Dr. Tony Holohan:

The Deputy asked about rolling out to all services. She is right that a significant number are being seen in the area of maternity services. That may be more of a reflection on the extent to which questions about maternity services have been current in public discourse and what that leads to than a true variation in the actual risk that attends to maternity services, as compared with other hospital-based services.

In answer to part of one of the Deputy's later questions, we have had good experience in the programme to implement the national incident management system, which has been developed by the State Claims Agency and is now a significant national asset in terms of a standardised way of measuring and capturing all incidents. However, that is not to say that we believe we are seeing a full and accurate representation of all adverse events in what comes through that system.

While Deputy Harty might have a different view, I believe my profession does not have a good track record when it comes to reporting incidents honestly and openly. It is not because people do not actively believe it should happen. Doctors are just not as good at it as other professionals. Nursing staff in the main are much more responsive and responsible when it comes to those kinds of things. We have to take all this into account when we interpret what we see coming through these incidents.

Extrapolating from international evidence on the frequency of incidents, medication error is predominant in numerical terms - not always in significance terms - in patient safety incidence. It could be the wrong drug, the wrong dose or the wrong patient or a combination of those. It could be the right drug prescribed and the wrong drug dispensed. Numerically they contribute the most; we do not see that coming through our systems. It indicates it is unlikely that the pattern of adverse events is significantly at variance with that experienced in most modern developed health-care systems. We want this rolled out to all services. Where safety issues arise, people should be appropriately trained and supported in meeting their responsibilities and requirements.

With regard to the council, if I am getting a sense of what Deputy O'Connell has said, I think we are all disquieted by some of what we see on the news, in particular medical professionals, because of the nature of the process with people being followed by television cameras down the street when perhaps they have no case to answer. I would find it disquieting and Deputy Kelleher is quite right that everybody is entitled to their good name in the first instance. We have to have a situation where there is appropriate accountability and at the same time there is a balance between all of these things. One part of it is the nature of our complaints system. We are doing some work around this now with the Ombudsman, and it would be a matter ultimately for legislation to look at all of this, but the system now has an artificial differentiation between complaints that are clinical in nature and those deemed not to be clinical in nature, and between those complaints deemed to be applying to those that involve doctors and those that do not. We feel that is an outdated way of looking at complaints which sees that all incidents in which doctors are involved, and which become the subject of complaints, are really matters for the regulatory body. Again, I am not sure that is appropriate. In many situations, even when adverse events occur and even where there is a responsibility on the part of a professional, it might not raise a question of that individual's competence. Poor performance does not always imply incompetence and competence does not always imply good performance. There is a distinction to be made between a framework that exists in law around professional accountability, as provided by the Medical Council or the Nursing and Midwifery Board of Ireland, and an appropriate framework around accountability within a service that is provided by professionals, if the service cannot stand apart from its need to account to patients in the first instance for the appropriate provision of safe and high quality services. That is something on which we want to do some further work, to see if we can look at the whole issue of complaints and see how that works for patients.

The committee might be aware that the Medical Council has done some very good work in analysing some of the complaints that they have experienced from whatever source over an extended period of time. It brought quite a bit of intelligence into this area. It has shown that in fact it happens very rarely in relative terms that service providers make complaints against individual practitioners which would put us at odds with other jurisdictions. Across the water service providers are frequently those who provide a lot of audited evidence of poor professional performance when they believe there is a regulatory issue arising for an individual practitioner. That does not really happen at all, to any appreciable extent, in Ireland. The other analysis shows that the percentage of complaints brought by patients that come through to a significant sanction is really very low. As an avenue for patients to pursue an issue where they may well believe that a medical practitioner has a case to answer, it does not appear that the Medical Council and that route is one that brings any redress for patients. That brings us back to the idea that the service has a responsibility in the first instance. In many issues where adverse events have occurred to patients it is the service that needs to provide the answer and not always the individual practitioner. It rarely actually relates to competence.