I thank the committee for the opportunity to make this presentation. I hope this will be the start of an ongoing relationship between the council and the committee because a key part of our duty to protect the public interest is that we be accountable. One of the main ways we can do that is to appear before the committee to tell it what we are doing and answer questions. We cover much ground in our work and today I plan to focus on two issues, but we will hopefully address any other issues that arise in questions from committee members.
The two issues I want to address are the inadequacy and flawed nature of the current Medical Practitioners Act and our plans for proactive regulation — what we call our competence assurance structures. These structures will confirm that most doctors practise to a high standard, protect patients from underperforming doctors and allow us to intervene with underperforming doctors to get them back on track before they cause patient harm or harm to their careers. The first aim is to reassure the public, because most doctors do a good job, keep up to date and work well for their patients. Second, we hope to prevent doctors falling away from that type of practice. The prime aim is to protect the public, but we feel we can do that by ensuring that doctors are kept in practice and that they practise to a high degree of competence.
The second issue I want to address is our role in medical education. This probably does not get the coverage it should. The issue is particularly pertinent following the recent Buttimer and Fottrell reports and the ongoing queries from the public as to why we do not have sufficient doctors from our medical schools to staff our hospitals. We need to ensure we produce more medical students. Unfortunately, the council has not been able to do much about this over the past 20 years due to the HEA's cap on EU medical students in our universities.
Members are probably aware that we have produced several reports on medical education pointing out the need for more resources to provide for EU medical students in our schools and the need to increase the capacity of the health service to train Irish doctors. We are concerned that because of lack of resources more medical students are being put into our hospitals, resulting in stress on patients and reducing the quality of medical education. If the recommendations of the Fottrell report are implemented, particularly if allied to aspects of the Hanly and Buttimer reports with regard to training doctors after medical school but before specialisation, that is the way forward. However, in view of the needs of our system, time is short.
The competence procedures for fully trained doctors, the educational plans for medical students and doctors in training will be of little use unless resources are put into them. We also need other changes in the system. We believe there needs to be a licensing systems for hospitals, private and public, so that hospitals are inspected on a regular basis to ensure they can do the job they say they can and patients will be safe when they go into them. As committee members are aware, there is no system currently whereby hospitals must be licensed before they can open their doors to patients. We do not find that satisfactory.
There must also be clinical governance systems. This will mean having a national audit of all procedures in all hospitals and health sites to discover the outcomes for treatments in various areas of the country, compare them across the country and ensure they are up to international standards so that patients get top quality service. Clinical governance would also support doctors, nurses and other staff in the health services in being competent and up to date and ensure there are robust risk management procedures in place so there is minimal risk to patients when being treated.
We also believe there must be action on the templates that have been issued. Members will be aware that the Bill dealing with the Health Information and Quality Authority, HIQA, is currently in the Dáil. It provides an opportunity to provide this type of robust governance structure within the health service. We are somewhat concerned that the legislation will only apply to public facilities, not private ones. In view of the private-public mix in this country, if we have a system in place that only audits the public facilities, patients will not be protected and standards will not be ensured. We ask for this to be examined as the Bill goes through the Dáil.
The plans for an increase in medical student numbers must take into account the needs of patients. Currently, there is no further capacity in the system for medical students, but there are options to use other sites for training students. We have suggested to the medical schools that these should be explored. It is also important that the establishments that grant funding for the establishment of new medical student programmes insist there is a realistic chance that those applying supply the proper outcome for students, namely, proper education based on international standards and research.
In general, doctors in Ireland practise to a high standard and want to show this. However, they are concerned that the type of advocacy I and my colleagues have made over the past few months for change in the Medical Practitioners Act will lead to a new Act that places demands on them without the requisite supports in place to help them deliver on those demands. If that happened, it would be bad for doctors and patients.
We exist in a time when there has been a failure in medical regulation in Ireland, but the real failure has been in the systems. We act under the 1978 Act, which was of its time. The council found out about Dr. Neary from a leak through the newspapers, but acted quickly. Dr. Neary was removed from practice within a short time of evidence being supplied that he was a risk to patients. The timeline was seven to ten days. Unfortunately, we did not find out about him until damage had been done. That is a fault with the general system in the health service and with our regulatory Bill, the Medical Practitioners Act.
Due to my ongoing nervousness about the air travel example, I have been using the example of the NCT. Any car that has been on the road for a certain length of time must have a regular NCT to ensure it is safe to carry passengers and be on the road. We do not wait until there is a major crash on the M50 and people are hurt to check the car that crashed. However, that is what we do with doctors. We wait until something major happens and only then try to see why it happened. We just deal with the doctor rather than what went on around him or her. That is no longer satisfactory.
Dr. Carmody is another example of why our system is not helpful for patient safety. He came to my and my predecessor's attention over many years as someone who should be reviewed in more depth. However, that is not possible at the moment. We can only intervene after patients have been harmed. We are looking for statutory powers to introduce a system of audit, peer review and practice review that all doctors would undergo and that would be especially intense for doctors who give cause for concern.
