§ Mr. Martin Salter (Reading, West)
I am pleased to have been given this opportunity to highlight the campaign by my constituent, Mr. Raymond Hook, who is here today, to get to the bottom of the circumstances surrounding the tragic death of his beloved wife, Vicki, on 5 April 1996. In doing so, I shall describe the shoddy way in which Mr. Hook has been treated and the inadequacies of current NHS complaints procedures and, I hope, make a powerful case for the reform of those procedures. I shall also be seeking an assurance from the Minister that she will use her powers to grant the independent medical review for which Mr. Hook has been striving, and to which he is entitled.
Before I continue, I apologise if my delivery is somewhat less energetic than usual. I am suffering from that dreadful flu bug—although not badly enough to prevent me from pressing my constituent's case.
I am aware that there is considerable media interest in the case, and I have been critical of the way in which Mr. Hook has been treated by the NHS. However, I also wish to put on the record my appreciation of the NHS in Berkshire, which coped with unprecedented pressures over Christmas and the millennium period. Those were made worse by the flu virus that I have brought with me today. I have seen a report to the board of Berkshire health authority on its performance over the holiday period, and it makes a mockery of the recent over-hyped scare stories about the NHS that have been appearing in some sections of the national press.
It is worth highlighting three points from the report. First, the detailed planning paid off, and the extra moneys that were made available by the Government were put into primary care, thereby protecting the emergency beds and helping the NHS to cope with the flu outbreak. Secondly, waiting lists were shown to have risen by less than would normally be expected under such circumstances. Thirdly, there was only minimal disruption to the work of the acute hospitals, and they were soon back to carrying out routine elective surgery. That is clearly at odds with the attempts of some of our newspapers to portray our health service as an organisation in deep crisis.
I shall now describe the plight of my constituent, Mr. Hook, and the less than satisfactory service that he has received from the local health authority. Mr. Hook came to see me at one of my regular advice surgeries on 27 March last year, some three years after his wife's death from a brain tumour. Since that time, apart from a period of intense grieving, Mr. Hook has been tirelessly seeking to get to the truth as to why his wife Vicki was not referred by her GP, Dr. Sanders, for a scan in time for medical treatment that stood a good chance of success. He has exhausted all the avenues that are open to him in the face of obstruction and intransigence from the Medical Defence Union and bureaucratic delays, including the unforgivable loss of medical records by the health service management. Mr. Hook has been to the health service ombudsman, who, tragically, could not help. Although his jurisdiction to cover complaints about GPs had recently been extended, it only covered events that occurred on or after 1 April 1996.
The alleged misdiagnosis by Dr. Sanders occurred in January 1996, less than three months short of the qualifying date.
100WH Mr. Hook made his first complaint through the national health service complaints procedure in March 1997, 11 months after his wife's death, and immediately fell foul of the rule stating that a complaint must be received within six months. I do not know how a bureaucrat can be so brutal and heartless as to construct a set of rules that take no account of the depth of grief and loss incurred by someone. It is fundamentally wrong to treat a complaint about plastic surgery in the same way as a complaint about the loss of a life.
After much argument and delay, the objections were overcome and Mr. Hook was offered local resolution. He was told that his complaint would be investigated by the head of the general practice concerned. That led to the second problem—Dr. Sanders was the head of the practice concerned. How could that local resolution be satisfactory? Understandably, Mr. Hook refused local resolution and took his complaint direct to Berkshire health authority. A hearing was established under a convenor in January 1998 to consider an independent review of Mr. Hook's complaint against Dr. Sanders. Despite the ruling that, with hindsight, Dr. Sanders' diagnosis was incorrect, the convenor rejected Mr. Hook's request and he was again referred to the ombudsman. To add insult to injury, Mr. Hook was denied access to the clinical advice that was made available to the convenor. That was monstrously unfair and unjust.
