Medical Act 1983 (Amendment) and Miscellaneous Amendments Order 2006

My Lords, I thank the Minister for introducing the order, which in broad terms I welcome. I have a few comments and questions. The first main change that the regulations will bring about is the abolition of limited registration for international medical graduates and its replacement with a single registration structure for all doctors. I recognise that the current system is seen as discriminatory towards graduates from overseas and as carrying with it an unwelcome element of complexity. Healthcare regulation has changed a great deal over the past few years and it is right that we should review the merits of having limited registration status when there are other checks and balances in the system, such as appraisal, clinical governance and notably, in the future, revalidation. Nevertheless, we need to remember why limited registration was thought in the first instance to be desirable. It was to introduce an additional safeguard for patients where doctors came to this country without having first gained their qualifications here. We need to make sure that international graduates who will now be eligible for full registration are of an equivalent standard to that of medical graduates who have qualified in the UK. It is impossible for the GMC to vet and approve every medical school overseas, so the suggested answer is to try to introduce an element of testing and supervision of international graduates who are applying for full registration. The PLAB test has been established for many years and will continue. The order proposes that overseas doctors with an acceptable qualification should now be channelled initially into approved working environments where there is provision for adequate supervision. That raises three, perhaps obvious, questions: what should count as an acceptable qualification, how should the approved working environments be selected and what mechanisms will ensure that supervision in those environments is adequate? The answers to those questions will largely lie with the GMC, which, I am sure, is under no illusion as to the need to deliver a system that is at least as safe for patients as the current one. We understand that much of the detail will be spelt out in GMC guidance. In passing, it is reassuring that new Section 21(c) refers to provisional rather than full registration in cases where international graduates who may have passed the PLAB test are nevertheless not able to satisfy the registrar that they have had the necessary clinical experience in their own countries. Knowledge and skill are essential, but, equally, so is experience. Does the Minister agree that it is important for there to be clear criteria governing what should qualify as an approved working environment and that approved status should not necessarily be viewed as being permanent, if, for example, there are reasons to question a particular organisation’s fitness for purpose in this context? The order contains a power for the GMC to erase a doctor from the register if it is shown that he failed to declare an impaired fitness to practise at the time of his registration. There is a distinction to be made here between someone who knowingly deceives the GMC and someone who does not. The order does not make that distinction, and perhaps the Minister could comment on that point. The GMC is also being given power to disclose fitness-to-practise information about doctors, including information about their fitness-to-practise history. If I have a concern about that, it is that doctors should be fairly treated as individuals. The GMC has a policy of not publishing information about the physical or mental health of a practitioner, and that seems right and proper. At the same time, the exercise of the powers granted to the GMC is highly dependent on what its policy happens to be at any particular time. The powers granted to the GMC are extremely broad. Given that we believe in professional self-regulation—and I was glad to hear the Minister’s comments on that point—I am not suggesting that that is wrong. However, where the GMC believes that it is in the public interest to disclose historic information about an individual, it is important for that practitioner to have at the very least an automatic right to make representations to the GMC if he or she wishes. The order allows the GMC to dispose of fitness-to-practise cases without a hearing where the doctor agrees to abide by certain undertakings. There are obvious dangers there. One is that if cases are disposed of in that way without a full hearing taking place, the public may believe that the issues are simply being brushed under the carpet. If an aggrieved patient is involved in the case, he or she needs to have a say before the final decision is taken. I am not sure how many cases the GMC believes can or should be dealt with in this way, but there seems to be a need for some ground rules as to what sorts of case should and should not be eligible for consensual disposal. At the moment, we lack that sort of information. Fitness-to-practise hearings are time-consuming and expensive and it would not be desirable for consensual disposal to be regarded as a cost-saving alternative to due process. Lastly, I should like to touch on the issue of mandatory professional indemnity or insurance. I am aware that there is widespread support for this proposal, which we have debated previously in the context of dentists. However, I have received representations on whether discretionary indemnity provides cover that is as robust and reliable as that provided by conventional insurance. My view is that both indemnity and insurance have their respective advantages and disadvantages and that both should be allowed in principle. However, it should be up to the GMC to draw up its own rules on what should qualify as adequate and appropriate cover. The level of cover for every individual doctor should be subject to regular review to reflect his or her type of practice. The penalties for a doctor not having adequate and appropriate cover are potentially severe, but what matters is that the right cover should be in place. Doctors need guidance on this. I look forward to the GMC publishing its detailed proposals on all these matters. Meanwhile, I am content for the order to be approved.