Annex A > Chapter 4 - National Accountabilities and Roles > National regulatory and professional bodies > Movement in attitudes and published guidance
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Movement in attitudes and published guidance
160 Sir Donald traced the series of amendments in consecutive editions of the `Blue Book' [196] which indicate the trend away from disparagement towards a duty to inform others.
161 The August 1983 `Blue Book' stated:
`Depreciation of other doctors ...
`The Council also regards as capable of amounting to serious professional misconduct:
`(i) the depreciation by a doctor of the professional skill, knowledge, qualifications or services of another doctor or doctors ...' [197]
162 The April 1985 `Blue Book' included an identically worded section. Although this advice in the `Blue Book' was unqualified, Sir Donald felt that disparagement required a malicious motive:
`Q. If one honestly reported poor practice but was wrong, that would be disparagement, would it not?
`A. I am not sure that that would be disparagement; I mean, it comes back to the motive behind it. Disparagement was about reporting with malice.' [198]
163 The GMC's guidance on disparagement was perceived to discourage doctors from expressing legitimate concerns. Dr Ernest Armstrong, Secretary of the BMA, said:
`Q. So one consequence ... of the doctor whistle-blowing the colleague would be that it might be said that he was actually acting in breach of his own contract?
`A. Not in breach of his own contract, but certainly in breach of his own codes of professional conduct as set out by the GMC.
`Q. And those are those codes of conduct to be expected explicitly under his contract?
`Q. Because they are the only standards there are under his contract?
`A. That is correct.' [199]
`Q. So one had the rather Alice in Wonderland, topsy-turvy position that the doctor who might very well be incompetent in particular areas could not be dealt with for that in any realistic way, other than through the Regional Medical Officer as you have described, the informal mechanisms, whereas another doctor complaining about him would, at least until the early 1990s, until the culture began to change, himself be transgressing in a clear and objective way the standards to be expected of him?
`A. That, sadly, is a very neat encapsulation of the doctor's dilemma.' [200]
164 In March 1984 Dr Frempong's case before the Professional Conduct Committee (PCC) raised the question why doctors had not reported a colleague whom they knew to be a danger to patients. Some doctors said they did not do so because they feared falling foul of the GMC's guidance on disparagement. In response, the Council made clear in its next Annual Report that:
`... there may be circumstances in which it would be the responsibility of doctors to report to the Council evidence which may raise a question of serious professional misconduct'. [201]
165 Thus it was that Sir Donald could say there was a policy change between April 1985 and April 1987 that:
`... came about because of an increasing awareness inside the Council that reporting poor practice - that there was a problem here that had to be addressed, and it was articulated by both lay and medical members who took this matter very seriously, but it was also illustrated by the case of Dr [Frempong] in March 1984, and I think it was Esther Rantzen who made a film about this particular situation in which, in this case, there were clearly circumstances in which colleagues had known about the doctor's quite wrong practice and had done nothing about it, so that created the debate which led to this change of policy.' [202]
166 As a result, the April 1987 `Blue Book' incorporated the first explicit duty to inform others about a colleague who was apparently guilty of serious professional misconduct or experiencing serious ill health. [203] Sir Donald said:
`This change was highlighted in the Annual Report (1987) which went to all doctors on the Medical Register.' [204]
`"Disparagement of professional colleagues
`"65. It is improper for a doctor to disparage, whether directly or by implication, the professional skill, knowledge, qualifications or services of any other doctor, irrespective of whether this may result in his own professional advantage, and such disparagement may raise a question of serious professional misconduct.
`"66. It is however entirely proper for a doctor, having carefully considered the advice and treatment offered to a patient by a colleague, in good faith to express a different opinion and to advise and assist the patient to seek an alternative source of medical care. The doctor must however always be able to justify such action as being in the patient's best medical interests.
