COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY

OFFICIAL REPORT
(Hansard)

Dental Issues in the Belfast Health and Social Care Trust

10 February 2011

Members present for all or part of the proceedings:

Mr Jim Wells (Chairperson)
Mrs Michelle O’Neill (Deputy Chairperson)
Mr Mickey Brady
Mr Pól Callaghan
Mr Alex Easton
Mr Tommy Gallagher
Mr Sam Gardiner
Mr Paul Girvan
Mr John McCallister
Ms Sue Ramsey

Witnesses:

Professor Donald Burden	)
Mr Colm Donaghy	)	Belfast Health and Social Care Trust
Dr Tony Stevens	)

Dr Andrew McCormick	)	Department of Health, Social Services and Public Safety
Mr Donncha O’Carolan	)	Department of Health, Social Services and Public Safety

The Chairperson (Mr Wells):

I welcome the witnesses, who are well known to most members. With us, we have Dr Andrew McCormick, who is the permanent secretary; Mr Donncha O’Carolan, the Department’s Chief Dental Officer; Colm Donaghy, who is well known to many members as the chief executive of the Belfast Health and Social Care Trust; Dr Tony Stevens, director of medicine at the Belfast Health and Social Care Trust; and Professor Donald Burden, who is clinical director of dentistry at the Belfast Trust.

Donald may not have been here as often as the rest of you, who have been here many times. I suggest that you make an opening 10-minute presentation, after which members have quite a few questions to ask.

Dr Andrew McCormick (Department of Health, Social Services and Public Safety):

Thanks, Chairman, and thanks for the opportunity to have this discussion. I will make some opening comments, and I am sure that Colm will want to add to those.

The first thing to say is that we are profoundly sorry for what has happened in this case: for the delays that people have experienced in accessing treatment; and for the anxiety, inconvenience and stress that has arisen for those who had to be recalled as a result of this exercise. Our first concern throughout all of this has to be the interests of the patients affected, and that has governed all that the trust and everybody else has been doing over this past year. The first consideration is to find what is in the best interests of patients, so that we act with that as the first criterion. That affects all the handling of the discussions and interaction, every aspect of which is governed by what is the best that we can do in that context.

The Minister made his statement on Monday 7 February 2011. I do not need to repeat all the facts. However, I will recap briefly the main points on the timeline. An issue arose in November 2009, when it emerged that a small number of people who had been referred following a diagnosis of oral cancer could, potentially, have been referred at an earlier stage. At that stage, it was very much just a possible issue. The trust’s action, which was absolutely correct, was to take a measured and appropriate response and to establish the facts. It is always right to do that in that type of situation.

I want to affirm total confidence in what the trust did at that time. It acted correctly. It organised the right steps to establish the facts and to undertake a look-back exercise, which was very time-consuming and very complex. As others will explain much more fully than I can, it is a highly complex area of medicine. There are few black-and-white issues. There are many shades of grey and a lot of room for scientific differences of opinion. It is important to get a handle on that fact because we are talking about complex diagnoses. That is why it depends on only one such specialist in Northern Ireland. It is a highly specialised area of medicine.

What we are doing as a society is placing responsibility for making those judgements on a small number of people, and we depend on them. I return to what I said to the Committee previously: it is right that the Department focuses on setting standards and ensuring that the right people are in the right places. There is an inherent risk in all that we do. Risk is inherent in the management of health and social care. The right response is not to seek scapegoats or carry out witch-hunts on individuals. The correct response from an organisational and public policy point of view is to set standards; to ensure that the right people are in the right places; and to ensure that there is effective, proper, balanced regulation that provides for fair accountability and is fair to all parties and fulfils all our responsibilities under the statutory duty of quality that applies to all health and social care organisations. We must also adhere to a lot of legislation that relates to human resources practice. It is important to emphasise those points at the outset.

During the look-back exercise, some major concerns came to light. I want to make it clear that action was taken appropriately and immediately to respond to the individuals. As it turns out, all of the individuals for whom a major concern was identified were already receiving appropriate attention. Therefore, it was not that people were found to have cancer and had to be recalled; they were already being treated. Again, that was absolutely the right response.

As the look-back exercise progressed during the past year, the trust acted, checked and ensured that appropriate action was being taken, which it was in relation to the people who were most directly affected. What happened then was that the look-back exercise identified a further number of people about whom there was what is called “intermediate concern”. Hence the recall, which we hope is, as much as possible, precautionary, but it is absolutely the right thing to do. If there is a doubt or suspicion about their care, it is right that it is checked out speedily. The trust has put immense effort into identifying carefully the right people to recall and organising the process so that they are being cared for in the best possible way now.

We recognise that there will be many questions. We also recognise that there are always lessons to be learned. All of us here now and the other organisation affected are covered by the terms of reference of the independent inquiry that the Minister announced. We want to be careful in all that we do this afternoon not to prejudge or pre-empt anything. We will give evidence on the facts as we see them. If you hear us, from time to time, express doubt or hesitation, that is because we need to leave room for the inquiry to investigate us and to establish its independent view of what has happened. That is proper process, and it is important to emphasise that.

I also want to make the point that we are not in a position to answer any questions on the individual concerned. It is right to be clear about that upfront. We simply cannot answer any such questions because the inquiry will investigate those issues, and there is also the possibility of legal action. We need to be very careful, but we will obviously do everything that we possibly can to answer your questions as fully as we can.

I go back to what I was saying about how we manage risk: it is important to see this as a fundamental aspect of the system. The system that the Assembly approved in the reform legislation a couple of years ago is designed to ensure effective governance and management of highly risky services. That is what we are for as a set of organisations. The constitutions of the governing bodies of the trusts, for example, make it a statutory requirement that there are medical, nursing and social representatives as directors and executive directors on trusts. That is part of the way to ensure that there is the right balance of input to decision-making and effective accountability for a range of very risky services.

