Medical Act 1983 (Amendment) (Knowledge of English) Order 2014
(10 years, 9 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, this Government recognise that overseas doctors make a valuable contribution to the NHS, and we are keen to ensure that highly skilled professionals do not face unnecessary barriers. However, it is vital that all doctors practising in the UK have the necessary English language skills in order properly to care for and communicate with patients.
Due to the legislation that governs the regulation of doctors, the General Medical Council is not able to apply language controls to applicants from the EU as a pre-condition to registration as a medical practitioner. This is of great concern to the Government and to the General Medical Council, as it raises a clear risk to patient safety.
The same restrictions in law do not apply to international applicants from outside the EU. Therefore, the General Medical Council is able to require all international applicants to provide evidence of their English language capability—for example, by taking an English language test—before being registered and given a licence to practise in the UK.
We have worked with the General Medical Council to identify a system of language controls which provides greater patient safety while being compliant with European law. We believe that the proposed legislative changes contained in the draft order will achieve this outcome. The draft order gives the General Medical Council appropriate powers to ensure that only those doctors who have the necessary knowledge of English to do their jobs safely and competently are able to practise medicine in the UK.
The draft order makes changes to the Medical Act 1983 to do two things: first, to give the General Medical Council the power to refuse a licence to practise in circumstances where a medical practitioner from within the EU is unable to demonstrate the necessary knowledge of English; and, secondly, to create a new fitness-to-practise category of impairment relating to language competence. This will strengthen the General Medical Council’s ability to take fitness-to-practise action where concerns are identified.
The licensing amendments will enable the General Medical Council to require evidence of English language capability as part of the licensing process where language concerns have been identified during the registration process. This is compliant with EU law, which sets out under the mutual recognition of professional qualifications directive that a professional’s qualifications must be recognised by the host member state before any language checks can take place.
The order makes amendments to Section 29G of the Medical Act 1983 which will require the General Medical Council to publish guidance setting out the evidence, information or documents which a medical practitioner must provide to demonstrate that they have the necessary knowledge of English. Any person who is refused a licence to practise on the grounds that they have failed to demonstrate they have the necessary knowledge of English will have a right to appeal.
The process for determining whether a person has the necessary knowledge of English will be set out in the General Medical Council (Licence to Practise and Revalidation) Regulations, which will be amended by the GMC in due course to enable the policy to be implemented.
With regard to the fitness-to-practise amendments, a new category of impairment relating to English language capability will be created. This will allow the General Medical Council to request that a doctor undertake an assessment of their knowledge of English during a fitness-to-practise investigation where concerns have been raised, which it is currently unable to do. These changes will strengthen the General Medical Council’s ability to take fitness-to-practise action where concerns about language competence are identified in relation to doctors already practising in the UK.
The proposed amendments to the Medical Act 1983 are designed to complement and further strengthen the existing language controls imposed through the responsible officer regulations, performer list regulations and checks undertaken by employers at a local level. These amendments will enable the General Medical Council to carry out proportionate language checks where there is cause for concern, and ensure that all doctors practising in the UK have the necessary knowledge of English to do their jobs well and reduce the risk to patient safety. I commend this order to the Committee, and beg to move.
Lord Walton of Detchant (CB)
My Lords, I cannot say how welcome this order is. Forty-three years ago I was elected dean of the medical school of the University of Newcastle. By virtue of that election, I was immediately appointed to the General Medical Council. I became a member of its education committee and three years later I became the chairman of that committee. By virtue of being chairman of the education committee of the GMC, I was then appointed, under the new arrangements for the European Union, to the Advisory Committee on Medical Training, which met twice a year in Brussels and was required to make recommendations on basic medical education, specialist medical education and the mutual recognition of qualifications.
That was an interesting experience. Under the treaty of Rome, the first directive derived from that treaty said—I am not quoting exactly but the meaning is clear—that in the movement of doctors across the European Union there should be mutual recognition of qualifications and registration should be granted, but that it should be up to the host country to see to it that the incoming doctor had such ability to communicate with patients to make him or her safe to practise. That seemed to give us at the GMC full authority to embark upon establishing a language test.