`"67. Furthermore, a doctor has a duty, where the circumstances so warrant, to inform an appropriate body about a professional colleague whose behaviour may have raised a question of serious professional misconduct, or whose fitness to practise may be seriously impaired by reason of a physical or mental condition. Similarly, a doctor may also comment on the professional performance of a colleague in respect of whom he acts as a referee."' [205]
167 The June 1990 `Blue Book' included an identically worded section. [206]
168 The April 1987 and June 1990 editions of the `Blue Book' contained no guidance on the meaning of the qualifying phrase `where the circumstances so warrant' [207] which was open to individual interpretation by individual doctors. [208] Sir Donald said: `... we [the GMC] also acknowledged the difficulty inherent for the doctor in that guidance, because it then changed'. [209]
169 Coupled with the series of `clarifications' and `refinements' of the duty to inform, the GMC tried to publicise the duty as widely as possible within the medical profession: [210]
`In 1990, the Council - in public session - considered whether to remove the guidance on disparagement from the "Blue Book" altogether, but concluded that it was not right to do so. However, it was agreed that the focus of the guidance should be on reporting colleagues, with questions of disparagement - defined as "gratuitous and unsustainable comment" - being raised as a subsidiary matter. All doctors were told of the importance of this in the 1990 Annual Report.' [211]
170 The February 1991 `Blue Book' stated:
`Comment about professional colleagues
`62. Doctors are frequently called upon to express a view about a colleague's professional practice. This may, for example, happen in the course of a medical audit or peer review procedure, or when a doctor is asked to give a reference about a colleague. It may also occur in a less direct and explicit way when a patient seeks a second opinion, specialist advice or an alternative form of treatment. Honest comment is entirely acceptable in such circumstances, provided that it is carefully considered and can be justified, that it is offered in good faith and that it is intended to promote the best interests of patients.
`63. Further, it is any doctor's duty, where the circumstances so warrant, to inform an appropriate person or body about a colleague whose professional conduct or fitness to practice may be called in question or whose professional performance appears to be in some way deficient. Arrangements exist to deal with such problems, and they must be used in order to ensure that high standards of medical practice are maintained.
`64. However, gratuitous and unsustainable comment which, whether directly or by implication, sets out to undermine trust in a professional colleague's knowledge or skills is unethical.' [212]
171 For the first time `honest comment' was explicitly acceptable in relation to doctors called upon to express a view (para 62), [213] but the duty to inform was still qualified by the phrase `where the circumstances so warrant' (para 63), so that the difficulties of its interpretation remained. [214] The words `arrangements exist to deal with such problems', it was said, `... referred to the local arrangements such as the informal procedures which local medical committees operated in general practice, or the "three wise men" procedures in hospitals.' [215]
172 Identically worded sections were included in the `Blue Book' editions of May 1992 [216] and December 1992. [217]
The Dunn case and `Good Medical Practice' [218]
173 The first edition of `Good Medical Practice', published in October 1995, [219] contained the first unqualified statement of a duty to inform others about a colleague. [220] It arose from the case of Dr Dunn, a clinical director who had known of a locum consultant's deficient practice and had done nothing about it. [221]
`8. The Dunn case in March 1994 marked a further step in making clear the GMC's policy on the importance of reporting poor practice. The case against Dr Dunn arose from that of Dr B S Irani, an anaesthetist who was erased following a PCC [Professional Conduct Committee] hearing in July 1993. The case involved a patient left with permanent brain damage after anaesthesia. Dr Dunn was Chairman of his hospital anaesthetics division during the time that Dr Irani was employed there as a locum consultant. Serious concerns had been expressed to him about Dr Irani's competence and conduct, but he failed to take appropriate action.
`9. Dr Dunn was found guilty of serious professional misconduct. In its determination, the PCC drew on the draft guidance being prepared for "Good Medical Practice" in stating:
`"Doctors who have reason to believe that a colleague's conduct or professional performance pose a danger to patients must act to ensure patient safety. ... This Committee has already drawn attention to the existence of appropriate procedures for response to the reports of evident, and dangerous, incompetence. Doctors have a duty to activate these procedures promptly, where such cases arise. At all times patient safety must take precedence over all other concerns, including understandable reticence to bring a colleague's career into question." [222]
`10. The Dunn case was well publicised by the GMC because of the central importance of patient safety. The GMC took the unusual step of issuing a press release giving details of the case to all national and medical press editors on 18 March 1994. Furthermore, the Annual Report for 1994 alerted all registered doctors to the forthcoming publication of "Good Medical Practice" and reminded them of their duty to protect patients from colleagues whose health or professional conduct poses a danger. "The Dunn case" was highlighted in the same report and part of the judgement was reprinted, repeating once again that patient safety must take precedence over all other concerns.
