals who express concerns about a colleague are protected, and I assure hon. Members that that is very much part of our thinking.
We had a useful debate on the standard of proof, and I suspect that we will return to the subject another time. Again, I was pleased to have the support of the hon. Member for South Cambridgeshire. Perhaps there is a need for better communication with the medical profession so that people fully understand what is being proposed and so that liberties are not taken with the serious issue of people’s livelihoods, but Lady Justice Smith and the chief medical officer both firmly concluded that what has been proposed is the right thing to do. In my view, too, it is the right thing to do, and the Bill will include the proposal.
On the composition of the General Medical Council, I believe that the hon. Member for Oxford, West and Abingdon said that he supported the proposal for parity between lay and professional representation. He is nodding, so I am pleased. Personally, I preferred a lay majority—I will be open about that. I felt that that would be right, but, in discussion with the medical profession and the GMC, I accepted that parity was a fair compromise and that it enshrined the two interests that have to be balanced. In many ways, it perfectly embodies the balance that has to be struck between the public interest on the one hand and the professional interest on the other. That is what we are seeking to do.
The hon. Gentleman also raised concerns about people being elected to bodies and asked why the Government were moving away from that. There is a clear conflict between representation and regulation in the public interest. The responsibility of anyone serving on a regulatory body in the health care sector is to uphold the public interest and to improve patient safety. I do not doubt for a moment that that is uppermost in the mind of the vast majority of people—in fact, all the people—who are elected to serve on regulatory bodies. Nevertheless, the impression is created that the first priority is to the constituency of people who put the person on to the regulatory body. Indeed, in many ways it is why we are asking the Royal Pharmaceutical Society to make changes to its structure, too. That body in itself combines a representational role on behalf of the industry as well as a regulatory role, and my view is that the roles are not compatible if we want a transparent and fair system.
I will reflect on what the Minister has said. It has implications for elected people who regulate licensing and our planning systems, and who take a quasi-judicial approach. However, I want to reassure him that what he has just said does not alter for one moment my view on targets. Politically motivated targets are contradictory, and they create perverse incentives in respect of appropriate patient care. That is why I thought that the Conservative party was right to seek to abolish them. I was surprised by who was prayed in aid, but it is a matter for that party. I want to reassure the Minister that I have stuck to my view throughout.
I know that the hon. Gentleman has stuck to his view. I do not seek to inject a party political note into the proceedings, but it is legitimate for me, on behalf of the Government, to say that waiting lists would be longer today than they are, waiting times in accident and emergency would not be four hours for everybody, and cases of MRSA would not be falling if we had not introduced national targets in the NHS. Experts in the Department tell me that in 2005—the very point at which the national target was introduced—cases of MRSA fell for the first time since 1991, which is when incidents of MRSA began to appear in any significant number. The hon. Gentleman has a view, but I find it impossible to accept that targets are entirely contradictory to the interests of the public or to good patient care.
I believe that I have covered most of the issues that colleagues raised. The hon. Gentleman mentioned metrics and whether trusts would be measured on the number of complaints. That would not be sensible. He may know that the Department has launched a new website this week called NHS Choices. It is not just a website; it is a comprehensive information service for the public, who can find information on the NHS that previously might have been difficult to find or that was in the hands of the professionals.
There are things that the public need to know and should be encouraged to know about their local hospital, such as the number of complaints it receives—I do not understand why that should not be in the public domain—readmission rates, the incidence of MRSA and patient satisfaction rates, but that is very different from saying that anyone is using a performance management regime to make an overall judgment on the organisation. I agree that that would not foster an open learning culture like the airline industry culture that the hon. Member for South Cambridgeshire rightly referred to, in which complaints are encouraged.
It is absolutely correct that a goodly number of complaints is indicative of an open and learning organisation—it is important to say that. Indeed, in making his recommendations, the chief medical officer carefully considered the parallels between the airline industry and the medical profession. We can learn something from the principle that to err is human, but to cover up the mistake does not serve the public interest. We have to go further in that area.
Issues were probably raised that I have not fully covered, but we shall return to them in the House before long. The Government will continue to listen on these important matters, to make changes if we need to, and to make proposals in a spirit of collaboration and consultation so that this country gets the generational settlement that it needs. As I said, I am grateful for the tone of the debate.
The Department’s officials have provided enormous support in taking forward the proposals. The team has performed exceptionally well. It is invidious not to name everyone, but I mention Gavin Larner, Charles Dobson, Nick Clarke and, in particular, Gina Radford, who encouraged me to address the subject of death certification. I want to put on the record my personal thanks to them for their professional work on the proposals. There are many more people across the Government whom I could mention, but I wanted personally to thank those people for their excellent work on the package of measures. I am sure that they take huge personal satisfaction from the excellent service that they have given to the public.
No system of safeguards can ever provide us with an absolute guarantee against abuse from a criminal as devious and subtle as Harold Shipman. Nevertheless, we are confident that the wide range of measures that we are putting in place, which build on the invaluable recommendations of the Shipman and other inquiries, will deter any future wrongdoing and make it difficult for it to remain undetected.
I thank you, Mr. Hancock, for the way in which you chaired our proceedings, and I thank all hon. Members for attending the debate.
Thank you, Mr. Burnham. Before I put the Question, I want to thank the Minister and all hon. Members for the way in which they participated in the debate. The issue presents real difficulties for many people. The debate was a great credit to the House.
Question put and agreed to.
Adjourned accordingly at one minute to Five o’clock.