At that time, for historical reasons, some doctors from outside the European Union—from Commonwealth countries such as Australia, New Zealand, the West Indies and many others—had enabled the General Medical Council to inspect their examinations and qualifications so they were automatically granted full registration under the Medical Act. But doctors from many other countries who had not had that ability to have inspections were required to apply for temporary registration if they wished to come to the UK, and they had to take a test set by the Professional and Linguistic Assessments Board, which established tests of not only clinical and academic competence but language capability. That was the so-called PLAB test.
It is important to make the point that the rights of doctors graduating in any other member country of the European Union applied only to those who had graduated in those countries but who were also nationals of EU member states. For instance, if a doctor from a country outside the European Union graduated from, say, Heidelberg, they were not entitled under that treaty to come to the UK and had to go through the same procedure as a doctor from India, Pakistan or other parts of the world.
Indeed, there was one such doctor, an Iranian, who qualified in medicine in Heidelberg. He applied for registration with the General Medical Council and was turned down. He took the GMC to a judicial review. Of course, he lost because he did not qualify. The result of this was that I was interviewed by Special Branch because he had made serious threats against my person, including threats of violence. However, we will leave that alone for a moment.
The point I wish to make is that it is so important that we have this language test. We at the GMC, having read what the directive said, tried to impose a language test on incoming doctors from the European Union, but we were threatened with being taken to the European Court because we were told very clearly by our lawyers and by the lawyers from Europe that this was contrary to the treaty of Rome. We tried again 10 years later when I became president of the General Medical Council, again with a total lack of success. All we were able to do then was to persuade the employing authorities in the UK, through the Department of Health, that they could impose a language test as a condition of employment. Regrettably, that agreement with the Department of Health was never properly or widely fulfilled across the UK, so a language test as a condition of employment for European doctors was not widely employed. Our attempts at that time were lost.
The great thing about this order is, first, that it makes it clear that the GMC can properly design and employ a test of the language ability of an incoming doctor from the EC as a condition of registration. Secondly, the responsible officer can make certain that any doctor coming up for revalidation speaks English adequately. Finally, when any doctor who is already a specialist from the EC or is working either in general practice or in a specialist grade and is brought before the GMC on the question of fitness to practise, the fitness-to-practise procedures can take note of the doctor’s ability to speak English. These are extremely welcome developments. Perhaps I am wrong about the condition of registration but the GMC, I think, is hoping that that is the effect of this order. Perhaps the Minister can clarify it for us. The whole process set out in this paper is extremely welcome and long awaited.
Lord Turnberg (Lab)
My Lords, it is always a challenge to follow the erudition of my noble friend Lord Walton, who certainly has no difficulty with the English language. I am sorry to add to the noble Earl’s load of potential medical speakers this afternoon but it is a pleasure to welcome this initiative which at long last gives the GMC the powers to ensure that doctors coming to work in the UK can speak and understand English. It has been long awaited and although it has always been part of the assessment of non-EU doctors it will now be a requirement for EU doctors too. After all that, it might sound a little churlish to say that there remain some things to be done about long-running issues that are not addressed in this statutory instrument. I hope the noble Earl will forgive me for mentioning them here.
I go back a little while, not quite as long as my noble friend Lord Walton, to when I was chairman of the Specialist Training Authority and the EU directives were being produced in the 1990s. Since those directives governing the free flow of workers across the EU came in, doctors trained in other member states can come to practise in the UK quite freely. However, we recognised from the very beginning that we know relatively little about the training of specialists in other EU countries. We have no knowledge of the curriculum they go through or the skills and knowledge of, for example, cardiologists, neurosurgeons and paediatricians from a selection of EU counties such as France, Italy, Spain and Germany. They may be perfectly fine, of course, and they probably are, but apart from knowing that they have spent a certain minimum number of years in training, we are not allowed in the UK to assess any of their knowledge or skills before they are put on the register of specialists. That is not the case for specialists coming from, say, America, Australia, New Zealand or any other non-EU country; they have to have their training and skills properly assessed and they may be required to take more.
