Medical Act 1983 (Amendment) (Knowledge of English) Order 2014

Lord Walton of Detchant Excerpts

Tuesday 11th March 2014 Grand Committee

[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.

NHS: NICE-appraised Medicines

Lord Walton of Detchant Excerpts

Thursday 27th February 2014 Lords Chamber

[Lord Walton of Detchant (CB)]

My Lords, can the Minister say what consideration the Government are giving to the availability of the highly expensive so-called orphan and ultra-orphan drugs that are now coming on stream, which are effectively treating many rare diseases?

[Earl Howe]

My Lords, this important class of drugs will be subject to a special evaluation process by the National Institute for Health and Care Excellence. That methodology has been worked through and over the coming months we will see NICE evaluating orphan medicines and medicines for highly specialised conditions to inform clinicians in the NHS and, where appropriate, provide a funding direction for those drugs.

NHS: Patient Data

Lord Walton of Detchant Excerpts

Tuesday 25th February 2014 Lords Chamber

[Earl Howe]

My Lords, we take that concern extremely seriously. The draft text that has been published by the so-called LIBE committee would, if enacted, pose serious obstacles for our research effort in this country. We are taking every opportunity and using every effort to persuade both the Parliament and the European Commission that the original text is the one we should go with. That work is on-going and the Ministry of Justice is leading on it.

[Lord Walton of Detchant (CB)]

My Lords—

[Lord Cormack (Con)]

My Lords—

--- Later in debate ---

[Earl Howe]

My Lords, I have seen quite a lot of comment on this aspect of the issue in the press. At present, the Information Commissioner’s Office already has the power to impose a fine under Section 55A of the Data Protection Act and the current penalty is up to £500,000, which is quite a severe penalty. To amend that would require changing the Data Protection Act and, at the moment, the Government have no plans to do that.

[Lord Walton of Detchant]

My Lords, does the Minister accept that all appropriate steps are being taken to protect the anonymity of these data? In the light of that, is it not more important to the future of medicine in this country that the availability of this massive database should be taken advantage of in relation to medical research, which will in turn have the undoubted effect of giving huge potential for improvement in patient care?

[Earl Howe]

The noble Lord is absolutely correct. It is worth pointing out that the vast majority of medical research in this country relies on fully anonymised data. It does not require patient-identifiable data. An organisation making an application for information that is identifiable would be allowed to do so only if it had obtained patient consent or had been granted legal approval to do so, either by the Secretary of State or the Health Research Authority, or where there is a public health emergency of some kind.

Drug Companies: Medical Trials

Lord Walton of Detchant Excerpts

Monday 24th February 2014 Lords Chamber

[Earl Howe]

My noble friend raises a topical question. The industry’s trade body, the Association of the British Pharmaceutical Industry made clear, in its code of practice in 2012, that companies are obliged to publish all clinical trial results within a year of marketing authorisation and publicly register new clinical trials within 21 days of the first patient being enrolled. That, of course, is a forward-looking exhortation, but we are encouraged by the fact that the industry is taking an increasingly responsible view in this area by publishing data voluntarily, as demonstrated by companies such as GSK, AstraZeneca and Johnson & Johnson. We want to encourage more companies to do the same.

[Lord Walton of Detchant (CB)]

The noble Earl has made very clear the legal background to the present situation. He is fully aware that if a drug that has been fully tested and shown to be highly effective, and NICE has recommended that it should be prescribed to patients, the authorities have the legal responsibility to prescribe it. If, on the other hand, NICE has been given evidence to indicate that a particular remedy is ineffective as a result of negative clinical trials, is it equally incumbent on health authorities to recommend that that drug should not be prescribed?

NHS: Cancer Treatment

Lord Walton of Detchant Excerpts

Wednesday 29th January 2014 Lords Chamber

[Earl Howe]

My Lords, the noble Lord may recall that the Government pledged an additional £750 million to support the cancer strategy. We are doing that, and a range of actions are proceeding there. On the cancer drugs fund, we initially pledged a total of £600 million for the first three years of the fund and we recently pledged another £400 million, making £1 billion in all. I am pleased to say that the cancer drugs fund has so far helped more than 38,000 patients.

[Lord Walton of Detchant (CB)]

My Lords, some two weeks ago, the Minister agreed that, when NICE recommends that a particular form of treatment should be given to patients with cancer, rare cancers and other rare diseases, it is incumbent on clinical commissioning groups to see that those drugs are prescribed. Does the Minister agree that clinical criteria must be employed in reaching decisions as to which patients are to receive those drugs and that age alone must never be a barrier to the prescription of drugs in patients with cancers of that type?

[Earl Howe]

My Lords, I agree. The noble Lord may recall that in December 2012 we worked on a project with Macmillan Cancer Support and Age UK to improve uptake of treatment in older people. That established some key principles for the delivery of age-friendly cancer services. In December 2013, NHS England published an analysis of chemotherapy uptake in older people, and that report reaffirmed those principles and set out some new recommendations around improving the uptake of chemotherapy.