In 1997, my predecessor, Professor Gerry Bury, who appeared before the committee a few years ago, launched a document for the profession outlining a system of competence assurance for all doctors who complete their training. Since 2000 we have been recording the activities of professional development of most doctors in independent training. We have conducted pilot studies in audit and peer review and we are setting up a pilot study in performance assessment. Some doctors have volunteered to undergo this process and we have just finished a series of interviews with members of the public who will be assessors in this process. We have been very pleased with the number of people who have come forward. We plan to start it in the autumn. Again, I emphasise that this will be a pilot and will be voluntary. We cannot do anything until we get legislation and resources to ensure this will be a nationwide and ongoing activity.
I repeat this issue, which is important. On many occasions since the report into Our Lady of Lourdes Hospital was published I have been asked how patients can be happy that they are safe when they go to see a doctor or go to a hospital. Obviously, knowing that one's doctor is competent is a start. However, unless the systems surrounding the doctor are also competent, a patient cannot be secure in the knowledge of having a safe outcome. We need licensing and inspection of clinical sites, continuing education, audit and risk management for all people and procedures in the health service, which needs to be supported centrally. I believe the model is about to come into the Oireachtas. However, the concern is that it does not apply to all sites. We need all staffs, not just doctors, to be manifesting their competence. This needs to include nurses, physiotherapists, dieticians, administrators and everyone who is involved in patient care. What doctors do is just part of what is needed.
We have a rather large remit, which can be broken down into committees. We were not able to bring everyone along today and we would not have time to talk about all our activities today. Unfortunately our registration takes place at point of exit from training, which in the modern world is unsatisfactory. People finishing their internship go on the register of medical practitioners. They can go on the register of medical specialists when they finish their training, but that is voluntary. Once on that register they remain there for life unless they cause severe problems and are found guilty of professional misconduct, in which case we can ask the High Court to remove them from the register. That is not satisfactory in any profession today and everyone recognises it needs to change.
Regarding the medical schools and postgraduate training, we welcome the Buttimer and Fottrell reports, which we hope will be implemented sooner rather than later. The expansion of places for training students and doctors must not be done at the expense of patients, which means we need more capacity in the system. There must be no dilution in the standards of education in an effort to provide more doctors. We are gravely concerned that people see a market opportunity to build medical schools nationally. We do not feel that is the way it should be done. We should consider the needs of the State and should be looking at a critical mass of expertise and research in the institutions that are granted the licences to provide this education. The council would be concerned if it was expected to accredit every person who was planning to establish a medical school. A partnership approach needs to be taken between ourselves, the educational providers and the legislators on how this moves forward.
We will not address today the issues of ethical guidance or medical ionising radiation, which is an activity of council of which hardly anyone is aware. We are about to write to the Minister to suggest that control of medical ionising radiation should rest outside the council because the people using this radiation for treatment are not just doctors.
Our proposal on competence assurance structures is that everyone who has finished training should be on the register of medical specialists, including general practitioners. All those on the register should need to undergo or show they are undergoing a five-year cycle of activities to maintain their competence. While we believe that most doctors are doing this at the moment, we cannot prove it to the committee and we want to be in a position to do so. We believe that if there is no compliance then the person should not be registered as a specialist and should not see patients as a specialist. However, in most cases there should be remedial processes available to them to get back into a position where they can be in independent practice and see patients.
We will be asking people to provide yearly evidence of such activities, showing that they are involved in audit of their practice, that is they are comparing what they are doing with international high standards, changing their practice if need be and then reviewing it again. That should be a constant part of everyone's work as a doctor. They should be involved in peer review in a formal setting where they sit down with people from their specialty, look at what they have been doing to keep up to date, review the audit and their practice to see if this is satisfactory, and get advice as to what they should do if they need to change it. We also want this to involve non-medical assessors.
For those who give cause of concern that there may be a risk to the public, there should be a more in-depth procedure involving a number of different tools and approaches including visits to their practice, and meetings with patients and colleagues. As I indicated earlier, this would involve trained assessors, both medical and non-medical. Some of the examples given recently that doctors are not capable of doing such monitoring are based on caricatures of assessment and are not based on assessments done by trained assessors. In the modern world this process needs to be trained and professionalised. We have suggested that each year 1,000 doctors in independent practice should undergo an in-depth assessment. Judge Harding Clark suggested 2,000 and we are considering the financial implication of that. However, we will do it once that is what is requested of us.
The current reactive system is bad for patients and doctors. We wait until damage is done. The council has proposed proactive systems that would promote standards, protect patients and show that most doctors are doing a good job. Doctors are afraid that this might be introduced without appropriate resources and legislation and that they would end up carrying even more stress than they do at present. If it is properly resourced and properly legislated for, the profession has nothing to fear and definitely patients can feel considerably better about how they are looked after on a daily basis.
I reiterate the point about medical education, which must be based in academic institutions with the capacity and clinical systems in place to provide high quality education fit for doctors who can deliver high quality care and enter the type of independent practice we have outlined in the years to come.