Questions about the safety of our patients as far as EU doctors are concerned have been raised in this House in the past, but I have little confidence that we will be able to change the arrangements now when we would, it seems, have to convince the other EU member countries of this problem. Will the noble Earl seek advice from the GMC on how it intends to check on the safe practice of specialists from other EU countries? It is possible that its system of responsible officers may help. However, the GMC can act only after a doctor is already on the specialist register. There is a question of whether there is sufficient capacity in the responsible officer network. It would helpful if this issue could be aired a little further. I hope that the noble Earl will be able to find out from the GMC how far it can go on this.
Baroness Finlay of Llandaff (CB)
My Lords, I rise, somewhat cautiously, as the third medical speaker in a row. I welcome the order.
It is worth noting that in 2013, the GMC had 13 fitness- to-practise cases that involved concerns about the language skills of doctors. In its 2011 review, the England Revalidation Support Team found 66 cases where the responsible officer has dealt with linguistic concerns. Part 3 of the order is therefore particularly important because it relates to fitness to practise. I hope that we will have an assurance today that in a fitness-to-practise procedure the doctors will not themselves be paying for the English language competence test. I have a bit of a concern, if they are paying for it themselves, that there may be a seeking out of a centre that is different from another centre, so it has to be fully conducted by the GMC, although it seems completely reasonable that the payment for the test prior to licence to practise is borne by the person applying for a licence to practise.
I understand from the GMC that it will be using the International English Language Testing System—IELTS—which costs from £130 to £145 depending on where you sit it, and that that will remain valid for about two years, on the recommendation of the Commonwealth. There is evidence that language skills, if they are not used, begin to decay after about two years.
It is also important to recognise that in this order we are talking about “ordinary” English language; we are not talking about testing medical English. It has been suggested that the dictionary for medical English is about the same size as the dictionary for another European language. It is a huge language. However, many of the words are very similar across the different European languages—although, of course, they are very different in some other languages.
We are talking about the ability of a doctor to take their medical knowledge and translate it into what you could call everyday English so that they can communicate it to patients. One point that I hope will be part of a fitness-to-practise procedure, however, is a recognition that communication involves far more than language. In terms of communication skills and communicating, although about 20% of communication is verbal, much of it is non-verbal. When you look at complaints against doctors in relation to the way they have communicated, although they sometimes have very good English language skills, other aspects of their non-verbal communication might reveal an attitude that is below the standard that one would expect from somebody on the GMC register.
I have to say, from my experience of teaching postgraduate students, that at Cardiff University they are required to sit the IELTS. It is a good test of English language skills. Since it was introduced as a statutory requirement by the university, we have found that it has become easier to teach and to mark the work done by those whose first language is not English. When teaching communication skills, it is easier to separate out the non-verbal problems from the verbal problems.
My view is that this is an important regulation. The ability to look back at those currently practising in the UK about whom there are concerns is crucially important and the GMC needs to be empowered to do so. I would just sound a note of caution following on from the remarks of the noble Lord, Lord Turnberg; of course we do not know what is set out in the curricula of different places. Medical students can graduate from some universities with almost no patient contact at all. If they are moving into training jobs, there is a concern that the baseline level of their medical training may be very different. This order may be the first step towards looking at the competences that we expect of a doctor coming from anywhere in the world in relation to practising in the UK.
Lord Kakkar (CB)
My Lords, I declare my interest as a member of the General Medical Council and I would like to take this opportunity to congratulate the noble Earl and Her Majesty’s Government on dealing with this important issue in what I think we can all agree is a very sensitive way. There is no question but that our health services are vitally dependent on a steady flow of doctors coming from all parts of the world, including the European Union. Not only can they learn from our healthcare system, they can also serve in it. But it is absolutely right that a professional regulator must enjoy the confidence of the public, and it is the responsibility of the General Medical Council first and foremost to ensure that patients are protected and that clinical practice in our country is safe.