We placed those responsibilities in these organisations, and it is very important that we have the right procedures to allow each organisation to fulfil them. That is what I mean by saying that we need to have the right people in the right places in governance, management and in the deployment of professional staff at all levels throughout the service. That is what all of us depend on for care and for proper governance and management of those systems. It is important, therefore, that the issues are handled in a way that allows those procedures to take their course to fulfil public accountability.

Ultimately, public accountability lies here, with the Minister in the first instance, with this Committee and with the wider Assembly. In everything we do, it is ultimately for you to judge what is done, and we recognise and accept that. We are subject to political direction; that is the nature of public services. We also recognise that there has been a lot of concern about issues that have gone into the public domain.

One positive, which I hope that we can develop — or maybe it is just normalisation — is that the Minister has agreed that, from time to time, there can be confidential briefing on emerging issues for the Chairperson and Deputy Chairperson of this Committee. That is something that I was pressed on last time, and it is important to acknowledge that. As I said, it is probably just normalisation, but it is the right thing to do. As issues emerge, we undertake that we will give a briefing where that is appropriate.

I ask you to recognise that there will be times when there is a tension between disclosure and the interests of the patient. That goes directly to this issue. The last time I was here, I was asked whether there was anything else, anything that I was not saying. Having read Hansard, my answer was inelegant. Also, I would, given more time, want to withdraw a couple of the remarks that appeared in Hansard and change my answers.

The point remains that we do not hide anything inappropriately and that we are very sensitive to unmanaged risk. As soon as anyone becomes aware of unmanaged risk, it has to be acted on immediately. That is very clear throughout the service, and everyone is aware of it. It is, at times, very difficult to draw the line between what is a managed risk and what is not a managed risk. There are services in Northern Ireland that are vulnerable, and part of what we need to do as a service is make sure that we deploy resources and ensure that the staffing rotas, and so on, are the best that they can possibly be.

However, there will also be a range of services in Northern Ireland that is stretched and stressed. That is management of risk, not irresponsibility. It may not be ideal, and there will be issues of judgement as to whether those are concerns that should be escalated. That is a judgement call, but specifically in relation to this issue, Colm was aware of it the last time that he was here. I know that, and I want to affirm my confidence that Colm did the right thing last time round. Had I been aware of the issue at that time, it would not have been appropriate for me to have talked about it, because we were not ready. Had the issue been disclosed prematurely, anxiety could have been caused to many more people than the 117 who are being recalled. An uncontrolled announcement about an issue with the service could have caused concern to many thousands of people. That would not have been in the public interest. My judgement is that, had I known, I would not have said anything and for Colm to have done so would not have been appropriate.

I return to the point about normalisation: what should now be possible through informal contact, confidentially, to the Chairperson and Deputy Chairperson, is that there is an issue. We could do that now, but we were not in a position to do that the last time. That is just a matter of fact. We are now in a better position, and I hope that that helps everybody concerned.

I commend the trust for the speedy action that it took from that moment onwards to organise the work, identify the numbers and ensure that things were done properly. Over recent weeks and the whole of last year, the trust has managed a very difficult and complex issue with patients’ interests at the heart of everything that it has been doing. I want to express my full confidence in what the trust has done. That is all that I need to say at the moment.

Mr Colm Donaghy (Belfast Health and Social Care Trust):

Chairman, are you happy for me to give you some further context and background?

The Chairperson:

We are very keen to hear from you, Colm.

That is quite right. However, I am not in a position to give you that information. For those who required a biopsy, it takes seven days for the results of a biopsy to be returned. The first clinics were on Monday and, therefore, we do not yet have the results of those biopsies. We will begin to get those results next week, and I am happy to share that information with you. However, I am not in a position to give you those outcomes, because I do not know at this point what they are.

Dr Tony Stevens (Belfast Health and Social Care Trust):

From my perspective, this started in November 2009, when I was advised of potential concerns regarding delays in treatment amongst patients who had previously attended the oral medicine service at the school of dentistry. That concern was raised by a surgeon from another hospital who treats patients with oral cancer. He talked to Donald, amongst others, and those concerns were brought to me. That is an example of openness, because it was a difficult thing for one consultant to do, and he would have had to have been absolutely certain about what he was doing. He had identified six patients about whom he had concerns, and perhaps later Donald will be able to provide you with a little more detail on that.

As Dr McCormick said, I asked for the facts to be established. In any situation in which I have two doctors who may genuinely have different views on the care of treatment, I need to establish some facts. At that point, it was a difference in medical opinion and, therefore, I had to treat it as nothing other than that. Departmental guidance on this, ‘Maintaining High Professional Standards’ allows for and expects me to establish the facts. The guidance calls that an informal stage. We did that fairly promptly, and the initial view was that there was a legitimate concern. This was more than just a difference in medical opinion; there was legitimate concern.

In December, I asked to establish a formal investigation under ‘Maintaining High Professional Standards’. That investigation deals specifically with an individual. As we have said, I am a little uncomfortable about talking in great detail about an individual. I am conscious of the potential implications of doing that in a public forum. However, the investigation was initiated.

At the same time, conscious that this was a concern about delayed treatment for patients with cancer, I asked Professor Burden to identify the resource that we would need to carry out a review of the oral medicine service and other patients in the system. We had to handle two things at once. We had to handle what was more than a possibility that one of our very senior consultants was in difficulty, and we had to identify and manage any patients who may have been, at the same time, at risk as a consequence of that. Professor Burden identified two very recently retired senior clinicians to undertake the review of patients. That review pretty much started in December.

The job of the clinicians was to review patients attending the service and to report back to Professor Burden and me on any concerns that they saw. They were also given a very explicit instruction that, if they identified problems as they went along, they were not to hold those back until the end of the review, but to make sure that those patients were being managed as much as possible. Again, Professor Burden can give you detail on that. At the same time as the formal investigation started, we notified the General Medical Council (GMC) and, unusually, the General Dental Council (GDC), because, again, this is specific to one individual who was dually qualified.

