Dáil debates

Friday, 23 February 2007

Medical Practitioners Bill 2007: Second Stage

 

Photo of Mary HarneyMary Harney (Dublin Mid West, Progressive Democrats)

I move: "That the Bill be now read a Second Time."

It has been argued that trust, rather than deference, authority, control or contracts, is the fundamental glue that binds people together in our modern, educated and liberal society. In many aspects of the new and better Ireland we are creating and experiencing the old glue of deference to institutions and submission to authority is being removed. Not only has such behaviour lost its binding force, but it is no longer appropriate to the type of society we want to have. It is important that we replace one binding force with another based on mutual respect, accountability and agreed standards. The new structures we are developing need to support relationships of trust.

Few relationships require more trust than the relationship between a patient and a doctor. Like all relationships within society, the personal relationship between patients and doctors and the more general relationship between the public and the medical profession have changed in the past 30 years. It would be wholly wrong and counterproductive to allow ourselves to facilitate the development of an adversarial doctor-patient relationship based on contracts, threats of litigation, mutual fear and suspicion. The role of the Government and the legislators in this Parliament is to take a better route by putting in place structures, laws and processes that support a real and respectful relationship of trust between the public and the medical profession. The development of such a relationship is the fundamental purpose of this legislation.

The Medical Practitioners Bill 2007 updates and modernises the regulation of medical practitioners by the Medical Council. It is acknowledged that the current legislative framework which is almost 30 years old needs to be revised. The Health and Social Care Professionals Act 2005 has been agreed and further legislation governing pharmacists, nurses and midwives will be considered in the near future. Therefore, the Bill before the House is part of a set of legislation aimed at enhancing patient safety, which is at the heart of the health reform agenda, and the accountability of health professionals.

The Bill has been the subject of extensive consultation and consideration. When I published the draft heads in 2006, I was pleased that many organisations and individuals responded with comments on the proposals. A total of 58 submissions were received from members of the public, patient groups, individual doctors and their representative organisations, the third level sector, medical specialist training bodies, Departments, State agencies and other interests. In addition to that consultation process, the Medical Council and other bodies organised seminars to allow the public to debate and identify the key issues which were to be addressed. As the Minister for Health and Children, I am pleased to bring this much needed legislation to the House.

The need to act decisively is more evident than ever following the publication of the reports of various health care inquiries, including the inquiry into events at Our Lady of Lourdes Hospital in Drogheda. The Bill is consistent with the Government's commitment, as outlined in the health strategy, to strengthen and expand the provisions for the statutory registration of health professionals, including doctors. If we are to maintain the trust of patients in the doctors who treat them, we need to demonstrate and maintain quality at all levels. Patients want to know that the service they receive from doctors is based on the evidence of best practice and meets the highest standards. Improving quality involves implementing internationally recognised evidence-based guidelines and protocols and ensuring professionals engage in ongoing education and commitment. The maintenance of trust requires that deficiencies in practice are identified at the earliest possible stage, corrective actions are taken and future progress is monitored. If we are to put people first, we should ensure patients are given more influence and responsibility.

One of the priorities of this legislation is to strengthen and clarify accountability. In April 2006 the Department of Health and Children issued a framework for corporate and financial governance to all statutory bodies, including regulatory bodies, which operate under its aegis. The provisions of the legislation are in line with the Department's framework. The governance procedures and arrangements outlined in the Bill are accepted as normal by public bodies across the wider public sector. The various bodies under the aegis of the Department will have to produce statements of strategy, annual business plans and other documents. The Medical Council's annual accounts will be audited by the Office of the Comptroller and Auditor General. The laying of such documents before the Oireachtas will give the public a chance to see how the Medical Council and other bodies are fulfilling their statutory delegated functions. Some argue that these provisions increase the potential for ministerial or political interference in the workings of the council, but that is not the case. The provisions are about openness, accountability and responsibility which should be embraced by any statutory body undertaking public functions in a modern and democratic society, rather than political interference.

I do not doubt that doctors are working in a much more demanding environment than they previously did. While evidence-based guidelines, tighter professional standards and increased patient rights and expectations are welcome and necessary, they add to the demands faced by doctors. Such forms of accountability will be strengthened by these legislative proposals. This legislation will ensure members of the public are guided, protected and informed in order that they can be confident that doctors are properly qualified, competent and fit to practise on an ongoing basis. Importantly, it will support doctors by allowing them to demonstrate the high standards they strive to maintain on an ongoing basis. It will increase the trust doctors have in the profession and their continuing personal and professional competence and strengthen the confidence of the general public in those who treat them.

