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General and Specialist Medical Practice (Education, Training and Qualifications) Order 2010

Volume 716: debated on Thursday 14 January 2010

Motion to Approve

Moved By

That the draft order laid before the House on 18 November 2009 be approved. First report from the Joint Committee on Statutory Instruments.

My Lords, the order being debated today is the first in a series of legislative instruments implementing the recommendations made in the report of the Tooke inquiry, Aspiring to Excellence—Findings and Final Recommendations of the Independent Inquiry into Modernising Medical Careers. This is quite a complex order and my remarks will be quite lengthy. I apologise in advance for that. However, I hope they will be helpful in facilitating the discussion.

The draft order is made under powers in Section 60 of the Health Act 1999. It abolishes the Postgraduate Medical Education and Training Board and transfers its functions to the General Medical Council. The Postgraduate Medical Education and Training Board was created in 2003 and took over the functions of its two predecessor bodies—the Specialist Training Authority, the STA, and the Joint Committee on Postgraduate Training in General Practice, known colloquially as the JCPTGP—in September 2005. It currently approves standards for assessments, trainers and programmes for the delivery of postgraduate medical education and training, and monitors training, quality standards and outcomes through inspection visits and other arrangements in the UK. It also awards certificates of completion of training, CCTs, and determines the eligibility of doctors for inclusion on the specialist and GP registers. The effect of the draft order is to transfer to the GMC statutory responsibility for delivering these functions, which are central to ensuring the delivery of effective patient care.

The GMC already has responsibility for setting and assuring standards in undergraduate medical education and for ensuring that all doctors participate effectively in continuing professional development to ensure that they keep their skills up to date after completing training. While taking on responsibility for postgraduate medical education and training is a significant extension of the GMC’s remit, it is in a functional area in which the GMC already has a strong track record.

When the Postgraduate Medical Education and Training Board was created in 2003, it brought together, for the first time, responsibility for setting and maintaining standards in both postgraduate general practice education and training and specialist medical education and training. The rationale for merging the functions of the Postgraduate Medical Education and Training Board with the GMC originates from the report of the Tooke Inquiry, Aspiring to Excellence—Findings and Final Recommendations of the Independent Inquiry into Modernising Medical Careers.

This is not a new idea. It was first recommended in 1975 in the Merrison report. The Tooke inquiry demonstrated dissatisfaction among the profession with the current fragmented system and found evidence that the medical profession sought an education and training standards-setting authority that was independent of both the Government and the NHS, had strong lay representation and which could work in close partnership with the profession. Such a body would also need to draw on relevant specialist expertise to facilitate flexible training and set standards across the continuum of medical education, from undergraduate studies through to postgraduate qualification and continuing professional development.

The inquiry suggested that a merger of the two bodies responsible for medical education and training would provide the potential for shared expertise, the development of a shared philosophy and facilitate economies of scale. The merger will also create a single competent authority for medical education and training and a single point of contact for doctors, employers and other partner organisations.

Historically, the financial burden of standard setting in postgraduate medical education and training has fallen primarily on the trainee. The Tooke report also revealed that there is strong support for the view that it would be more appropriate for the costs to be borne by the profession as a whole. Transferring responsibility for setting and assuring standards of postgraduate medical education and training into the GMC’s remit will enable changes to the current funding structure to be made so that, in future, the system of assuring postgraduate medical education and training could be funded through GMC fees with the burden of costs shared across all licensed doctors.

Both the GMC and the Postgraduate Medical Education and Training Board support the merger, recognising that it creates an opportunity to realise more far-reaching improvements in the way that medical education and training are regulated. During the public consultation on the proposed legislation, there was also very strong support for the proposal, with a large majority of respondents supporting a merger of the two bodies.

Turning to the proposed transfer of functions, I have already said that the draft order makes provision similar to that currently in the General and Specialist Medical Practice (Education, Training and Qualifications) Order 2003. I apologise for going into some detail. As the order integrates the provisions of the 2003 order into the Medical Act 2003, it is, I am afraid, rather complicated legislation.

Article 3 of the order formally abolishes the Postgraduate Medical Education and Training Board. Article 4 then introduces a number of amendments into the Medical Act 1983, made in Schedule 1 to the order.

