Health and Social Care Bill

Lord Ribeiro Excerpts

Monday 13th February 2012 Lords Chamber

[Lord Ribeiro]

My Lords, my name is on this amendment, and I wish to say a few words about it. First, I welcome the amendments moved by the Government in Committee which give the Secretary of State a duty to secure medical education and training. A comprehensive health service cannot be achieved without a properly trained and educated workforce. Health Education England, as a Special Health Authority, not only must be given the authority to influence the function of local education and training boards in the short term, as it is established this year, but must influence local providers of all sorts—private, NHS or any other type—and other organisations responsible for the education and training of their workforce.

The influence of Medical Education England and the Medical Programme Board, of which I was a founder member after the MMC/MTAS débâcle, will provide HEE with invaluable information about the oversight of doctors and dentists. For that reason, I believe there should be a medical director of MEE within HEE. While I welcome funding for education resting with Health Education England, as mentioned by the noble Lord, Lord Patel, I remain concerned that the education levy will be raised from providers who may not have the same objectives and consider that their obligation to patient care trumps their obligation to provide training.

I have concerns about who should be responsible for quality assurance and through that for quality improvements. I believe it would be best to have this done at national level. The LETBs and providers cannot be judge and jury in relation to quality assurance and the principle of independent assessment and assurance must be maintained. Quality control and quality management are local functions, currently performed by the deaneries. Quality assurance and quality improvement, which imply that after the assessment lessons can be learnt and good practice passed on, must be at national level. They must have input from the profession to provide the appropriate oversight. In this regard, royal colleges, as national bodies, are ideally placed to assist deaneries in providing independent quality assurance and quality improvement. I hope the Minister will give assurances that this will be the case.

More specific functions of HEE as a Special Health Authority are outlined in Amendment 16. It may present more of a problem for the Government as the role and function of the LETBs are not defined in the Bill. If they are to take responsibility for funding, then the lessons of the strategic health authorities’ 2006 raid on the education budget to balance the NHS budget must be learnt and the education and training budget must be ring-fenced to prevent this happening. I hope the Minister can give the House assurances on this point.

[Lord Turnberg]

My Lords, my name is also attached to Amendment 13. The case has been very well made by the noble Lord, Lord Patel, so I have very little to add, except that it is obvious that education and training are a key part of any service provision. For a service under pressure, looking after the patients always comes first, and it is very difficult in some circumstances to provide the time that education and training need. It takes a bit longer in an outpatient clinic to teach a young medical graduate; it takes longer in the operating theatre, I suspect, to show how it should be done. It takes time to allow junior trainees to go on education courses and rotations. The pressure on a service is always to concentrate on caring for the patients, and education and training can easily be given a back seat. This amendment helps straighten that balance.

--- Later in debate ---

[Lord Ribeiro]

My Lords, I would like to comment on the good medical practice to which the noble Baroness, Lady Finlay, referred. It was introduced some time ago to ensure that medical practitioners would know how to communicate with their patients and were always honest and truthful when things went wrong. In surgery, we produce good surgical practice to complement that exercise. In relation to patient communication, we require surgeons to keep patients fully informed both during and after their treatment. We require them to act immediately when patients suffer harm and to apologise.

As for anecdotes, I had one patient on whom I operated for varicose veins. I pulled up something in the back of her leg that looked like a vein, but in fact it was a nerve. The net result was that the next day she had a foot drop. I went to see her and explained that I had made a mistake—I thought that it was a vein but it was a nerve. I said that we would get a plastic surgeon to see her and we would re-explore the nerve to see if it was all right. The operation was done, and, fortunately, the nerve was not torn. The period required for regeneration was likely to be six months. Every time she came to my out-patients’ clinic—although she was a private patient—I used to get a terrible feeling in the pit of my stomach, because I could hear her coming down the corridor as her foot drop made a flopping sound on the floor. She would sit down opposite me and say, “You know, I really ought to sue you”. She never did, however, because she had been told straight away the whole truth of what had gone on.

Therefore, I have tremendous sympathy for this duty of candour. What worries me is that we could end up with a contractual mechanism in legislation that leads to nothing more than a tick-box exercise. The problem with such exercises is that people will fill them in to try to avoid the legal implications that we have heard of. They will try to avoid litigation. The quality of any genuine explanation may well be lost in such a mechanistic approach. Although it has taken five or six years since the CMO first introduced this concept, we need to do very much more to change the culture. I hope that with the creation of new organisations such as local healthwatch there will be opportunities to raise the profile of the issue and to achieve the sort of explanations that patients rightly deserve.

[The Countess of Mar]

My Lords, when my daughter was a little girl I brought her up to tell me immediately if she had done something that she should not do or if she had had an accident, and to say sorry, and she would be forgiven immediately. It has been my experience with the OP sufferers from sheep dip, Gulf War veterans and ME sufferers that, if a mistake has been made, all they want is an apology and an explanation and to be able to say, “Please do not do it again”. That has happened over and over again. I have a drawer full of letters from people saying that.

I suspect that it is not necessarily the doctors and nurses—the medical practitioners—who are covering things up when there is a cover-up. It might be what we euphemistically call the pen-pushers—the people behind the doctors and behind the organisation who are afraid that the organisation will come into disrepute. That is where much of the problem lies. Many doctors would like to be able to say, “I’m sorry—I made a mistake”, but they are held back, which is what the noble Lord, Lord Harris of Haringey, said. If we are going to change the culture, we must start with leadership. We have heard about leadership in nursing. A nurse leader or a doctors’ leader can say to the whole of his team, “If you make a mistake please come and tell me immediately and we will go and tell the patient”. That would wipe out a whole lot of anxiety.

The noble Lord, Lord Faulks, talked about litigation. People go to law because they are angry. They have not had an explanation and they are worried that something has gone wrong with a relative or themselves. That is when they go to law. That is what happened with the sheep-dip farmers, and it certainly happened with the Gulf War veterans when Mr Soames, the MP with responsibility for the Gulf War veterans at the time, said, “See you in court”. They rise to that. If people have an explanation, they will accept it. Everybody makes mistakes, and they will understand it. So I support the noble Baroness, Lady Masham, in her cause.