The principles contained in the Government White Paper, Regulating Better, have informed the new system of regulating the medical profession. Those who drafted the Bill considered the requirement that consumers should be placed at the top of the policy agenda. The regulation of any profession is enhanced by opening its systems to the new ideas of people who are not members of the profession. In providing for the membership of the Medical Council I have been conscious that the regulation of doctors cannot solely be the remit of doctors themselves with minimal input from patients and other professionals. There are many interested parties and stakeholders who have an important role to play in the regulation of the profession, including patients, employers and other caring professionals who work alongside doctors on a daily basis. However, in opening up the system of regulation it is necessary to take a broader view.

Education is key to quality medical practice, as is research. I have endeavoured to ensure the third level sector, as well as those representing the broader science and humanities areas, are represented. I have also included a representative from the Health Information and Quality Authority. The Medical Council's functions under the legislation will be significant in setting and monitoring standards and quality and this new membership will only serve to enhance that role. The council exists to regulate the medical profession, not to represent the interests of that profession or any constituent group within it. The public interest comes first and everything in the Bill, including the membership of the council, is designed with that in mind.

While it has always been normal practice for medical practitioners to register with the Medical Council, some isolated incidences of non-compliance have occurred during the years. Consequently, for the first time the legislation imposes a clear requirement on all medical practitioners to register with the Medical Council before engaging in the practice of medicine and includes offences with significant penalties attached for breaches of these requirements. The Bill empowers the Minister for Health and Children to designate titles for the sole use of those registered medical practitioners or particular classes of registered medical practitioners on the basis of specific criteria. Such criteria include the potential for harm to the public, as well as the existence of a defined scope of practice. This will help to guide members of the public in their dealings with medical practitioners as to the level of competence of the medical practitioner responsible for their care.

Registration procedures will be more streamlined for all. A new register, including divisions for those undertaking specialist training, those with specialist qualifications and those undertaking a more general scope of practice, will be clear. The system of temporary registration for doctors from outside the European Union will be discontinued, in order to allow for those doctors who have given such significant support to our health service to enjoy the same benefits of registration as their Irish and EU-qualified colleagues and peers. For the first time, doctors with suitable non-EU specialist qualifications will be able to gain direct access to specialist registration. Provisions are also included to help doctors holding refugee status to become registered.

Legal registration and the consequent right to practise a profession confer a professional privilege which demands the adoption of a consistent and ongoing high standard of professional conduct for each registered medical practitioner. We are all aware, however, that sometimes things go wrong. Therefore, a comprehensive fitness to practise structure which can act quickly and appropriately in such circumstances is required. A central feature of the Bill is the adoption of a contemporary approach to fitness to practise issues. In this modern and contemporary context, the Bill provides for a number of routes for complaints and concerns to be addressed, rather than just the existing complex legal process of a fitness to practise inquiry. A mediation process for less serious complaints by agreement of the parties concerned is provided for. The Bill also includes a means for a complaint to be referred to the statutory complaints process established under the Health Act 2004, or to the procedures of another body or authority, or for the referral of a matter to competence assurance procedures, where appropriate.

Openness and transparency in procedures must be demonstrated. During the years it has been of significant concern that fitness to practise procedures are conducted behind closed doors and that the Medical Council is precluded by the existing legislation from disclosing any details regarding the conduct of inquiries. Arising from these concerns, I have decided that fitness to practise inquiries will be held in public. In order to allow for individual situations where this may not be appropriate, provision is included for the fitness to practise committee to decide to hold all or part of an inquiry in private, depending on the circumstances. Any such decision must be taken as a result of a request by a witness, including the complainant or the doctor concerned, to hold proceedings in private. The committee and the council are obliged by legislation to undertake their functions in the public interest. Any decision to hold proceedings in private must satisfy this public interest test.

As a demonstration of the commitment to the support of medical practitioners, a health committee is provided for in order to assist individuals with health issues. However, this procedure should only be used where the committee and the council are satisfied that this can be achieved without risk of harm to patients.

The support of doctors and the protection of patients also require the modernisation of medical education and training processes. Provisions on medical education and training have been significantly developed over those included in the 1978 Act. The overall approach is consistent with the broad thrust of the recommendations of the Fottrell and Buttimer reports on medical education and training at basic and specialist level. As recommended by the Prospectus report entitled, Audit of Structures and Functions in the Health System, streamlining of health service agencies will be progressed further by the dissolution of the Postgraduate Medical and Dental Board established under the 1978 Medical Practitioners Act. The Health Service Executive will assume a significant role in the development and co-ordination of medical education and training, in co-operation with the Medical Council and the medical specialist training bodies. The Medical Council's role in education and training has been significantly redrafted to provide more clarity on the requirement to set standards and develop guidelines to assist all.