In May 1998, Mr. Hook again wrote to the health service ombudsman outlining the circumstances of his wife's death as he saw them and the failure of Dr. Sanders to refer Vicki to a neurological consultant as a matter of urgency, despite advice from her optician. Tragically, an appointment with a neurologist was received for 24 June 1996, 11 weeks after Vicki's death.
Vicki's medical records for the preceding four years showed constant headaches, blurred vision, double vision, extreme tiredness and the comment "all very bizarre". Despite that, when she visited Dr. Sanders on 12 January, she was told that there was nothing to worry about and that there was only a problem of tunnel vision. During the February of her last year, Vicki's condition continued to deteriorate and she had become incontinent. Dr. Sanders then called in a psychiatrist, who sent Vicki to a psychiatric hospital, which arranged for her to see a consultant neurologist, Dr. Hyam, who immediately arranged a brain scan for the next day. That scan revealed that Vicki had a brain tumour in an advanced state. She was transferred to the John Radcliffe hospital in Oxford and died in the intensive care unit following a biopsy on 5 April 1996. Subsequently, Dr. Sanders told Mr. Hook and his daughter that in his opinion the tumour had been forming over the previous four years and that he would have done things differently with hindsight. At around that time, some of Vicki's medical records mysteriously went missing from the local hospital trust in Reading.
Hopeful that the ombudsman would find in his favour, Mr. Hook was shattered to be told that he was still falling foul of the 1 April 1996 rule. He had been sent, deliberately, round the same circle a second time for no purpose.
Not being someone to give up, Mr. Hook commissioned his own medical report. Having finally obtained the necessary medical records, Dr. Rogers produced a devastating critique of the situation on 101WH 6 October 1998. It claimed that Vicki Hook should have been admitted to a medical ward much earlier and that, if she had been, it was possible that her life could have been saved. Mr. Hook then presented his new evidence to Berkshire health authority in November 1998 in support of his call for a full, independent, medical review. That was rejected and as the local community health council was unable to help and he had exhausted the NHS complaints procedures, his only remaining option was to seek the help of his Member of Parliament.
I have the greatest respect fo the new chairman of Berkshire health authority, Mr. Bernard Williams, but it was he who eventually ruled that Mr. Hook could not have an independent medical review because Dr. Rogers' work constituted a new opinion rather than new evidence and, furthermore, it was felt that such a move would be liable to a procedural challenge by the Medical Defence Union and result in a field day for lawyers. That is a stunning indictment of the NHS complaints procedures.
I have read the recent evaluation of the effectiveness of the complaints procedures, which was published in September last year by the Public Law Project. It provides instructive but unpleasant reading for those who are responsible for the NHS. For example, it criticises local resolution because it lacks impartiality and transparency. It is scathing about the ability to deal with complaints that raise serious questions about performance, conduct or competence, which may place patients' lives at risk. In other words, it is high time that the conflicts of interest and the impression of professional collusion and cover-up were ended. The report calls for greater independence and efficiency in the establishment of independent reviews.
My constituent, Mr. Hook, asked me to make some specific points when pressing for reform of the NHS complaints system. First, time limits should allow for a proper period of grieving. Secondly, local resolution cannot be achieved with an individual GP practice when the complaint involves the head of the practice or anyone in that practice without some independent input. Thirdly, why are people told that they have only six months in which to lodge a complaint, when it took Berkshire health authority 12 months to decide not to grant an independent medical review? There must be an open and transparent appeals process. Fifthly, relatives of deceased patients must be told of their right to see copies of the patient's medical notes. Finally, is it right that the GP who provides the first medical assessment of the complaint may be drawn from the same health authority area?