For that confidence to exist, the public have to be sure in their own minds that the elements of what they would consider to be essential clinical practice—the ability to practise in a responsible and safe way—are met and tested by the General Medical Council whenever it feels the necessity to do so. The ability to communicate effectively, and therefore to use our language in a way that the public and patients appreciate and would expect, is an essential part of the responsibility of the regulator of the medical profession. As we have heard during this short debate, it is anomalous that the GMC is able to ask that question of potential registrants and licensees from outside the European Economic Area, but has not been able to do so of those who come from within the European Union. It is quite right that the Government have focused on this issue and decided to act in this fashion.
The fact that this order makes provision not only for the question at the time of licensing of a professional, when concerns about language skills might have been raised during the provisional registration process, but also that the new category of considering the ability to use language and to communicate becomes part of the broader question in fitness-to-practise considerations, is vitally important. It means that not only at the time of coming on to the register and being licensed to practise in this country, but throughout the practice itself, the public and patients can now feel confident that the General Medical Council will be in a position to act if it needs to do so. The importance of that cannot be overestimated.
We have heard about the additional question of competence skills, which is a matter that your Lordships have considered in the course of a number of debates in the Chamber over the past few years. The issue remains to be addressed, but I think that most would agree that ultimately, wherever a doctor comes from in the world, whether they have trained and qualified in our own country, elsewhere in the European Union or elsewhere in the world, they should be expected to demonstrate their skills to the same standard and to deploy those skills throughout their professional career in a way that enjoys the confidence of the people of our country.
Viscount Bridgeman (Con)
My Lords, I rise with some diffidence as the first layman to address your Lordships in this debate. I, too, thank the Minister for his statement and pay tribute to his department for the leadership that it has shown in securing from the Commission the remedying of what was a glaring and potentially dangerous anomaly in the 2005 directive. The Commission has produced a very satisfactory outcome.
I believe the United Kingdom is among the first member states, if not the first, to incorporate the changes introduced by the revised directive into legislation. I note that the order is headed:
“Health Care and Associated Professions”.
I hope the new language-testing arrangements will be incorporated as early as possible into other branches of healthcare—I have nursing in mind in particular. I think it is the experience of many that nurses from the EEA are almost invariably pleasant, caring and considerate. They of course play a huge role in this country, but I know that many patients have had difficulty in communicating and in making themselves understood.
There are many reasons why this is a matter of some urgency, but I will suggest just one. I think I am right in saying that the practice of putting great emphasis on patients’ notes goes back a long way in the UK; possibly more emphasis than some other member states, even those with advanced healthcare arrangements. It is therefore all the more important that nurses from the EEA are proficient not only in spoken but in written English, a point which the noble Baroness, Lady Finlay, made in connection with doctors. As one facetious journalist put it,
“the difference between a microgram and a milligram is a coffin”.
I hope the Minister can give your Lordships the assurance that progress is being made in extending the provisions of the revised directive right across the healthcare profession, not least with nurses. I hope that this will include the fitness-to-practise hurdle, which is so important in reinforcing the ongoing responsibility of the relevant regulators for their members.
Baroness Brinton (LD)
My Lords, I am also a layman so the noble Viscount, Lord Bridgeman, need not feel completely alone. However, I preface my remarks by saying that my grandfather was the dean of St Mary’s Hospital Medical School. I remember him trying to explain to me why a bedside manner was not just about translating medical language but was all about speaking and listening. The one point I would add to the many that have been made by noble Lords this afternoon is the one about communication. A technical knowledge of English on its own is not enough—it needs to be one that picks up not just the body language but the nuance, including of regional language. If a Yorkshireman says he is “probably alright”, you know that you would want to question him further, whereas somebody coming from overseas might take that at face value.
I leave the rest of the medical comments to the medical professionals, who have spoken amply in that respect, and want to speak very briefly on freedom of movement in the EU. My party certainly believes that it is vital but—in true liberal tradition—it is fine up to the point at which it harms other people. It has been quite clear, certainly with one very celebrated case but also with others that may not have hit the public eye, that the capacity to cause harm is now at a level where action needs to be taken. These changes are well overdue and I am very pleased that they will set a new framework for the General Medical Council and restore confidence in foreign doctors from the EEA, wherever they are from and whatever level of language they have.