Although the PMETB is currently responsible for setting standards for entry to the GP register and the specialist register, the GMC as the body responsible for regulating medical practitioners currently holds and administers the registers. The GMC will continue to hold and administer the registers once the PMETB is abolished.

However, a number of consequential amendments to the Medical Act 1983 are required in order to ensure that the GMC is able to perform all the statutory functions necessary, both in connection with the keeping of the registers and postgraduate medical education and training generally. With this in mind, paragraph 10 of Schedule 1 inserts a new Part 4A into the Medical Act 1983 dealing with postgraduate medical education and training.

I shall not take up the House’s time by going through all the provisions of new Part 4A in detail as there is a comprehensive explanation of them in the consultation paper on the draft order prepared by the Department of Health. I should perhaps mention, however, the provisions where there is a departure from the current legislative position. These relate to the categories of registered medical practitioners, other than those who have been awarded a CCT, who are eligible for entry in the GP register and the specialist register. Whereas the 2003 order set out the eligibility criteria for doctors wishing to be included in the GP register and the specialist register, new Part 4A provides new delegated powers enabling the Privy Council to prescribe such criteria in an order. These new powers, at new Section 34C(2)(c) and Section 34D(2)(c), enable the Privy Council by order to specify other categories of registered medical practitioners who may be entitled to be included on the GP register or the specialist register respectively. There is also a power at new Section 34D(3) for the Privy Council by order to designate specialties as recognised specialties for the purpose of inclusion in the specialist register.

Creating a new regulation-making power will enable any necessary changes to the criteria for inclusion on the registers to be made more quickly and easily in order to reflect changes in the wider external environment. However, I believe that the necessary checks and balances would be provided, as many of the eligibility criteria are derived from European Community legislation. Changes would be consulted on and be subject to approval by Parliament.

The Postgraduate Medical Education and Training Order of Council 2010, which sets out detailed provisions relating to the categories of registered medical practitioners other than those who have been awarded a CCT who will be eligible for entry in the GP register and the specialist register, was consulted on at the same time as the draft order before us today and will be laid before Parliament as soon as this order is made.

The draft order does not make any substantial changes to standards of postgraduate medical education and training, the process for certifying that doctors have completed postgraduate medical education and training, or the way that any of the quality assurance functions in postgraduate medical education and training are undertaken. It was felt that changing procedures at the same time as significant personnel changes were taking place would increase the risk of disruption and that there was a need to maintain the operational stability of both organisations during the transfer. However, the need for a comprehensive review of the system of medical education and training is recognised.

The noble Lord, Lord Patel, chairman of the National Patient Safety Agency and former chair of the Specialist Training Authority, was invited by the GMC and the Postgraduate Medical Education and Training Board to lead the ongoing review of the current arrangements, which is due to make recommendations on an appropriate, contemporary approach to medical education and training in March 2010.

Noble Lords may be aware that the GMC and PMETB published for consultation recommendations arising from the review of the noble Lord, Lord Patel, on 11 January. I understand that the outcome of the consultation will then inform the final report and recommendations to the GMC.

A merger in advance of the noble Lord’s final report makes sense because it allows the GMC to take an overview of the whole continuous system. The GMC will then be better placed to identify and implement any changes required as a result.

Finally, I should also point out that the order makes a technical amendment to the Medical Act to enable GPs to be included on the GP register without the need to make a request to the GMC when they have been registered temporarily under Section 18A of the Medical Act in the event that the GMC has been advised that a civil emergency has occurred, is occurring, or is about to occur. As part of the Government’s planning in response to the recent swine flu epidemic, it became clear that, although the powers introduced in the Health Care and Associated Professions (Miscellaneous Amendments) Order 2008 enabled temporary registration of doctors generally, they did not give the GMC the explicit power to be able automatically to add former GPs to the GP register. To practise primary medical services, GPs need to be included on the GP register before they can be included on their employer’s local performers list.

New Section 34F(4) of the Medical Act enables the GMC automatically to include doctors’ names on the GP register as soon as re-registration occurs. I commend the order to the House.

My Lords, I begin by thanking the Minister for introducing the order, which I welcome entirely. I shall therefore not spend long in responding.