This country has bitter experience of what can happen when appropriate systems and supports for the maintenance of ongoing competence and high standards in medical practice are absent. Isolation of medical practitioners, even when working in a hospital setting, can lead to outmoded and outdated practice being continued, to the detriment of and, in some cases, damage to patients. The Lourdes Hospital inquiry report brought such matters into sharp focus. I am determined that we will learn and move on from these matters. As a result, Judge Maureen Harding-Clarke's recommendations have had a strong influence on the drafting of this legislation. Her recommendations for the reform of education and training and ongoing competence assurance structures have been studied and will be implemented in a number of ways.

While we can never guarantee that mistakes will not happen again, this legislation provides an important opportunity to learn from the past and put in place necessary elements to limit the impact of mistakes in the future. In this regard, I consider it significant and imperative that all employers of medical practitioners, not least the Health Service Executive, have been given statutory responsibilities with regard to the maintenance of the professional competence of qualified medical practitioners. The Medical Council will have a leadership role in ensuring doctors comply with what is a new legal statutory requirement for them to maintain their professional competence on an ongoing basis. This will require much commitment from all parties, individual doctors and the teams within which they work, their employers, the medical specialist training bodies and the Medical Council as the regulating competent authority of the profession.

Recognising the importance of these matters, I have ensured the Bill contains provisions which will allow funding for the administration of competence assurance structures and other matters to be provided for the Medical Council. While the council will continue to be funded in the main by the medical profession through the payment of registration fees, I recognise that the State must also share the burden of the costs involved in such issues. There is no doubt that regulation imposes economic costs. However, I consider that these costs will be offset in this case by such benefits as the quality assurance of the competence of medical practitioners; the addressing of public information deficits; strong public representation; the modernisation of the statutory registration and fitness to practise processes; and the bridging of shortfalls in education and training levels.

Deputies have been provided with an explanatory memorandum which sets out in more detail the content of the Bill. I wish to highlight some key elements of the new system of regulation.

Part 1 includes standard provisions relating to commencement, interpretation of terms and repeals. Part 2 section 6 sets out for the first time a statutory objective of the council, which is "to protect the public by promoting and better ensuring high standards of professional conduct and professional education, training and competence among registered medical practitioners".

Section 7 outlines in clear terms the functions of the council which relate to the registration of medical practitioners, the regulation of their education and training at all levels and matters relating to the recognition of qualifications of medical practitioners. The council's functions also include the setting of standards of practice, including advertising, and ethical guidance for medical practitioners, the handling of complaints and inquiries relating to the conduct of medical practitioners, and proactively advising the public on all matters of general interest relating to the functions of the council, its area of expertise and the practice of medicine.

Section 9 provides for the Minister to give general policy directions to the council concerning its functions, but this specifically excludes matters relating to ethical guidance, complaints, inquiries and sanctions. The Medical Council was established in 1978 as a statutory body, subject to oversight by the Minister for Health and Children. It cannot and does not operate in an independent way, despite the views expressed by some. It is important that it has regard to public policy, particularly with regard to areas such as medical education and training.

Section 11 outlines the council's power to make rules and details a range of matters for which the council may make such rules. Rules will be subject to publication in draft form for public comment and all rules of the council must be laid before the Houses of the Oireachtas.

Part 3 provides for the council to prepare a statement of strategy, an annual business plan and an annual report on its activities. A modern public body with powers and responsibilities delegated to it must demonstrate to the public how it plans to undertake its statutory functions and account for its progress and achievements in this regard. Part 4 includes provisions for the membership, committees and staff of the Medical Council.

Section 17 outlines the membership of the Medical Council, which shall continue to consist of 25 members. The membership has been significantly rebalanced. As I have consistently stated, it is my belief that public confidence in the Medical Council requires that a majority of its members should not be doctors. These members will represent a wide variety of interests and experience.

Section 20 outlines the council's power to establish committees to perform any of its functions and provides that persons who are not members of the council may be included in the membership of committees. This will allow all committees of the council to co-opt additional expertise, both medical and non-medical, as required.

The various sections in Part 5 of the Bill deal with the accounts and finances of the Medical Council. The council will continue to be funded by fees paid by the medical profession, but the Minister may provide financial assistance for the administration of competence assurance or other matters with the approval of the Minister for Finance.

Part 6 of the Bill is concerned with a new system of registration of medical practitioners. Sections 37 and 38 are new provisions which make clear that medical practitioners who wish to practise medicine in the State must be registered, unless acting lawfully in another professional capacity.