I want to read a short extract from Mr. Hook's last letter to me, which makes the case for action more powerfully than I ever could. It states:I can fully understand why people stop trying to see an independent review with what I have had to go through for the last three years and I feel it would be better if people's hopes of obtaining an independent review were not put up as an option in the first place. This merely adds to the cruelty of the situation.If you cannot get a review when two medical reports are completely at odds with each other when can you get one? The word 'independent' is wrong as all decisions taken are 'in house' and are not transparent. My advice to anyone contemplating 102WH trying to get an independent review is don't unless you are prepared for many brick walls to be put in front of you and a long hard struggle.Surely the Government wants an N.H.S. procedure that has the confidence of the public—not one that in certain circumstances leaves the bereaved feeling bitter and disillusioned? Please press our Health Ministers to look again into the situation surrounding my wife's death. We cannot bring her back but I don't want others to suffer as I have been made to.My efforts have merely moved matters to the desk of the chairman of the NHS region and from there back to the new chairman of Berkshire health authority, but to no avail. Mr. Hook's last hope lies with the Minister, and I trust that she will rise to the challenge. I hope that she will use her powers to grant Mr. Hook his independent medical review and change the NHS complaints procedures to ensure that others are not forced to endure the same indignities that have been imposed so unfairly on my constitutent.
§ The Parliamentary Under-Secretary of State for Health (Ms Gisela Stuart)
I am grateful to my hon. Friend the Member for Reading, West (Mr. Salter) for bringing this case to my attention. I also preface my response by thanking him for his powerful and supportive words about the way in which his local health service has dealt with him in the past few weeks. I offer my sincerest condolences to Mr. Hook for his loss and appreciate that trying to pursue his complaint must have been traumatic for him. I have examined the case and I should make it clear from the outset that he has now exhausted the NHS complaints procedure.
My hon. Friend asked me to use my powers to compel Berkshire health authority to grant Mr. Hook an independent review panel to investigate his complaint further. At the same time, my hon. Friend, using powerful words such as "collusion" and "collapse", said that he wished that the complaints procedure were independent. It is independent in the sense that, as a Minister, I have no powers to order the authority to do anything. The mandatory framework for the NHS complaints procedure is set out in secondary legislation, so it has the force of law. Neither I nor my ministerial colleagues have any authority within that legal framework to instruct the NHS to deal with a particular case in a particular way. That is entirely right and proper.
It is clear from my hon. Friend's remarks that Mr. Hook, having been unable satisfactorily to resolve his concerns through the NHS procedure, approached the health service commissioner—commonly known as the ombusdman. Unfortunately, however, the commissioner could not investigate the substance of his complaint because it related to clinical decisions taken at a time when they were outside his jurisdiction. I can appreciate that this must have been very frustrating for Mr. Hook, but primary legislation, such as that governing the role of the ombudsman, is not generally made retrospective. Inevitably, some people will find themselves on the wrong side of the implementation line.
The ombudsman has some power to be flexible, but only if he has good reason. He will make the decision. He can look at how an NHS body has dealt with a complaint, even if the substance of the complaint is 103WH outside his jurisdiction. I do not know whether Mr. Hook has approached the ombudsman about the health authority's handling of his case, but if he has not, he may wish to consider doing so. I remind my hon. Friend, however, that the ombudsman is not obliged to take up every case that is submitted to him, even when it is within his remit. The ombudsman is entirely—and rightly—independent of both the NHS and Ministers.
I turn to the issues raised in the powerful letter, which my hon. Friend quoted, from Mr. Hook, in which he said that he would not want anyone else to suffer as he had. I want to say something about the Government's initiatives, the NHS complaints procedures and the project to which my hon. Friend referred. We must start by recognising that people who are ill are at their most vulnerable. They have a right to expect the NHS to provide them with the treatment that they need and that is appropriate to their condition. That applies whether they contact their GP or have to stay in hospital. The previous Government left the legacy of a two-tier complaints procedure, which we shall tackle shortly. When dealing with a service that relies heavily on human beings, errors will occur, as none of us is infallible. When mistakes occur, it is our challenge to examine the issues and put in place systems that try to minimise human errors to the lowest level possible. Patients and representatives need to express their dissatisfaction and concerns when mistakes are made.