One of the very senior experts asked to undertake the review was also asked to supervise that senior consultant’s practice. That started in January. The first meeting between the supervising consultant and the other specialist was on 5 January. That was set up, and things were then moving. In February, I received the ‘Maintaining High Professional Standards’ formal report, which indicated to me that we needed to continue a process. The National Clinical Assessment Service was enjoined in that process. We are required to notify that body of any doctor on whom restrictions are being placed or whom we are managing through ‘Maintaining High Professional Standards’. It was enjoined in advising us on how we would deal with the situation, particularly from the individual practitioner’s perspective.

In March, we received notification from the General Medical Council that its interim orders panel, which does a relatively quick review of a referral, indicated that it wished to place some conditions on the individual’s practice, which included a requirement for supervision. We had already put in place supervision, so we predicted and put in place, ahead of a requirement from the first of the regulatory bodies, a requirement to put in place supervision. We were meeting the requirement that was laid down by the regulatory body.

I knew about those in June.

Mr O’Carolan:

They were made public on the website on 9 July. It is the exact same issue, just two different dates.

Dr Stevens:

The critical thing for you to be aware of is that the General Medical Council and the General Dental Council based their judgement on the information that we were able to provide, which included information on the original six patients about whom there were concerns. At that point, the General Medical Council, based on the information, felt that, in November, it could withdraw the restriction. It had reached a view on the situation at that point. Interestingly, that month, Professor Burden and I were in a position to meet the two experts and to receive their opinion on the review of the situation. At that time, it became clear to Professor Burden and me that there was, in our view, a substantial issue with the oral medicine service. I chose, at that time, to notify the GMC of my continuing concerns, and I can tell the Committee — things are moving at a fairly fast pace on this — that the GMC is reviewing the case again. That gives members an indication of just how complex this is and also how, in managing it, we have been subject to potential variances in professional opinion on the seriousness of individual cases or, indeed, the seriousness of the overall situation. That, I hope, will give the Committee a little bit of context as to just how difficult this has been to deal with.

In November, having been advised of the situation and of concerns about a number of specific patients, Professor Burden and I were given an assurance that those patients about whom there had been major concerns had been properly dealt with. We were not waiting until November to find out that there were problems and only then making sure that those patients were looked after. They had been in the system and were being cared for during the year and, in fact, quite early on in many or most cases.

However, Professor Burden and I asked the two experts whether we should do anything else about the 18 cases where they had major concerns and about the other cases about which they had interim concerns. In particular, I asked them, at that stage, whether any of those patients who were out of the system needed to come back into it. They asked for a short period to review all their case notes, which were extensive. After they did that, they came back with a list of 117 patients about whom they had lesser concerns. Those were not the 18 patients to whom we referred earlier. However, on reflection, they felt that it would be wise for those patients to be brought back into the system and reviewed. That, in a way, is where we are.

The only other thing to advise the Committee is that, having been advised by the two experts of their view of the situation, we notified the Health and Social Care Board at that time and, in December, we notified the Department that we had reached a conclusion on our position. At that time in December, we felt for a number of reasons that it was best that the individual who has inevitably been drawn into the centre of this did not see patients, and we made that decision. In December, we went substantially further than either the GMC or the GDC required us to go, but we made that decision on the basis that we felt that we had an absolute priority for patients at that time, and we also wanted to put every resource that we had, including those two experts, into dealing with patients. Since that time, Professor Burden and I have been preoccupied with and engaged in preparing for the recall of the 117 patients. Members are familiar with what has happened subsequently. I hope that that is of some help.

The Chairperson:

Thank you. Colm, we will deal with the issue of how the Committee has been treated and then get down to the problems that have arisen. Colm and Dr McCormick, you were here on 27 January. At the very end of that meeting — I think that it is important to read into the record exactly what was said that day — I said:

“That leads me to ask a difficult question of you, Andrew and Colm. You are expecting me to ask this: is there anything out there of which we are not aware, such as a major investigation, report or in-depth review of any description? Is there anything that, if it were to enter the public domain courtesy of some local newspaper, could catch us on the hop or ambush us and leave you saying that you should have let us know about it? What is out there that we do not know about?”

I distinctly remember, Colm, that you were sitting over there and Andrew was in his usual seat. He is here weekly, as you know. I remember thinking specifically about the Belfast Trust when I asked that question. Andrew’s answer to me was:

“Nothing out there matches the words that you used.”

Dr McCormick told us that he did not know on that day about the school of dentistry issue. However, you were aware of it, and you have now explained why you did not tell us about it. The problem is that that fundamentally undermines the relationship between the Department, the Belfast Trust and the Committee. Although you may have had good reasons for not telling us, we have to ask ourselves whether there are other issues — I am coming to that question at the end of this hearing, folks — about which we have asked the same question and, for “pure motives”, you decided not to tell us.

You had the option of taking me, the Deputy Chairperson and the Committee Clerk into a room to tell us what was going on, but that you and Andrew could not reveal it, because of its sensitive nature. At least the Committee would then have been reassured that there had been no attempt to cover the issue up. Had it subsequently emerged, I could then have said that there was nothing to worry about. I could have explained that the trust, for very good reasons, could not tell us about it and that we had been fully briefed but could not release the information. We could have said that it was all above board. However, what happened? We walked out that door and, 10 days later, while standing at a fishing harbour, I received a phone call from the Minister to tell me that there was, indeed, a major issue out there that we should have been told about and were not. I am speechless as to why an option was not taken to let us know somehow, so that we did not, quite frankly, look foolish, having asked that specific question.

Dr McCormick:

I recognise and understand entirely your concern and that of every member of the Committee about what happened. As you know, the Minister is concerned that he had not been informed. That is one reason that he initiated the inquiry, and we need to let that be the way in which that is addressed.

We recognise that there are learning points from what happened in this case. We recognise that the sequence was not right. We need to learn, move on and find ways forward. We all recognise that, and we recognise that part of the right way forward is, as you said, to have confidential briefings on any such issue. That is our commitment, and we will fulfil that. However, when it comes to investigating the whys and wherefores, the Minister has asked the inquiry to look into that issue. We have explained why Colm took the position that he did on 27 January, and I think that he had a very legitimate reason for acting as he did. We will all be able to do better in the future. We put our hands up in that sense. You have our commitment on that and our apology that things were not as they should have been. We will definitely find a better way forward. I hope that that is helpful.