Sections 39 and 40 provide for the Minister to designate titles which are reserved for use by certain medical practitioners. This could cover, for example, the use of the title "specialist". Offences and significant penalties for breaches of registration requirements are included in this part of the Bill. Section 43 establishes the register of medical practitioners to consist of four divisions: the general division, the specialist division, the trainee specialist division and the visiting EEA practitioners division.

Sections 46 to 49, inclusive, provide for registration in the different divisions of the register. Provisions are included to allow doctors who hold refugee status and who have had difficulties in the past providing the necessary documentation to prove they are in good standing to become registered and to work as doctors in this country. I am pleased that medical practitioners with suitable non-EU specialist qualifications will, for the first time, be able to gain direct access to specialist registration. This will open the door for many senior, qualified international doctors to come to work in Ireland and use their considerable talents and experience for the benefit of Irish patients.

Section 50 concerns the transposition of relevant articles of Directive 2005/36/EC on the recognition of qualifications. This section relates to temporary and occasional provision of medical services by medical practitioners who are already lawfully registered or legally established in another member state.

Part 7 relates to complaints regarding medical practitioners and the procedures for the handling of complaints. The sections outline the expanded grounds for complaint, what actions the new preliminary proceedings committee can and must take, and includes new provisions governing mediation, referral to other authorities and keeping the complainant informed. The committee may appoint persons to assist investigations, if required. The provision allowing for an emergency application to the High Court for an immediate suspension in the public interest is continued.

Part 8 relates to procedures to be followed by the fitness to practise committee in conducting inquiries, once a prima facie case has been established under Part 7. The fitness to practise committee must have a majority of persons who are not medical practitioners. It covers the conduct of the hearing, which generally will be held in public, the powers and protections relating to witnesses and evidence and the report to be given to the council following the completion of an inquiry.

Part 9 relates to the imposition of sanctions by the Medical Council following a finding against a medical practitioner. The role of the High Court in the confirmation of sanctions imposed is maintained and provision is made for rights of appeal to the High Court. The council will be required to notify various stakeholders regarding sanctions imposed, including publication, in the public interest, of such matters.

Part 10 provides for the roles of the Medical Council and the Health Service Executive with regard to the education and training of medical students, interns and medical practitioners undertaking specialist medical training. The provisions of this Part are influenced by the recommendations of the Fottrell and Buttimer reports on medical education and training. It is clear that medical education and training must be undertaken in partnership by the various stakeholders and this part of the Bill emphasises that requirement for co-operation and consultation.

The HSE's new role is also influenced by the dissolution of the Postgraduate Medical and Dental Board under Part 12. The HSE will now be responsible for the co-ordination and development, including funding matters, of medical and dental specialist education and training.

The role of the Medical Council was outlined in a minimalist fashion under the Medical Practitioners Act 1978. Sections 87 and 88 now outline in clear terms the role of the council in setting standards and guidelines on medical education and training, and monitoring adherence to those guidelines. The council will continue to be the body which inspects and approves medical training programmes and institutions at basic, intern and specialist level, and to approve medical qualifications. The Medical Council will also continue to act as the competent authority for the recognition of EU medical qualifications. Relevant articles of Directive 2005/36/EC on the recognition of qualifications are transposed in this regard.

Part 11 is new to the system of regulation of medical practitioners as it outlines new requirements for the maintenance of professional competence of registered medical practitioners. The Medical Council, the HSE and other employers and individual medical practitioners are given statutory responsibilities by this part. The Medical Council must satisfy itself as to the ongoing maintenance of professional competence of registered medical practitioners and must establish a scheme or schemes for this purpose. An appropriate link to fitness to practise procedures is included, where concerns arise as a result of a doctor's participation in the scheme.

Part 12 provides for the dissolution of the Postgraduate Medical and Dental Board and the transfer of its staff, assets and liabilities to the HSE.

Part 13 provides for a number of miscellaneous matters, including a power for the Medical Council to investigate unregistered persons and new provisions regarding licensing for the practice of anatomy. The opportunity is now being taken to modernise provisions dating back to 1832, by giving the council an appropriate anatomy inspection and licensing role.

Schedule 1 outlines the enactments and statutory instruments to be repealed or revoked. Schedule 2 provides for the rules on membership, tenure of office and meetings of the Medical Council, which shall continue to hold office for five years.

As I said at the outset, this Bill marks a further significant step in the process of strengthening and expanding provisions for the statutory registration of health professionals as set out in the health strategy. It is further confirmation of the Government's commitment to the delivery of a reformed health service which has as its core objective the maximisation of the level and quality of care provided to patients in the years ahead. Protecting patients and supporting doctors is at the heart of the policy behind this legislation and I urge Deputies to support the principles it outlines. I commend the Bill to the House.

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