As the Minister said, it was the report by Sir John Tooke two years ago which recommended that PMETB should be merged into the General Medical Council. The reasons for doing this are several, but the chief of them is to bring together a fragmented system of setting and monitoring standards in medical education and training and to create a clear connection between the registration of doctors, their certification and subsequent revalidation. In short, as a result of this order, there will be a single, competent authority responsible for the qualifications and the performance of a doctor at every stage of his or her career pathway. Those arrangements will bring with them clear and obvious benefits.

The noble lord, Lord Patel, is currently conducting a review into the regulation of medical education and training, and there was some feeling that we ought to have awaited the outcome of that review before asking Parliament to approve this merger. However, my own view is that this order, which deals merely with the transfer of basic functions, ought not to compromise the noble Lord’s freedom to make recommendations on a more detailed and practical level. I hope that the noble Lord himself does not feel that we are jumping the gun here.

The Tooke inquiry set out what it saw as the features of an ideal regulatory authority—that it should be independent of government, which PMETB is not; have strong lay representation; facilitate training that is flexible and which can adapt to change; and cover the whole continuum of medical education throughout a doctor's career. Tooke also said that there should be one authority overseeing medical education and standards and that that authority should work in close partnership with the profession. I do not think that many people disagreed with those conclusions. While there were several ways of delivering some or most of the desirable features which Tooke identified, the option which the Government chose and which we are now considering was the only one that delivered all of them without introducing an unwelcome degree of risk and expense. It was significant, I think, that 82 per cent of the members of the medical profession who responded to the consultation came out in favour of this option.

Everything that I have read and heard leads me to think that the GMC is well prepared to implement the merger smoothly, and strongly placed to cope with its expanded role—which, incidentally, should be facilitated by its well established IT systems and support staff. I am sure, too, that the GMC will be in a good position to take in its stride any improvements to postgraduate medical education that are deemed necessary in the future. It is right that we should thank PMETB for the role that it has played over the last few years and to wish the GMC well as it approaches its new tasks.

My only query about this order is technical. Could the Minister clarify why the amendments to the Medical Act 1983, which are set out in Schedule 1 to the order, do not have to be effected by means of primary legislation? How satisfactory is it, and how comfortable should we feel, that we are amending an Act of Parliament in a fairly major way by means of a mere statutory instrument? As I understand it, Schedule 1 says that the performance of the functions currently carried out by PMETB no longer have to be specified in primary legislation, but can instead be prescribed in subordinate legislation. That seems a fairly important change to me, and I would be grateful to hear from the Minister whether the gain in flexibility, which this clearly delivers, justifies the concomitant weakening of parliamentary control and scrutiny.

When I first looked at this document—despite the fact that I found it mildly intimidating, I read through it—the idea that all the training facilities are being consolidated in one body seemed very sensible to me. When something seems sensible, you then look to practical problems with it. Reading it through and trying to find out if there were practical problems, I did not think that there were any insurmountable ones. I must admit that the technical point that the noble Earl has just raised had passed me by, but an answer would probably help those who come after us. If the noble Lord, Lord Patel, has no objection to this, I suggest that the rest of us would be well advised to let it go through.

My Lords, I should like briefly to comment and I must declare an interest as someone with her name on the specialist register of the GMC and as an observer at the Medical Schools Council at the time of the Tooke inquiry. This is an important document; it is being welcomed generally and almost without major reservation, although there will always be some minor ones. However, I have a few questions for the Minister.

The first is for clarification. Proposed new Section 34F deals with the,

“Removal of names from the General Practitioner Register and the Specialist Register”.

That is not absolutely clear, but I hope that that is because of my not seeing the clarity in its wording. Should somebody fall below the level of their specialist competencies, when we get into revalidation and relicensing would they still remain on the medical register during a period of retraining and then re-enter? It looks as if it is written from the point of view of somebody being struck off for a time, then coming back on or having a suspended medical registration, rather than their simply falling below the line as a specialist. That is one question.

Secondly, I very much welcome the provision of emergency powers in the event of a national emergency. That fits completely with the report from this House on pandemic flu, with which everyone here is familiar. However, I wonder whether it should also include a provision that, in a dire emergency, those doctors who have ceased to maintain their GMC registration—within the previous 12 months, perhaps—could be rapidly reregistered, so that they could return to provide hospital services. That would particularly be in some of the specialities where not very many other people would be around. I am thinking of highly specialised areas in surgery, cardiology and so on, where a lot of high-tech medicine is going on. One would hate to see those areas fold completely because we have missed a technicality at this stage.