I end on the point that proportionate language competence must not only be checked but be checked more frequently than the BMA perhaps would like, because language and communication skills can get rusty.
Lord Hunt of Kings Heath (Lab)
My Lords, I, too, welcome the order. It comes, of course, from a report which followed the death of David Gray in 2008 after he received medical treatment from Doctor Ubani, a German national working his first shift as an out-of-hours doctor. Doctor Ubani gave David Gray an overdose of diamorphine which was 10 times the recommended maximum dose. A Select Committee investigation followed, looking at the use of overseas doctors in providing out-of-hours services, which was published on 8 April 2010. This recommended that the Government make the necessary changes to legislation that would allow the GMC to language-test those applying for registration. The order follows that and we welcome it. I commend the GMC and the noble Earl’s officials for their work in this area.
A number of points have been raised. I was interested in the BMA briefing on this matter which encapsulates some of the issues to which noble Lords have referred. It particularly concerns the area of fitness to practise. I agree with the noble Lord, Lord Kakkar, that the fact that the order covers the fitness to practise of doctors who are practising rather than those who are wishing to practise is a significant advance.
The BMA is right to ask for safeguards to ensure that testing for language competency is not abused. As it points out, a doctor’s language competence may not be a cause for concern but may be used as a conduit to prevent a doctor working where an employer may have more general concerns. One can recognise the circumstances in which this could be used. I would be interested to know what safeguards the GMC proposes in this area. Clearly, careful differentiation is required between situations when language is the main cause of concern and when there are other underlying problems such as professional or personal issues.
The BMA also states that an assumption has been made in these proposals that if someone is found not to hold a sufficient standard of English following a fitness-to-practise investigation, the situation is remedial and language competence could then be improved sufficiently over time to allow the doctor to continue to work in the UK. The BMA points out that while this may indeed be the case, it is concerned that the quality of English tuition may be very variable and that some responsibility might need to be taken by the GMC to signpost doctors to expert language training.
My next point was raised by both the noble Baroness, Lady Finlay, and the noble Baroness, Lady Brinton—namely that language competence is not the sole area which determines the likelihood of a doctor not trained in the UK experiencing difficulties. Effective communication is far broader and, indeed, has been highlighted by the GMC’s programme for doctors new to the UK, which looks at professional and ethical standards along with the importance of effective communication. I agree that it is essential that those new to the UK understand and apply the ethical and professional standards expected of them. That reinforces the point made by my noble friend Lord Turnberg that in the case of specialists from other countries, we sometimes do not know what we are getting.
I refer the noble Earl to a further briefing from the General Medical Council which stated that, by January 2016, the Government will have the opportunity to implement into UK law the new language requirements in directive 2013/55/EU on the recognition of professional qualifications. These clarify that competent authorities throughout Europe, such as the GMC, should have explicit powers to assess the language competence of all health professionals after their qualifications have been recognised but before they are allowed to practise.
The GMC considers that at that point we should be able to produce a more comprehensive scheme for language controls before doctors are given a licence to practise in the UK. Will the noble Earl confirm the GMC’s interpretation and can he say anything more about the timelines for this country implementing directive 2013/55/EU in the UK? Will he also confirm that, in so doing, we will be able to meet the point raised by the noble Viscount, Lord Bridgeman, in relation to other health professions? The point he raised about nurses is very well taken, particularly in view of the fact that they are very mobile in terms of where they work. It would be good if the noble Earl could confirm that as well.
Earl Howe
My Lords, I am very grateful for the welcome that this order has received from all noble Lords who have spoken. Perhaps I may begin by making clear one critically important point relating to the order prompted by a comment made by the noble Lord, Lord Walton. It is important to understand that the English language test is not a condition of registration. If a language test is required of a doctor, it would be a condition for that doctor receiving a licence to practise. Registration is granted on a full basis and language is assessed after registration.