`11. While developing Good Medical Practice, as well as strengthening the guidance on the duty to protect patients, the GMC also reviewed the need for guidance on disparagement. The GMC concluded that such guidance should be retained, but its scope should be restricted to cases where patients were affected - "You must not make patients doubt a colleague's knowledge or skills ..." - and not apply to cases which concerned only the reputation of a colleague or the profession. It was agreed that this guidance should appear in the booklet separately from the guidance on reporting colleagues whose fitness to practise is in doubt, in order that the advice on disparagement should not be seen as qualifying the duty to report dangerous colleagues.' [223]
174 The Dunn case and the change in emphasis are reflected in the wording of `Good Medical Practice'.
175 In October 1995 the GMC issued the package of guidance `Duties of a Doctor'. [224] `Duties of a Doctor' concerns `The duties of a doctor registered with the General Medical Council'. It states `In particular as a doctor you must...', followed by a list of 14 particular duties, including the duty to `act quickly to protect patients from risk if you have good reason to believe that you or a colleague may not be fit to practice'. [225] The list is repeated on the inside front cover of the leaflets in the pack, `Good Medical Practice', [226] `Confidentiality', [227] `HIV and AIDS: The Ethical Considerations' [228] and `Advertising'. [229]
176 `Good Medical Practice' (October 1995 edition) states:
`Professional relationships with patients
`11. Successful relationships between doctors and patients depend on trust. To establish and maintain that trust you must: [230]
`... respect the right of patients to a second opinion. ...' [231]
`Your duty to protect all patients
`18. You must protect patients when you believe that a colleague's conduct, performance or health is a threat to them, [232]
`19. Before taking action, you should do your best to find out the facts. Then, if necessary, you must tell someone from the employing authority or from a regulatory body. Your comments about colleagues must be honest. If you are not sure what to do, ask an experienced colleague. The safety of patients must come first at all times.' [233]
`24. You must not make any patient doubt a colleague's knowledge or skills by making unnecessary or unsustainable comments about them.'
`27. If you disagree with your team's decision, you may be able to persuade other team members to change their minds. If not, and you believe that the decision would harm the patient, tell someone who can take action. As a last resort, take action yourself to protect the patient's safety or health.' [234]
177 Although outside the time frame of the Terms of Reference of the Inquiry, it should be noted that the July 1998 edition of `Good Medical Practice' contained amendments making explicit a doctor's duty to inform on colleagues who were not doctors and to give more advice on whom doctors should approach with concerns. In the following extracts additions to the October 1995 edition are in bold, deletions in strikethrough.
`Your duty to protect all patients
`23. You must protect patients when you believe that a doctor's or other colleague's health, conduct, or performance is a threat to them.
`24. Before taking action, you should do your best to find out the facts. Then, if necessary, you must follow your employer's procedures or tell someone an appropriate person from the employing authority, such as the director of public health, medical director, nursing director or chief executive, or an officer of your local medical committee, or from a regulatory body. Your comments about colleagues must be honest. If you are not sure what to do, ask an experienced colleague or contact the GMC for advice. The safety of patients must come first at all times.' [235]
178 Since the Bristol case has been widely publicised there have been many other publications (including `Maintaining Good Medical Practice' [236]) that have explained the doctor's duty to inform others about colleagues, the appropriate channels for expressing concern and mechanisms for rectifying problems.
179 The changes in guidance on informing others about colleagues should be understood in the context of the shift in regulatory emphasis from conduct to performance, as explained above: there is not only greater encouragement of doctors to inform others, but also a change in the nature of that about which they should be concerned.
Disparagement and the duty to inform others if a colleague's conduct is in question - (nurses)
180 The evidence emphasised that a nurse has always been required to be the `patients' advocate'. It was accepted that this might bring a nurse into conflict with another health professional.
181 The UKCC's `Code of Professional Conduct' of 1992 [237] stated:
`As a registered nurse, midwife or health visitor, you are personally accountable for your practice and, in the exercise of your professional accountability, must ...
`11 report to an appropriate person or authority, having regard to the physical, psychological and social effects on patients and clients, any circumstances in the environment of care which could jeopardise standards of practice;
`12 report to an appropriate person or authority any circumstances in which safe and appropriate care for patients and clients cannot be provided;
`13 report to an appropriate person or authority where it appears that the health or safety of colleagues is at risk, as such circumstances may compromise standards of practice and care.' [238]
182 Although the 1996 guidance gives `inadequate resources to maintain standards of care', [239] amongst the examples of situations in which it is required that a nurse should report, the obligation on nurses to report applied and applies regardless of whether the substandard circumstances involve another nurse. [240] Thus, further examples include colleagues suffering ill health, [241] and colleagues' `inappropriate behaviour' [242] (which has overtones of misconduct and abuse of patients). There is no specific mention of colleagues underperforming, but there is an obligation to report `circumstances in the environment which could jeopardise standards of practice'. [243]
Changes since 1995
183 The Inquiry was told that since 1995 nurses have become more likely to express their concerns. It may be inferred, therefore, that the position in the period with which the Inquiry is concerned was less propitious for them to do so. Ms Lavin said:
`I think we are getting better at it. I think people are far more likely to express concerns and be the patients' advocates in circumstances where they have worries about individual practitioners across the board, not just doctors.' [244]
`Q. You talked about the changing situation of nurses now being perhaps more willing to challenge or complain about or comment on the conduct of doctors than they were in the past. Is that a change that has taken place since or during the period that the Inquiry is concerned with?