Children and Families Bill

Lord Walton of Detchant Excerpts

Wednesday 29th January 2014 Lords Chamber

[Lord Walton of Detchant (CB)]

My Lords, different views have been expressed by a number of noble Lords and I shall speak very briefly. The accumulated evidence relating to plain packaging of cigarettes that has arisen over the past few years is incontrovertible, and for that reason the Government’s amendment is extremely welcome.

So far as smoking in cars is concerned, there is no doubt whatever that passive smoking is extremely dangerous. The concentration of the effects of passive smoking within an enclosed space such as a motor car is particularly dangerous for children. Again, the medical evidence on this is incontrovertible. The point made by my noble and learned friend Lord Scott, on the issue of people smoking in a pony and trap, is an interesting one but could readily be dealt with by regulations under the amendment to restrict the provisions to enclosed motor cars and so forth.

I listened exceptionally carefully to the very erudite and persuasive speech by the noble Lord, Lord Cormack, whose views I normally fully support and accept. Unlike him, who was disgusted by smoking two Woodbines behind the bike sheds, I first smoked a Woodbine in a mining village in County Durham at the age of 10 and I enjoyed it. By the time I was a teenager, I was a regular smoker. When I was in the Army in the late 1940s as second in command of a hospital ship, I could get a can of 50 Senior Service for one shilling and eight pence, which lasted me two days, so I was a heavy smoker. It took me a long time to get over it.

The question I would put to the noble Lord and the noble Earl is this: the noble Lord, Lord Cormack, took a great deal of time to talk about the difficulty of policing this amendment if it were carried into law. But is it any more difficult for the police to recognise someone smoking in a vehicle containing children than it is to recognise someone who is not wearing a seatbelt or using a mobile phone illegally? I do not believe that it is. For that reason, I support the amendment.

[Baroness Hughes of Stretford (Lab)]

My Lords, this has been an important but very long debate. However, my name is attached to three of the amendments in the group and I beg the indulgence of the House to make a few comments in, I hope, concluding the debate before the Minister responds. I want to thank the Minister in particular for his role in responding to the widespread support for standardised packaging within and beyond the House. The crucial role that he personally played in the Government conceding on this measure is recognised across the House. I am also grateful for his commitment on the record today that it is the Government’s clear intention to implement these measures as soon as possible, subject to the outcome of the evidential review. I hope that he can further confirm that the action will follow very swiftly in response to the questions raised by my noble friend Lord Hunt and the noble Baroness, Lady Howarth, about the timetable.

The Government’s intention to bring forward at Third Reading measures to ban proxy purchasing of cigarettes and e-cigarettes, taken together with this amendment on standardised packaging, will make a significant difference to the exposure to and take-up of cigarettes by young people. However, there is one other distinct and significant health hazard to children from smoking that we should include in this package of measures, and that is in relation to smoking in private vehicles and enclosed vehicles.

Our Amendment 57BB would simply enable the Government to bring forward regulations to make it an offence to expose children to tobacco smoke in cars, once the Government, with others, had reviewed the detailed implications and practicalities that such a measure would entail. That process of review and developing regulations would take account of all the questions raised across the House today about what if, would it mean this and would it mean that. It is an enabling amendment.

When it was first proposed by the noble Baroness, Lady Finlay, in Grand Committee, I was profoundly struck by the power of her argument about the particular vulnerability of children in this very enclosed situation and the impact on their health and development at their immature stage. It is obvious. I have heard no dissent in the House today about why passive smoking by children in cars is a very bad thing and ideally should not happen. I will not rehearse those arguments, which have been very well made again today by Members across the House.

However, I want to focus briefly on concerns that have been expressed about the amendment and the arguments against it. There have been three main arguments. One is the basic libertarian argument that people should be free to do what they like in their cars because they are private spaces and should not be fettered. But when we are considering freedoms, as we have done in our history, there is always a balance. Freedom for some is often at the expense of freedom for other people. The balance we are considering here is between the freedom for adults to smoke in cars when they like and the freedom for children not to breathe in that smoke in a situation from which they, by definition, as several noble Lords pointed out, cannot escape.

When responding to the noble Baroness, Lady Howarth, the noble Lord, Lord Cormack, for whom I have great respect, as he knows, said that there is a difference between smoking, which is a legal activity, and other things that we have prohibited in the home in relation to children. But the things that we were talking about then, such as neglect of children and the beating of children, have not always been illegal in the home. They were made illegal because they are particularly harmful to the well-being of children. We take it for granted now that such things are illegal but they were not always. We invaded that private space because of the need to protect children. The same argument applies. Because of the degree of damage that we know smoking in cars causes, we should apply the same argument here.