The Chairperson:

If it happens again, it will totally undermine the confidence of this Committee in the Department.

Was that in 2009 or 2010?

Professor Burden:

They reviewed the patients during the 2009 calendar year. The practitioner was —

Mr Donaghy:

Sorry, perhaps I could clarify that the review was of patients seen during 2009. The review took place in 2010, but the patients were seen —

The Chairperson:

Yes. Did you know about the issue at the start of 2009?

Professor Burden:

No, not at all. As Dr Stevens said, we did not become aware of it until December 2009.

During the review of the patients seen in 2009, our experts found 16 additional patients about whom they had questions in relation to the management of their care while in our oral medical service. They were reassured to find that those patients were being cared for by the appropriate clinicians. Also during the review, they identified 117 patients about whom they had no immediate concerns. They categorised those as intermediate, and those are the 117 cases currently being recalled.

The Chairperson:

Yes, but you knew about those 117 cases long before last Saturday.

Professor Burden:

Yes. As they came to light, our clinicians were looking carefully and diligently at their clinical records, and they reassured themselves that there were no immediate concerns about those patients while they were reviewing the case notes.

The Chairperson:

Right, so you send out a courier on Saturday morning to deliver a personal letter to every one of them telling them to come in on Monday or as soon as they can for a review. That strikes me as being somewhat at odds with not being awfully concerned about the 177 cases that you have known about for a while.. Suddenly, there is a knock at the door at 7.30 on Saturday morning.

Mr Donaghy:

In any of the 117 cases, if there was any doubt, missing information or anything at all that gave us any cause for concern, we recalled people. We recognise that that caused anxiety to the individuals, but we feel that it was the right thing to do in the interest of patient safety when we had any doubt. In some cases, it may be that we had insufficient information to make a determination, but in such cases we still called or recalled the individual, because we felt that it was better and in the interest of patient safety.

Dr McCormick:

We have talked specifically about the urgency of getting letters out and even about what the letters said. Some of those points were themselves a consequence of the media’s handling of the issue. Had there not been an urgency dictated by a leak to the media, the trust would have been able to handle the issue more smoothly and in a more low-key way. The recall would still have been necessary, but it would not have been necessary to have courier letters or to put very special arrangements in place. Last Friday, I had a discussion with Colm, as well as with John Compton and the board, to establish what we could do to ensure that each and every individual who was going to be recalled would personally receive information personally as close as possible to the time when this story hit the press. That is part of our duty of care to patients. That is part of putting patients first. That has been our practice in previous recall or look-back exercises. There have been several such exercises. They happen, but the point always is to make sure that, at the point in time when the issue goes public, it is possible to say “If you haven’t received direct communication from the trust, you don’t have anything to worry about.” That was consistent with our objective, and it was necessary to do that only because there was a leak. The effect of the media coverage accentuated the anxiety. We apologise for that. That is unfortunate, but it was not entirely down to us. There were issues about how the issue was handled before it came in.

To handle things in an orderly, sensible, responsible way, confidentiality matters, and it is important for staff in our organisations to have regard for the patient’s interest in all that they do and say. What is overheard and what is passed on inadvertently will sometimes mean that information that causes anxiety is disclosed, and we have a responsibility to do all that we can to avoid that. That is why that happened, Chairman. It is important to understand that it was not a knee-jerk response. There was a plan in place, but that plan was disrupted by media handling.

The Chairperson:

As quite a few members want to come in, I will ask my final question. It is on a relatively minor issue, but it has to be asked. The ‘Belfast Telegraph’ revealed that, from 2001 until the present, the individual concerned was paid a bonus of £56,000 a year. That is a performance bonus for clinical excellence. Given this litany of investigations, supervisions, referrals to the GDC and patients being called back for further analysis, how on earth can you justify continuing to pay that £56,000 throughout? For most people in the Province, £56,000 is double their salary. It is a lot of money to most people in the Province. How can you justify that as a performance bonus? Why on earth was the decision not made, or why is there not a general policy in place that, if some person’s clinical performance is under review, his or her bonus stops immediately?

Dr McCormick:

Mr Easton:

My next important question is about the fact that, obviously, some people have passed away from cancer. Are we able to say that the failure to diagnose or call back those patients contributed to that? That is a huge concern out there, and we need to reassure the public. I ask again, as I did at the beginning, how far do we have to go back to make sure that everything is OK?

Dr Stevens:

I will pick up on the question about patients who have died and pass on to Donald to talk about the other issue.

The Chairperson:

Could we expand that slightly to those who died whose health had been compromised or whose condition deteriorated as an apparent result of this issue?

Dr Stevens:

I am happy to deal with that.

Obviously, we have a list of patients about whom we have concerns — I have to be very careful how I put this — and expert opinion that there has been, potentially, a delay in diagnosis and, therefore, potentially a delay in treatment. Of those patients with oral cancer, three have since died. We have to be exceedingly careful here, because the evidence on this is still potentially disputed, and expert opinion may be brought to bear on all of these cases. We find ourselves in a very difficult position. However, we have made a decision, because we have to, to make sure that all these patients are aware of our concerns. A proportion of them are already aware, because the treating clinician, and in particular the clinician who raised the concerns with us, has advised those patients that he treated that there was, potentially, a delay.

No. We have no evidence of that nature.

Mr McCallister:

That is reassuring. As the Chairperson said, that question seemed to be hanging there. I agree with your point that it is important that the individual involved is not named, or certainly this is not the place for putting anyone on trial in that regard. We want to see what the situation is. I was concerned, Colm, that the permanent secretary and the Minister did not seem to know, and, certainly, going by the tone of the Minister’s statement on Monday, he seemed somewhat concerned that he did not know.

Overall on the dentistry issue — this is probably for the Chief Dental Officer — is the school of dentistry receiving enough funding? Has this been an ongoing problem? Are there recommendations from the review of dentistry, and will they be implemented? What I am hearing is that the school of dentistry is possibly being run down somewhat. They are not getting the training. They are not getting the resources that they perhaps should for this area of medicine. I know that the Department puts in money and that some money comes from Queen’s. Is the school of dentistry getting a fair share of the resources?

