The UK Experience: Learning from Tough Lessons

1. The UK Experience: Learning from Tough Lessons Jonathan Bracken UK Health Professions Council

2. Murder, Abuse and Tragedy… Murder Harold Shipman Beverley Allitt Abuse William Kerr Michael Haslam Clifford Ayling Clinical Tragedy Richard Neale Rodney Ledward Bristol Royal Infirmary

3. Sexual Abuse William Kerr: convicted in December 2000 of indecent assault and placed on the sex offenders register. Voluntarily removed from the GMC Register in May 2003. Michael Haslam: convicted in December 2003 of indecent assault and rape and sentenced to seven years’ imprisonment (the rape conviction was quashed on appeal). Voluntarily removed from the GMC Register in April 1999. Clifford Ayling: convicted in December 2000 of indecent assault (13 counts on 10 patients) and sentenced to four years’ imprisonment. Erased from the GMC Register in July 2001.

4. Clinical Tragedy Richard Neale: Gynaecologist erased from the UK medical register in August 2000 for 34 charges of serious professional misconduct over more than a decade. Neale had been erased from the Canadian Medical Register on incompetence grounds in June 1985. Rodney Ledward: the self-proclaimed “fastest gynaecologist in the South-east” was erased from the UK medical register in December 1998 based upon 13 charges of surgical incompetence. Subsequently, over 500 women made further complaints about him. Bristol Royal Infirmary: Between 1991 and 1995 children under the age of one undergoing open-heart surgery at BRI had double the mortality rate typical of similar units in England.

5. The Inquiries An inquiry into quality and practice within the NHS arising from the actions of Rodney Ledward (Jean Ritchie QC, June 2000) Learning from Bristol: the report of the public inquiry into children's heart surgery at the Bristol Royal Infirmary 1984 -1995(Prof. Ian Kennedy, July 2001) The “Three Inquiries” Ayling Inquiry (Mrs Justice Pauffley, September 2004) Neale Inquiry (HHJ Suzan Matthews QC, September 2004) Kerr/HaslamInquiry (Nigel Pleming QC, July 2005) Safeguarding Patients: Lessons from the Past - Proposals for the Future (Dame Janet Smith, December 2004) Shipman: The Final Report (Dame Janet Smith, January 2005)

6. ORGANISATIONAL: weak appointment processes lack of support mechanisms for patients CULTURAL: loyalty to professional colleagues tolerance of sexualised behaviour unwillingness to act on rumours STRUCTURAL: poor governance consensus management ineffective disciplinary processes INDIVIDUAL: concerns at being a whistleblower inability or lack of will to scale barriers PROFESSIONAL : less MDT working belief that colleagues “do no harm” weak/opaque regulatory procedures Common Causal Factors

7. Recommendations • Better recruitment, supervision, and training, including guidance on standards of behaviour; • Clear corporate responsibility for health services; • Improved information, advice and assistance for patients; • A professional regulatory regime which: • responds appropriately; • minimises the risk of abuse; and • maximises detection.

8. Reviews and responses Learning from Bristol: The Department of Health's response to the Report of the Public Inquiry into children's heart surgery at the Bristol Royal Infirmary 1984-1995 (January 2002) Good Doctors, Safer Patients: Proposals to Strengthen the System to Assure and Improve the Performance of Doctors and to Protect the Safety of Patients (“Donaldson Review”, July 2006) The Regulation of The Non-medical Healthcare Professions: A Review by the Department of Health(“Foster Review”, July 2006) Trust, Assurance and Safety – The Regulation of Health Professionals in the 21st Century (February 2007) Learning from Tragedy, Keeping Patients Safe: Overview of the Government’s Action Programme in Response to the Recommendations of the Shipman Inquiry (February 2007)

9. The Solution: Regulation Regulate the delivery of care • improved clinical governance • National Institute for Health and Clinical Excellence • National Patient Safety Agency • Care Quality Commission Regulate the professions • increased public involvement • greater rigour and consistency in public protection Regulate the regulators • Council for Healthcare Regulatory Excellence

10. Overarching principles • Protection of patients and the general public must be the overriding priority; • It must be done in a way that minimises any impact on patient care and supports the overwhelming majority of health professionals - who act in the best of patients; • Additional safeguards should build on existing clinical quality and safety processes; • Safeguards should be consistent across all healthcare sectors and apply proportionately to doctors and other health professionals. Based upon Learning from Tragedy, Keeping Patients Safe

11. Pro-Consumer Regulation • The overriding interest is the safety and quality of care that patients receive from health professionals • Regulatory bodies need to be independent of • Government, • Professionals and • all other interest groups • Equally important, regulators must be seen to be independent and demonstrably impartial in their actions • Regulation is as much about sustaining, assuring and improving professional standards, as about identifying and addressing poor practice and bad behaviour Trust, Assurance and Safety: Regulation of Health Professionals in the 21st Century.

12. The Key Issues • composition and accountability of regulators • revalidation • complaints and ‘fitness to practise • education • English language competence • regulation of new professional roles

13. But, it’s not about punishment “We need a system that understands the pressures and strains under which professionals operate and shows understanding, compassion and support where these are appropriate. It means a system that is better able to identify people early on who are struggling, showing the same care to them that they have shown to their patients…” Trust, Assurance and Safety: Regulation of Health Professionals in the 21st Century

14. Conclusion The changing professional compact: • expertise • altruism • self-scrutiny

15. Speaker Contact Information Jonathan Bracken Chief Legal Counsel Health Professions Council Park House 184 Kennington Park Road London SE11 4BU E: jonathanbracken@bdb-law.co.uk T: +44 20 7227 7000