NHS: Essential Services

Lord Walton of Detchant Excerpts

Tuesday 14th January 2014 Lords Chamber

[Earl Howe]

I fully agree with the noble Baroness and her point about mobility is very well made. However, NHS England has stated to me explicitly that the assumption that there should be a rising trend in the number of operations proportionate to the rise in the number of elderly people may not necessarily be right, so we have to be wary of using a statistic in isolation to prove one thing or the other.

[Lord Walton of Detchant (CB)]

My Lords, can the Minister say whether it is still government policy that clinical commissioning groups should accept the recommendations of the National Institute for Health and Care Excellence in relation to the availability of expensive drugs in the NHS? What sanctions are available for those that do not comply with those recommendations?

[Earl Howe]

The noble Lord is right that when NICE gives a positive appraisal on a medicine, whether it is for a rare or a common disease, the funding for that medicine must be available through CCGs or NHS England. If a patient is denied the drug, contrary to the instructions or wishes of their clinician, then there is a route of appeal through either the clinical commissioning group or NHS England.

G8 Summit on Dementia

Lord Walton of Detchant Excerpts

Tuesday 17th December 2013 Lords Chamber

[Earl Howe]

My noble friend raises a very important point. I come back to the point that I made a short while ago: people with dementia in practice access all parts of the health and care system. We want all staff who care for people with dementia to be trained to the level of their engagement so as to deliver high-quality care for people with dementia. I mentioned that dementia training was a key part of Health Education England’s mandate. Already, 100,000 NHS staff have received dementia training. As my noble friend will know, decisions on the commissioning of admiral nurses are made locally, but I recognise the work that they do.

[Lord Walton of Detchant (CB)]

My Lords—

[Lord Davies of Stamford (Lab)]

My Lords—

[Lord Walton of Detchant]

Does the Minister accept that much of the increased incidence of dementia is a result of the fact that many of us are living much longer than was the case in the past? Does he further agree that there is clear research evidence to suggest that continuing intellectual and physical activity, care and attention to diet, and control of blood pressure can delay the onset of dementia in many individuals, and that, as a consequence, once early dementia appears, programmes to promote such physical and intellectual activity are very valuable? In such programmes, volunteers play a very important part across the country. What are the Government doing to promote these projects?

[Earl Howe]

The noble Lord, as ever, makes some extremely good points. My department is looking at the role of volunteers in a number of areas. He is right that increased age is the greatest predictor of dementia. It has been estimated that delaying the onset of dementia by two years could decrease the global disease burden by 22.8 million cases by 2050. The point that the noble Lord makes is therefore well made, and I have no doubt that there will be an increasing focus on this over the coming years.

Mesothelioma

Lord Walton of Detchant Excerpts

Thursday 5th December 2013 Lords Chamber

[Earl Howe]

I am very grateful to my noble friend and that is certainly something I can undertake to do, perhaps in conjunction with the British Lung Foundation.

[Lord Walton of Detchant (CB)]

My Lords, what makes mesothelioma such a fatal disease is the length of the incubation period, in that individuals who have been exposed to asbestos may not develop the disease until many years later; indeed, 2,000 new cases have been reported this year. The developments to which the Minister has referred are helpful and encouraging, but have the Government been able to persuade the relevant insurance companies to increase significantly their contribution to the research programme?

[Earl Howe]

My Lords, I said earlier that the discussions between the British Lung Foundation and the insurance industry have not so far resulted in a pledge for further funding, but as my noble friend Lord Avebury has indicated, that door may be open. However, we should bear in mind that asking insurance companies to fund research is an unusual mechanism in itself. I suggest that we should not push the envelope too far because in the end the cost will fall on the industry.

Health: Tuberculosis

Lord Walton of Detchant Excerpts

Thursday 21st November 2013 Lords Chamber

[Earl Howe]

The noble Baroness is absolutely right about the seriousness of the position, especially in some of our big cities. I can tell her that a TB control board has been set up in London, where about 40% of TB cases occur in the UK. The board is developing a dedicated London TB plan to strengthen measures to prevent, diagnose and treat TB in London. There are similar initiatives in Manchester and Birmingham. However, she is also right to say that we need to focus on the rest of the country, not least some rural areas, and the strategy there will be different to identify cases, diagnose them quickly and intervene early. Work is going on to roll out the plans for that.

[Lord Walton of Detchant (CB)]

My Lords, does the noble Earl accept that some years ago there was an increased incidence of drug-resistant tuberculosis in the UK, and it was discovered that that was, at least in part, the result of the disease being detected in an increased proportion of immigrants? When I went to the United States in 1953 as a visiting fellow, I had to take an X-ray with me to show that I did not have TB. What is now government policy on the medical screening of potential immigrants?

[Earl Howe]

My Lords, the policy now is that migrants to the UK from outside the European Union who apply for a visa for more than six months need to be screened in the country of origin. That work is proceeding, although I have to say that implementation has proved patchy, so we cannot be complacent. That is why it is vital to have services in this country capable of identifying people, particularly with multidrug-resistant TB, who may pose a threat to the community in that sense.