Lastly, I have a much more general question. This order is important for protecting patients. It states clearly how training up to specialist competencies will occur and it says that those doctors on the specialist register have the appropriate skills and competencies and are maintaining them. I hope that the other healthcare professions will pick up that example. We recently had the document Post Registration Career Framework for Nurses in Wales, which Rosemary Kennedy, our Chief Nursing Officer for Wales, led on. That lays out the specialist competencies for nurses. I do not wish to sound disrespectful, but the definition of specialist competencies as regards certain healthcare disciplines is long overdue. In some healthcare disciplines, staff may be graded, paid and viewed by patients as specialists but have no specialist register and, by and large, no framework. I urge the Government to discuss taking forward specialist registration with other registration bodies, thereby enabling patients to assess the skills and competencies of everybody looking after them who is a member of a specialist team. We live in an era of multiprofessional teams, not unidisciplinary ones.

My Lords, I, too, welcome the order. The transfer of functions, which, as we have heard, was recommended in Sir John Tooke’s independent inquiry into modernising medical careers, is widely supported, with responses to a recent consultation on the draft order overwhelmingly positive. This legislation is one of the final stages of a merger which is already well under way and which will bring a number of benefits, including the rationalisation of medical education and training regulation, a single point of contact for key interest groups, a more efficient delivery of functions and the enhanced opportunity to share best practice.

I also welcome the current review by the noble Lord, Lord Patel, of the regulation of medical education and training and its focus on the developments needed to achieve an appropriate and modern approach to regulating medical education and training.

I am reassured to hear that fees for trainee doctors completing specialist GP training, or seeking certification via the equivalence routes, will be frozen at the current levels for the 2010-11 period and I welcome the news that the GMC will hold a consultation on a future fees framework later this year.

I have three questions for the Minister. In view of the current problems with an out-of-hours doctor making a very serious mistake, can she confirm that the single competent authority for medical education, or the GMC, will ensure that all doctors will have to show and prove an ability to be able to communicate in English with both colleagues and patients? Is she aware of any similar plans to transfer postgraduate dental education to the General Dental Council, or does the Specialist Dental Education Board, which sounds as if it deals just with specialist training, cover all postgraduate dental training, so that there is no need for any change? Does she not agree that plans for re-inclusion on the register in the event of an emergency such as a major pandemic, which is covered in this order for the medical profession, would also be beneficial to the dental profession?

My Lords, I support the order. Putting all the regulation related to medical training under one regulator will be very beneficial. I was previously chairman of the specialist training authority and I remember the difficulties that I experienced when I tried to regulate postgraduate medical training.

Like the noble Earl, Lord Howe, I pay tribute to the Postgraduate Medical Education and Training Board. Under the current and previous chairmen, the board has done a fantastic job in implementing the required regulatory framework for postgraduate medical education and training. The review that I am conducting on behalf of the General Medical Council and the PMETB has now gone out to wider consultation and is available on the GMC’s website for anybody who wishes to see it. People should feel free to comment on the consultation. We are looking at a regulatory framework that covers a doctor’s career from entry to medical school to the day that he or she retires. It should cover every stage of training at undergraduate and postgraduate level, continuous professional development and recertification. It may well be that, after consultation, some consequential changes are required to the duties and powers of the GMC to fulfil its duties in relation to making sure that people have the competencies necessary to remain on the register, whether that be a generalist or a specialist register.

In that context, I support the part of the order on temporary registration in an emergency. This pertains only to general practice, because it is the competencies of a GP that would be required. The issue of whether retired specialists might be able to contribute—an important point made by the noble Baroness, Lady Finlay—would have to be considered, including what regulatory framework would be required. I hope that the consultation document from the review that I am conducting will address that. Other powers may be required to fulfil that aspect, because it is slightly different on the GP side.

Perhaps I may ask a brief question. Heaven forbid that we should have a catastrophe such as the recent earthquake, but in that situation we would desperately need anaesthetists and surgeons. It would not be helpful to expand the GP base. Does the noble Lord in his thinking recognise that, sadly, we have to plan for everything?

It is fortunate that we are not on any fault lines that I know of, but I take the noble Baroness’s point that, in a disaster, all skills would be required. Equally important is that a regulatory framework exists that allows people with competency to practise accordingly—not everyone else. I hope that covers the question.