Mr O’Carolan:

There is the dental school and the dental hospital; they are two distinct functions. The dental hospital treats the patients, which is the Health Service side, and its other function is to train consultants of the future — specialist registrars. On the university side, the school of dentistry trains undergraduates, teaches them and undertakes research. Most dental schools across the UK have teams of Health Service consultants and teams of clinical academics on the university side, all of whom are housed in one building.

Belfast is unique. Belfast has the smallest dental school in the UK, and, because of its size, we are not able to run that model of having a team of NHS consultants and a team of university consultants. Therefore, the model in Belfast has what are called joint consultants. The same people who do the Health Service work also do the teaching and research. That means that two streams of funding that go into it. There is funding through the Department for Employment and Learning (DEL), through the Queen’s University side. There is also funding from two sources on the Department of Health side, one of which is the pure Health Service side for treating patients. However, we also have the supplement for undergraduate medical and dental education (SUMDE) money, which may have come up before at the Health Committee. That SUMDE money is from the Department of Health, Social Services and Public Safety to help with the cost of teaching the students, because the students on the university side are taught in lecture theatres, and the university pays for that. However, most of their training, from second year onwards, takes place in clinics. That means that Health Service consultants in the clinics may be slowed up as a result, so the Department has to put in money to supplement the Health Service side for having to take on the teaching.

Have we enough money on the SUMDE side? I think that the answer to that is yes. Have we enough money on the university side? I think that the answer to that is yes. Have we enough money to refurbish the dental school? Well, the dental school badly needs to be refurbished. I am pleased to say that the Minister has made it a priority to earmark capital for the dental hospital, so that will be completely refurbished. So where is the problem? The problem is in staff numbers. There were 20 consultants in the dental hospital/school 10 years ago, and they performed both functions. There are now fewer than 10.

You are right, John. There was a university-led review, which was carried out in December. As the Health Service is a large stakeholder, I sat on that review. That draft report has not yet been signed off by the university. I know that people are aware of it but it has not been officially issued. My take on the situation is that, when the School of Medicine, Dentistry and Biochemistry was restructured in 2008, the dental school lost out. That restructuring did not suit the dental school. As a result, there has been no recruitment by the university into the dental school. You may ask why we do not just recruit on the Health Service side. As they are all joint appointments, if we do not recruit on the university side, there is automatically no recruitment on the Health Service side. We are acutely aware of that problem.

The ironic thing, John, is that, despite the current economic climate, the funding is there, but there has been a delay in recruitment. The university stance on that is that we want to make sure that we have a strategy in place to take the dentist school forward before we start recruiting. We do not want to recruit willy-nilly. We want to recruit the right people. My argument is that we do not have the time to do that. To the university’s credit, it undertook that review in December. Although the report is still in draft form, that review has thrown up some very serious concerns, both on the teaching side and on the service delivery side. It boils down to the fact that we do not have enough dental staff in there. The money is there. I will say so to the university, and I will speak to it over the next couple of days. This draft report arrived on my desk only on, I think, 24 January, so it is that current, John.

The board and the trust want to have their say on the final draft, but the gist is that there are not enough staff in there to deliver Health Service work and teach. So I think that the university needs to get on and do its bit by starting to recruit, and very quickly; ditto on the Health Service side. We need to do both. Funding is complex because of the various streams, but it is ironic that funding is not the problem. The problem is the university and the trust getting together and getting their acts together to bring this forward.

Mr McCallister:

Based on those figures that you gave, in 10 years’ time that trend would leave us with no consultants.

Mr O’Carolan:

Dr Stevens:

In reflecting on what Donncha has said, which is that there are challenges in the dental school for us, it is a very important educational institution to Northern Ireland because it helps to ensure that we have sufficient dentists to provide care for patients. It is also a very important centre as it delivers specialist care and a range of specialist treatments, but size presents challenges to us.

We have very small specialties, and oral medicine is an example of a single specialty. That will be seen, by a single specialist in an area, as a mitigating factor and, no doubt, by the individual. We are working very hard with Queen’s and engaging very actively with the Health and Social Care Board to think about how we would staff the dental school of the future. It will be a different model, and this episode, very unfortunate as it is, is not the sole catalyst for this, although I think that it will add impetus. I probably will not say any more than that.

Ms S Ramsey:

Thank you for your presentation. I know that that this is a live issue. We are talking about human beings and families who have suffered bereavement. At the outset, I want to say that I was a patient at the school of dentistry a number of years ago, and it is important to say that it provides great care and treatment for a lot of people. So I am quite sympathetic to the staff who have been caught up in this. Rightly or wrongly, they have all been caught up in this madness and brought into this crisis. It is important to acknowledge the fact that we have been brought up with a “doctor knows best” attitude. I now know that that is not true, but we have that in this society. We need to commend a consultant for challenging another consultant. That would not have happened a number of years ago. It is the start of the process, and we need to recognise that.

I am concerned with the comments that Andrew made about the media stuff. The reason why I am concerned about that is, although you have accepted that things have not happened as well with providing information to the Committee, I have no doubt that, unless the media had run with that — whether you believe that it is right or wrong — we would not be discussing this or getting any information. So I think that the media had a part to play. The Committee has a part to play, and it is important that we are all singing off the same hymn sheet and all playing our part.

I have a number of questions. Is this deemed a serious adverse incident? I am glad that Donncha cleared up the point that it was not a funding issue. If student fees increase, we might not get the doctors, the GPs and the dentists that we need. John can take that point back. There is an issue about the board level. I know that the inquiry will cover that. I am concerned that nearly four years have passed, and the Department, at whatever level, has realised and recognised the responsibility and role of this Committee. That is four years too long. However, we are there now, and we need to work on that. I also think that the Minister — he is not my party colleague — was left quite vulnerable in all this. The review will look at how information goes up and down, and Andrew said that we are accountable to the public. We are. So it is important that we get all the information because we were left looking quite stupid, and people were asking what was happening and, given that it was in the media, why we did not know about it. We cannot do our job unless we get the information.