The noble Lord, Lord Turnberg, questioned the quality of the training of specialists who come from other EU countries and asked what was being done to assure the safety of those doctors. If the specialism of a doctor is listed as a specialism under the directive then he or she will be required to comply with the minimum training standards set out in the directive. However, I will seek the advice of the GMC on this matter and will write to the noble Lord accordingly. A similar point was made by the noble Lord, Lord Kakkar, around the competency of EU doctors. I am sure he will know that it is not possible for the GMC to assess the competency of an EU doctor on registration. However, the council could assess an EU doctor’s competency in fitness-to-practise proceedings if questions are raised about the competence of that practitioner.
The noble Baroness, Lady Finlay, asked who would bear the cost of the fitness-to-practise case where there were language concerns. I can confirm that a doctor will not be required to pay for his or her own assessment in fitness-to-practise cases. The GMC has confirmed that it will bear this cost. She made the point, rightly emphasised by a number of noble Lords, including my noble friend Lady Brinton, that good communication skills are about more than just language competence. The issue is one that falls squarely to the GMC and we look to the council to ensure that it is addressed in guidance. If communication skills result in deficient professional performance, that matter could certainly be considered as part of a fitness-to-practise issue.
The noble Baroness spoke with her customary experience about the International English Language Test. On 25 February, the GMC announced a change in the score it requires in the English language test. As she pointed out, this is a test that many international medical graduates currently use to demonstrate their knowledge of English when they apply to join the register. Currently, IMG applicants must achieve a minimum score of seven out of nine in each of the four elements, and an overall score of seven. From the middle of June 2014, doctors will have to achieve a higher overall score of 7.5. They will continue to have to achieve scores of at least seven in each of the four domains. The new requirements for IELTS will be the same for all those applying to join the register. This move follows research commissioned by the GMC which suggested that the level should be enhanced. Moreover, IELTS will be one of the pieces of evidence that European doctors can use to demonstrate that they have the necessary knowledge of English.
My noble friend Lord Bridgeman asked about the extent to which the principle behind this order will be extended to other medical professionals, including nurses. The Government believe that in order to maximise patient safety, nurses coming to work in the NHS should not be able to work unless they have the necessary knowledge of English to perform their job well. Departmental officials are having ongoing detailed discussions with the NMC to seek to establish a system that will enable them to carry out proportionate language checks which are in line with EU law. I cannot give him further detail at this point but I can assure him that this matter is very definitely under scrutiny.
It must also be remembered that registration with the Nursing and Midwifery Council does not guarantee employment in the UK. Individual organisations are responsible for ensuring that the people they employ have the necessary skills for the post for which they are applying. EU legislation does not prevent the employer from assuring themselves that the nurse being recruited is competent, safe to practise, has up to date and contemporary knowledge, and has the necessary language and communication skills.
The noble Lord, Lord Hunt, raised the concern that the test for language competence should not be abused, and asked what safeguards the GMC was proposing in this area. As I mentioned, the GMC will be issuing guidance to provide absolute transparency of what evidence and documents are needed to demonstrate the necessary language competence. That should provide not only the necessary clarity for all applicants but also minimum scope for the kind of abuse that he referred to. It is for the GMC as the independent regulator of medical practitioners in the UK to decide the necessary knowledge of English to practise safely in the UK. As regards the guidance, in its recent consultation it suggested that where there is a cause for concern, similar evidence may be required to what is currently required for IMG doctors—for example, the required score in the academic version of IELTS or that the doctor has a primary medical qualification taught and examined in English. But, of course, in making that determination, the GMC will need to be mindful of EU law and ensure that such requirements are necessary and proportionate in view of the job to be performed.
The noble Lord, Lord Hunt, also asked whether the language requirements will be in any sense new. Systematic language checking is not permitted under the new directive. Any testing, as I mentioned, must be proportionate, and we anticipate that the new directive is likely to come into force in January 2016.
As regards the noble Lord’s other question, about the quality of language tuition where a doctor has been found to be deficient—and he asked whether the GMC will be signposting such doctors to good language schools—I have no doubt that this is an issue that the GMC will consider. However, it is ultimately an issue for it.
I hope that I have succeeded in answering most if not all of noble Lords’ questions. If I have not I will of course write. I conclude by thanking noble Lords for their very constructive and helpful comments.