The current complaints procedure was implemented in April 1996, following a major external review of the previous arrangements, which had generally been accepted as unsatisfactory. The new system—if it can still be called new after four years—has been to develop a mechanism that is basically the same, whichever part of the NHS a patient wants to complain about. It focuses on complaints being dealt with quickly but thoroughly at local level. A wholly new, more independent review of the complaint has been introduced for those cases that cannot be resolved by local action. A non-executive director of the NHS body concerned re-examines the complaint and reaches one of three decisions. I remind my hon. Friend that there is often a presumption that because the convenor is a non-executive director, he is part of the system, but non-executive directors are appointed by the Secretary of State. They are an independent part of a local structure and they are expected to act as such.
If the matter cannot be resolved locally, these non-executive directors may reach one of three decisions. They may decide that more can be done locally and advise accordingly. They may take the view that all that could reasonably be done to satisfy the complainant has been done and that no further action can be taken. Finally, they may decide that the issues can be resolved through a formal investigation by an independent review panel.
These changes represent a major sea change and are simply the beginning of a much wider process. The change that is most marked is in the primary care sector. In the past, GPs and family dentists were used to a system that was constrained by having to consider complaints only in terms of whether the standard terms of service had been breached. That was an adversarial, disciplinary approach that tended to leave both complainant and the individual complained about dissatisfied. Now they are expected to have effective 104WH practice-based procedures for dealing with complaints. Understandably, it has taken a while for some practitioners to get fully to grips with the new world.
When a system that brings about such significant changes as this one is put in place, it is inevitable that it is not welcomed across the board. Independent commentators have felt the system to be impartial, which is a good deal better than what we had before. We are aware of the criticisms, some of which have been very public—not least the recent report by the Select Committee on Health, when it inquired into procedures relating to adverse clinical incidents and the outcomes in medical care. We shall, of course, respond formally to the Health Committee.
I draw my hon. Friend's attention to an independent evaluation of the complaints procedure, which is under way. It is a major UK-wide study, it is about half way through its work, and it is looking at all aspects of the system. We need to examine the whole system; it is not piecemeal reform. The study has three key objectives: to highlight barriers to the effective operation of the procedure; to suggest ways of overcoming them; and to identify examples of good practice that can be shared with the NHS as a whole. Again, we want to ensure that good procedures are in place wherever a patient lives. The evaluation project's final report will be submitted to the Department of Health at the end of this year and we shall consider it carefully.
I was particularly encouraged this morning to read the parliamentary briefing issued by the NHS Confederation, which supports the evaluation project and our commitment to a complete and systematic examination of the procedures, rather than piecemeal tinkering at the edges. Such a conservative approach is exactly what we want.
My hon. Friend mentioned the research on the complaints procedures published by the Public Law Project last year. The study focused on the complainant's perspective, whereas one of the key features of our evaluation project is that it will be informed by the experiences of a whole range of people involved in the operation of the procedures. It is worth mentioning, too, that despite the clear statement of consumer focus, the PLP study interviewed only 36 complainants during the two years of its work. Our evaluation will involve literally hundreds of interviews. We welcome anything that will contribute to an informed debate on the issues.
§ Mr. Salter
Will the Minister deal with one matter that I raised and say whether the current evaluation, which is welcome, will cover time limits for complaints to be received? If not, will she ensure that it does? My hon. Friend said that Ministers have little power to intervene in complaints. Is she saying on the record that no Health Minister has ever intervened and that Ministers have neither the ability nor the power at least to express a view to the chairman of the health authority?
§ Ms Stuart
I remind my hon. Friend that discretion is already available to investigators. Strict time limits are set for medical negligence cases, but discretion to deal with complaints about procedures is exercised by the ombudsman.