I have some specific questions. Has anyone resigned, left or even taken early retirement in the Belfast Trust because of this or any associated incidents? I want to thank Tony for giving that outline. That was helpful because, in any employment law or contractual law, it is important to go through that. If it is not done properly, we could end up with other issues. That is important. It is important that, in their roles, the Chairperson and the Deputy Chairperson — the wise people that they are — should have been told of that. We can deal with things off the record. It is important that we get that information out there. Are we going to punish families further by closing ranks if there are any legal cases?

Mr Donaghy:

I will deal with that. You asked specific questions about the SAI, whether anyone has resigned, left or taken early retirement and how the litigation might affect how we deal with families. Those are the three specific questions as I have seen.

This is now reported as a serious adverse incident to the board.

Ms S Ramsey:

It is or it is not?

Mr Donaghy:

It is. It is now reported as a serious adverse incident to the board. Over the course of 2010, it was dealt with by the trust under the Maintaining High Professional Standards process, which Tony outlined earlier. I am not aware of anyone who has resigned, left or taken early retirement as a result of this.

Dr Stevens:

Given the earlier conversations about openness, I would have liked notice of a question like that.

Ms S Ramsey:

I did not think that I would ask it until the conversation came up. If you do not want to go into that in detail, I am content for you to send the information to the Chairperson.

The Chairperson:

Information is sent to both the Chairperson and Deputy Chairperson on all occasions. That is only right for fairness and to provide a bit of balance.

Mr Donaghy:

We will do that.

Dr Stevens:

We also have to ensure that the culture is right. What I mean by that is that the culture has to be one in which every professional has the power and responsibility to act on the basis of patient safety. That is what clinical governance is all about. I am sure that Tony and Donald can speak much more eloquently on clinical governance than I can. It empowers every member of the team to have and to fulfil a responsibility for patient safety. That fundamentally important assurance exists. It is backed up by clear procedures for regulation, both professional regulation with regard to each and every staff member and organisational accountability through a strong independent regulator.

The role of the Regulation and Quality Improvement Authority (RQIA) as an assurance mechanism is very important. As part of how we operate, we ensure that the RQIA is strong and able to investigate and can provide a planned programme of inspections to ensure that there is confidence in accountability back to the Department and the Minister and, hence, to the Assembly that we are fulfilling those obligations. Therefore, the right response to anxiety about standards is to ensure that they are in place, good, scrutinised and updated. We have professional staff who update and review standards that are set for each and every aspect of health and social care. That matters strongly in a publicly accountable system.

It is about setting standards and ensuring that the right staff are in place. I am clear that professional staff throughout health and social care earn their money. They are tasked with highly responsible jobs on which our lives depend. I am personally very conscious of that given my experience during the past couple of years. We depend on those individuals to manage risk on our behalf. It is important to build confidence and to ensure that there are effective procedures, governance and regulation in place to ensure that we continually review and improve those things so that the public can have full confidence that everything possible is being done to manage risk. There are risks around. That is the nature of what we do. It is important that that is recognised and understood. As a set of organisations, we accept that it is our responsibility to do everything that we can to manage risk and to ensure that there are grounds for confidence. We want to ensure that that is fulfilled in every possible way.

Mr Callaghan:

First, it is not a declaration of interest by any means, but given that we are beating on about transparency, I just want to put on record that in a former life, when I worked for the trust, Tony was my line manager’s line manager, briefly, for about three months. We met at one stage, long before any of this happened. Sue knows that I have been elsewhere before.

I want to perhaps pick up on some of the things from the debate on Monday to do with numbers. We started off with six people being identified by the surgeon. That was in November 2009. Correct me if I am wrong on any of this, because a lot of information and data is being thrown around. The look-back exercise flagged up 18 cases in which there were serious concerns. That is 24 people about whom we can say that there were serious concerns. Is that correct?

Mr Donaghy:

Not quite, Pól.

Mr Callaghan:

The Minister’s statement said that there were 22 people.

Mr Donaghy:

There is an overlap in the six people and the 18 people. Perhaps Professor Burden can outline that.

Professor Burden:

The best way to explain it is that six cases were initially flagged up, and the review of cases in 2009 identified a further 16 cases. That is the 22 figure.

Mr Callaghan:

Mr Callaghan:

The answer as of today is that the information is not available to you. It is a separate question as to whether or not we are going to have that information made available to us.

In his statement, the Minister said:

“As regards the six people identified initially, I have been informed that they have all had the opportunity to discuss their condition with their clinician and are aware of the potential delays in treatment.”

When the Minister’s statement, the Department and the system — which I use as a generic term for everybody else — uses the phrase “serious concerns”, and then uses the phrase “intermediate concerns”, I would find it helpful, and I imagine other members may do as well, to know what exactly you mean by that. Donald mentioned earlier an “immediate concern” relating to “serious concerns”. What does that actually mean about the potential scope and seriousness of the conditions that we are talking about?

Dr Stevens:

I will start answering that and then hand over to Donald. The two experts who carried out the review used the terms “major concerns” and “intermediate concerns”. They were talking about concerns about the quality of the care as much as about the severity of any illness. You are absolutely right in that there is the potential for confusion or a little uncertainty about exactly what we are talking about.

For example, in some cases where they thought there major concerns about the quality of the treatment, those patients are actually fine. Unfortunately, there are others in that group with cancer about whose treatments we have concerns, but there are others in that group for whom, even though major concerns were raised, there has actually been no detriment.

The intermediate concerns related more to their feelings about the quality of care. That is why we then asked our two experts to go away and refine very carefully, from that and their experience of the whole review, exactly who they would call back. I will hand over to Donald to explain that group to give you a sense of those 117 people whom we chose to call back.

Professor Burden:

The experts involved in carrying out the review, as Tony said, designated the two groupings into one of major concerns, about whom they immediately took action to reassure the patients and themselves that they were being cared for, and the second group of patients, which they termed intermediate concerns. In those cases, they indicated that there was no immediate problem that they could see with those patients, but to reassure ourselves, we decided in our meeting when we looked at the completed review that we felt it appropriate to call those patients back.