I support both parts of the order. Furthermore, the question was asked as to whether I feel that we could have waited for this order until my report was finalised. I do not believe that that is the case. I think that I have the freedom that I need to get the report through. I do not need to wait for this order to be finalised. In any case, as the noble Earl well knows, I do not require particular freedom. I am not and will not be constrained by this.

However, I wish seek assurance from the Minister that the Government remain committed to supporting this merger, that it happens in the specified period and that therefore there remains a commitment to support the transitional costs of the merger that the Department of Health has already entered into. If that commitment is given, I have no doubt that the merger will go ahead speedily. I support the order.

I thank noble Lords across the House for their support for this important order. I hope that I can answer some of the questions that we have been asked. I do not need to respond to the question of the noble Earl about the review of the noble Lord, Lord Patel, and the merger—in fact, it was not really a question, because the noble Earl agreed with us that there was no restraint on the noble Lord’s work from this issue and that it was an organisational matter.

The noble Earl also asked about primary legislation. The answer to that is our old favourite; Section 60 of the Health Act 1999 provides the power to amend primary legislation. The noble Earl will recall, given that we have dealt with several orders in that way, that the process is speeded up when we can take powers under Section 60. However, the safeguard is, of course, that these orders have to be debated and agreed by both Houses of Parliament.

The noble Earl also raised the issue of different types of legislation, which relates to the point that I have just covered. Our approach is to put the overarching framework into the Medical Act 1983 but much of the operational detail into subordinate legislation. This will help to ensure that legislative provisions can be amended more easily if necessary and enable a speedy response to changes in the system of medical education and training; for example, possibly those arising out of the review being conducted by the noble Lord, Lord Patel.

The noble Baroness, Lady Finlay, raised the issue of re-registration. The GMC already has powers to include doctors on the specialist register in an emergency. The noble Baroness also raised the question of revalidation and asked what happens to doctors. Doctors undergoing a period of retraining would normally remain on the specialist register. However, the noble Baroness raised an interesting point. If she thinks that the current provisions are not sufficient, we would certainly be very happy to discuss them with her in more detail.

Currently, doctors who are suspended from duties and are subjected to further assessment remain on the register while they are being assessed, but they do not necessarily practise.

I thank the noble Lord for that clarification. The noble Lord, Lord Colwyn, raised the issue of dentists. As he will be aware, dentists are regulated by the General Dental Council and do not fall within the remit of either the GMC or the Postgraduate Medical Education and Training Board. The only registered dentists who will be affected by the scope of the draft order are consultants in oral maxillo-facial surgery. This group of specialists is required to be registered with the General Medical Council as well, as I am sure the noble Lord is aware, and to be included in the specialist register, as well as maintaining registration with the General Dental Council. Any changes to the current arrangements would be for the General Dental Council to consider, and certainly the department would work with it should the council wish to do so.

The noble Lord, Lord Colwyn, also asked whether dentists need powers to re-register. If the General Dental Council indicated that it needed more powers in respect of emergency re-registration, we would be happy to consider that. I understand that discussions with the regulator about legislative changes are currently in hand.

The noble Lord also raised the question of language testing. We are working with the GMC to explore whether there is any scope to include a language test as part of the registration. Our advice to date is that this is not possible under existing legislation, but we are certainly pursuing the matter because we think that it is very important.

I am very grateful for the support of the noble Lord, Lord Addington. I think that, if he does not mind my saying so, he and I are the least expert people in the Chamber on these matters, although I have the benefit of a department.

Finally, I thank the noble Lord, Lord Patel, for his remarks and wish him well with his review. I assure him that the department is consistent in its support for the cost of the merger and for ensuring that it takes place in an orderly fashion.

We are grateful for the support for these proposals given by the GMC, and I join the noble Earl in paying tribute to the Postgraduate Medical Education and Training Board. Indeed, we are grateful for the support of the medical royal colleges and all the bodies that have an interest in improving the quality of medical education and training.

In closing, I remind noble Lords that these changes bring benefits to the medical profession by placing in a single body responsibility for setting and assuring standards across the continuum of postgraduate medical education and training. Most importantly, over the longer term, the proposed merger will bring significant benefits to NHS patients by improving standards of education and training for doctors in the UK.

Motion agreed.

House adjourned at 5.29 pm.