105WH As to impartiality, we must recognise that, when Government Departments set up independent structures to investigate procedures, Ministers have the responsibility to satisfy themselves that the structures are formed in such a way that they can respond. However, once the process is started in a particular case, it is impossible for procedures not to be properly followed. In this case, the procedures were followed. However, I would like to take it further.
I do not want anyone to be under the impression that we are not deeply committed to improving the system. It is not perfect. It needs improving, hence the PLP evaluation. Despite our feelings that 36 complaints may be a small base, I put it on record that the team is evaluating the report and there have been continued contacts with the complainants.
In the limited time available, I want to be sure that my hon. Friend is aware of the work that goes into reducing the incidence of complaints arising from the practices of general practitioners or doctors working in hospitals. It is important not to focus only on how to deal with mistakes; we try also to ensure that the number of mistakes is reduced. The NHS should function in a way that keeps mistakes to an absolute minimum, and all parts of the NHS should work to the same standards. The National Institute for Clinical Excellence and the national service frameworks will help the NHS to achieve that. Clinical governance, underpinned by a statutory duty of quality, will provide the NHS with the mechanisms for translating national standards into high-quality local services. However, neither NICE nor the Commission for Health Improvement can provide a quick fix.
I want to focus on our work in relation to general practitioners and doctors. To meet the high standards that we expect from general practitioners and doctors, we must ensure that those few who do not work hard and with total commitment—I stress that the vast majority do—are dealt with fairly quickly. Last November, the chief medical officer published the consultation document that began the process, entitled "Supporting Doctors, Protecting Patients". The second part of the title is the most important. The document sets out a new approach to how the NHS and the medical profession deal with poor professional performance.
The document makes proposals in five key areas. First, it suggests better prevention and earlier recognition of poor clinical performance. Secondly, it would require fast and effective action to evaluate emerging poor individual performances by referring them to an assessment and support centre that will advise on appropriate action. Thirdly, it suggests a 106WH consistent approach across all grades and types of doctor, including those in primary care. Fourthly, it suggests a closer working partnership between the NHS, the General Medical Council, the royal colleges and other professional bodies. Last, and by no means least, it would require strong patient participation in the new mechanisms. Taken together, those proposals will create mechanisms that will allow problems to be identified quickly, before patients are put at risk, yet provide the necessary help and support for the clinician.
Separate from those proposals, but parallel with them, the General Medical Council has plans to introduce revalidation, to ensure that the continued inclusion of a doctor's name on the medical register represents an assurance that the doctor has kept up to date in his chosen field and remains fit to practice.
I am only too aware that my remarks will have been of little comfort to my hon. Friend's constituent. I acknowledge that. However, it would have been wrong to offer Mr. Hook false hopes, when the fact is that few options are left to him to enable him to pursue his complaint further. Nevertheless, I would not want him to think that his efforts—and those of my hon. Friend, who has spoken on his behalf—have been in vain. The south-east regional office of the NHS executive will be working with the health authority to ensure that the lessons from this distressing case are learned. And there are lessons to be learned. Equally, it is vital that we get to hear about cases like Mr. Hook's.
§ Mr. Salter
If, as the Minister said, procedures had been properly followed in this case, will she please explain why there are lessons to be learned?
§ Ms Stuart
Even though procedures have been followed, it does not mean that their implementation cannot be improved or that we should not consider changing the procedures or the framework.
It would be wrong of me to offer hope or to promise something that cannot be delivered, but it is important that cases like Mr. Hook's are brought before such a forum as this, and that we should be able to revisit them. We should not consider only forward-looking complaints procedures, although we recognise that they are not satisfactory. We should look back and revisit the procedures that have been followed.
I assure my hon. Friend that we will give careful consideration to the matters that he has raised today. I would not want him to go away feeling that his time had been wasted. It was a valuable debate, and I am grateful to him and his constituents for being here today.
Question put and agreed to.
Adjourned accordingly at four minutes to Two o'clock.