Mr Callaghan:

I want to return to something that Tommy raised earlier, and I think that Donncha was responding at that point, about the terms of reference of the review. I have just seen those terms of reference this afternoon, as, I think, most Committee members have. The review makes two specific references to the school that I can see. It makes one in the first paragraph, but that is a general one. Paragraph 2(a) states that the purpose of the inquiry will be to:

“Evaluate the general quality of care provided by the School of Dentistry”

and the trust. Paragraph 2(b) continues that it will be to:

“evaluate the systemic nature, extent, timeliness and effectiveness of communications between and within each of “

the school, the trust, and so on.

First, on the matter of the school, I do not profess to speak for Tommy, but if I were to rephrase what I think he may have been getting at: in light of what you can see in those terms of reference, is there any potential concern that the fact that some people are employed by two different bodies or serve two different purposes could impact on the fulfilment of the inquiry? I think that the Committee would be interested in knowing about that.

Mr O’Carolan:

I have one final question on the issue of the clinical excellence committee. In the terms of reference, paragraph 2(b) refers to:

“evaluating the systemic nature, extent, timeliness and effectiveness of communications between and within each of”

and it names a number of entities including the Department. Can the permanent secretary tell us, implicitly or otherwise, if it is his understanding that this clinical excellence committee is included as one of the bodies if it is appointed by the Department? In other words, whether or not any determination by a body such as the GDC or the GMC in a case such as this, and whether what took place in this case was or was not referred to them.

Dr McCormick:

As Donncha said, we ourselves are subject to these terms of reference. They have been approved by the Minister. It is the Minister’s inquiry, so we are subject to them. My reading of paragraph 2(b) does not explicitly bring in the committee that you mentioned or the regulators because the focus on communications is communications in the context of the actual substantive communication of the issue and, hence, ultimately telling patients and the wider public that there was an issue. I do not see any impediment if the inquiry wanted to secure evidence in relation to the:

“extent, timeliness and effectiveness of communications”

with the clinical excellence committee or the regulatory bodies. I am sure that that could be done. It is not explicitly there, but I do not see any impediment. However, it is not my inquiry: it is the Minister’s inquiry, and that will need to be judged. If the Committee wants to write to suggest that, I am sure that the Minister will consider it.

The Chairperson:

We may well follow up that idea. I have a couple of final questions, one is routine and the other is the one that you are expecting. The routine question is: does any of what has happened affect the ability of a clinician in that position, though not specifically this one, to continue private practice?

Dr McCormick:

Again, speaking generally, the right thing that happens in a context such as that is that when a concern is raised, all employers or potential employers are alerted to the concern. That is the right procedure to follow so that there is an awareness of issues. That is the first step. The second step is to ensure that there is effective regulation of all such bodies, and most of our regulations are already in place and fully effective. Donncha will explain the issue that is outstanding following actions last year.

Mr O’Carolan:

I am glad that you raised that question, Chairperson. You may remember that the last time that I was at the Committee, on 2 December, that very issue was raised. You had the BDA on the one hand saying that we need only to regulate purely private practices. I said to you at that stage that we needed to regulate the mixed economy. Again, we cannot name individuals, but let us take a theoretical example: somebody in a similar position could go and work privately. I am glad that the Minister brought forward the regulations, which came before the Committee and which it supported, and they will come into effect on 1 April 2011.

Dr McCormick:

We will have a further meeting next week following discussions with the Minister on that topic, and we will be happy to explore that more fully. I want to try to deal with the issue of public confidence, because the first concerns for the Department are patient safety and public confidence. Let us just take issues that might be a cause for concern from first principles.

Two broad categories are important from the point of view of patients. The first of those are situations in which patients have received care in the past, and there is evidence that it might have been substandard. That is the territory that we have been in today, but there is no regional or major-scale issue with that. There will always be cases that need to be followed up and reviewed. We set very high standards, and all aspects of health and social care are subject to those very high standards. However, the Health Service depends on human beings, and we need to have failsafe mechanisms and ways to ensure that people are protected. The way in which we do that is to ensure that proper governance is in place. There will, of course, be individual cases in which people receive substandard care, but those are caught, followed up and pursued through normal procedures. There are no further imminent look-back or recall exercises that the Committee has not heard about. I am not aware of any such case.

The second area that may cause worry is when there is a risk that a patient might receive substandard care now or in the future. Some services are vulnerable, and it is difficult to always secure the right standards and to have the right rotas in place. However, as I described earlier, the protection that we have comes through our statutory obligation on every provider to ensure that they are providing safe and high-quality services. That means that those providers are obliged to act on and correct any material risk of substandard care.

I come back to the main theme that we, as a community, depend on people to manage risks on our behalf. That applies to the individual front line professionals and to the organisations that have been put in place to ensure a high standard of care for the population of Northern Ireland. Several things need to be really strong to make that work. The first foundation is training, and we need people who are trained to the highest standards and receive the necessary continuous professional development. We also need strong clinical governance. As I said earlier, that means every member of every multidisciplinary team putting patient safety first and speaking up when they see issues going wrong. That is what happened in this case, and that worked. The system fundamentally works on that basis. We also need strong corporate governance. The trusts are very large organisations, and they have strong internal systems to assess and review all these governance issues. That is the way in which it works.

We also need strong, effective and credible professional regulation so that there is — the phrase I always use — fair accountability. Some people talk about needing a no-blame culture. My position is that we need fair accountability at an individual level so that individuals know that they will be held to account but that they will receive fair treatment. That is the only way to ensure the confidence of the public and confidence in that each member of staff knows that he or she can do his or her job without being hung out to dry for no good reason. We have to have confidence in both those dimensions.

We also need strong statutory regulations, so the role of the RQIA is vital in providing a further check and information base as to how things are working out and a planned inspection programme based on risk management. The final assurance is that we have an open and valid complaints process that is well thought through and provides the right checks and balances and access for individuals to redress or correction. There is also a strong body responsible for fulfilling that role — the Patient and Client Council — to act and speak on behalf of patients.

Those are the assurances that are there to provide public confidence. Will we get everything right? Will we always notify you in time? Can I guarantee that there will not be another headline in the ‘The Irish News’? I cannot do that, because the criteria are not always applied in the way in which I described them. I am speaking about how we try to fulfil our responsibilities properly and effectively. The best we can do is to set the right standards, to ensure that the right people are in place and that communication is good among the organisations. That is what we can do, but if it is judged by journalists that something that they have heard about is of regional significance, and they put it on the front page of a newspaper, that does not mean that it is of regional significance or that it is important.

The Chairperson:

Andrew, you must accept that everything that has been on the front page of the papers — not just that one, but several — since Christmas has all been of a regional significance. We are talking about swine flu, the X-rays and the children’s hospital. They are all issues that clearly —

Dr McCormick:

I am trying to get my head around what I think is still a fairly straightforward question. Let me put it a different way: if I had been one of those people and, say, a senior practitioner in the school became aware — for whatever reason, formal or otherwise — on St Valentine’s Day 2010 that I was one of the 16 for whom there were serious concerns, and I am still here, getting ready to bring my wife out to dinner on St Valentine’s Day 2011, which is news for her — maybe it does not happen every year —

Ms S Ramsey:

I hope that that is not the case. St Valentine’s Day is next Monday.

Mr Callaghan:

I am getting ready.

I have still not been told. It is legitimate for people to wonder, especially by virtue of the fact that the trust itself has recognised that some people were told, which was appropriate. Why was I not told? When did those issues arise? I accept that we do not have a quantum today and that that will be provided. However, it should be disclosable when those issues became known to somebody in the trust regardless of the final precis, or whatever, that came to you, Tony, in November.

Dr Stevens:

I am conscious that I, at least, in part answered your question when I responded to questions from either Alex or Sue on how we handled that. I reiterate that the issue of delay is still a matter of medical opinion and some degree of conjecture. I would still qualify that and say that we need to be exceedingly careful. The six original patients who were seen by the surgeon who had the original concerns were told at that time. He felt able and confident enough to say that. We have to be exceedingly careful that we go out with the right message to the remaining patients. It is only as we accumulate all the evidence in the case that we will be in a position to tell people confidently what we think is the situation. I really do have to counsel caution here. It remains an issue of debate. Even some of the information that we pass on may be subject to legal challenge.

The Chairperson:

There is inconsistency, Tony, because you told some people and did not tell others. That is an argument for telling nobody or telling everybody.

Dr Stevens:

No: clinicians made a choice to tell people. I have not gone out deliberately either to tell people or not to tell people. As I said, since I knew in November, we have been action-planning for the events that have occurred. They have occurred very quickly over the past day or two. In fact, we were just action-planning all those points, ready to move to inform patients. As I think that I said in a previous answer, we were putting together a very detailed process to inform those patients what we believe that we can say, with the appropriate support.

I think that I answered the question earlier. I am not clear whether there is still some ambiguity.

Mr Callaghan:

Dr McCormick:

Let us go away and think exactly how to re-express this. The Minister’s commitment is clear, and our obligation is to fulfil the Minister’s commitment. We will do so. I give an assurance on that basis. We will think very hard and make sure that we fulfil and address all the points that Pól and you have made, Chairman, if that is OK. We give you that undertaking.

The Chairperson:

Right, gentlemen. I think that this is even longer than the last four sessions that we have had on similar issues. Thank you for your time. We, as a Committee, will not be around on 31 May, when the report is issued. Some of us might not even be MLAs; we do not know. However, I am sure that the incoming Committee will be very interested to see the report. All I can say is that I really hope and pray for you and us that we do not have to through another Star Chamber — that is the only phrase that I can think of — again because it is taking up huge amounts of everyone’s time. I am reassured by your comment that there is nothing out there. That often seems to be the starter gun for the press to go and find something.

COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY

OFFICIAL REPORT (Hansard)

Dental Issues in the Belfast Health and Social Care Trust

10 February 2011

Members present for all or part of the proceedings:

Witnesses:

The Chairperson (Mr Wells):

Dr Andrew McCormick (Department of Health, Social Services and Public Safety):

Mr Colm Donaghy (Belfast Health and Social Care Trust):

The Chairperson:

Mr Donaghy:

The Chairperson:

Mr Donaghy:

The Chairperson:

Mr Donaghy:

The Chairperson:

Mr Donaghy:

Dr Tony Stevens (Belfast Health and Social Care Trust):

The Chairperson:

Dr Stevens:

The Chairperson:

Mr Donncha O’Carolan (Department of Health, Social Services and Public Safety):

The Chairperson:

Mr O’Carolan:

The Chairperson:

Dr Stevens:

Mr O’Carolan:

Dr Stevens:

The Chairperson:

Dr McCormick:

The Chairperson:

Dr McCormick:

Mr Donaghy:

The Chairperson:

Mr Donaghy:

The Chairperson:

Mr Donaghy:

Professor Burden (Belfast Health and Social Care Trust):

The Chairperson:

Professor Burden:

Mr Donaghy:

The Chairperson:

Professor Burden:

The Chairperson:

Professor Burden:

The Chairperson:

Mr Donaghy:

Dr McCormick:

The Chairperson:

Dr McCormick:

The Chairperson:

Dr Stevens:

The Chairperson:

Dr McCormick:

The Chairperson:

Dr McCormick:

Mr Easton:

Dr Stevens:

Mr Easton:

Dr Stevens:

Mr Easton:

Dr Stevens:

Mr Easton:

Dr Stevens:

Mr Easton:

Dr Stevens:

Mr Easton:

Dr Stevens:

Mr Easton:

Dr Stevens:

Mr Donaghy:

Mr Easton:

Mr Donaghy:

Mr Easton:

Dr McCormick:

Mr Easton:

Dr Stevens:

The Chairperson:

Dr Stevens:

Mr Donaghy:

OFFICIAL REPORT
(Hansard)