`Q. So in the mid-1980s, the culture would be other than that that you have described as being the one that is developing now?
`A. I qualified as a nurse in 1987 and at that time I think the change was starting to happen.' [245]
184 Ms Lavin explained the possible reasons for nurses being more likely now to express concerns:
`A. I think there have been a number of reasons for it. I think that many people would say the changes in nursing education have resulted in practitioners who perhaps have got better skills in terms of expressing concerns and feeling able to do so. I am not sure I entirely concur with that view.
`Q. May it be that now that nursing is more of a university-orientated, educational environment than it was before, that nurses are taken more seriously by doctors than they were before?
`A. Again, I am not sure about that. I certainly have been in a position as a fairly junior nurse in challenging a doctor about not telling a patient the truth, and in latter years, as a Hospital Manager holding a nursing registration, tackling a consultant about not telling a patient the truth and in fact suggesting I was going to go and tell the patient the true state of affairs myself if he was not willing to do so. I think much depends on the individuals and the dynamics and the relationships between people in the organisation as to how seriously and how credible nursing is viewed. [246]
`I think that there are some areas of nursing where nurses still see themselves in a very subordinate role to doctors, but again, I think that is changing. Nurses are extending the boundaries of their competence and knowledge; they are taking on many tasks that I think traditionally might have been associated certainly with a junior doctor's role.' [247]
Duty to inform - whistleblowing: healthcare staff in general
185 There was concern, following the introduction of trusts, that healthcare staff, in some trusts, might be in breach of their contract of employment if they were to speak out about issues relating to healthcare in the trust. It was thought that this might be a breach of the duty of confidentiality an employee owes to an employer in respect of information that might be commercially sensitive. Sir Alan Langlands noted that:
`... the rights and responsibilities of all NHS staff when raising concern about health care issues were set out in guidance to the NHS in 1993. [248] It is the NHS Executive's policy that there should not be confidentiality clauses in contracts.' [249]
Recent developments
186 The Public Interest Disclosure Act (PIDA) 1998 [250] inserts additional sections into the Employment Rights Act (ERA) 1996.
187 In effect, they provide that any provision in a contract which purports to preclude a worker from making a `protected disclosure' is void; that an employee may not lawfully be subjected to any detriment by any act or deliberate failure to act by his employer, done to him because he has made a `protected disclosure`, nor may he be dismissed, or selected for redundancy on that basis. If detriment, dismissal, or unfair selection for redundancy is proved, the employee is entitled to compensation, in respect of which there is no limit.
188 All depends upon the meaning of `protected disclosure'. Under the Act, it is a `qualifying disclosure' [251] meaning:
`... any disclosure of information which, in the reasonable belief of the worker making the disclosure, tends to show one or more of the following -
`(a) that a criminal offence has been committed, is being committed or is likely to be committed,
`(b) that a person has failed, is failing or is likely to fail to comply with any legal obligation to which he is subject,
`(c) that a miscarriage of justice has occurred, is occurring or is likely to occur,
`(d) that the health or safety of any individual has been, is being or is likely to be endangered,
`(e) that the environment has been, is being or is likely to be damaged, or
`(f) that information tending to show any matter falling within any one of the preceding paragraphs has been, is being or is likely to be deliberately concealed.'
189 To be protected, a qualifying disclosure must not only be of information in one of those categories, but also must be made:
`(b) where the worker reasonably believes that the relevant failure relates solely or mainly to -
`(i) the conduct of a person other than his employer, or
`(ii) any other matter for which a person other than his employer has legal responsibility, to that other person.'
190 Thus, the disclosure is protected only if it is made to the employer, or to someone in an analogous position - or (perhaps oddly) to the person whose failing is criticised.
191 However, it is also a `protected disclosure' if made to a legal advisor in the course of obtaining legal advice, [252] to a Minister of the Crown, [253] to any person prescribed in an Order made by the Secretary of State for the purposes of the section [254] and otherwise (by Section 43G) if:
`(a) the worker makes the disclosure in good faith,
`(b) he reasonably believes that the information disclosed, and any allegation contained [255] in it, are substantially true,
`(c) he does not make the disclosure for the purposes of personal gain,
`(d) any of the conditions in sub-section (2) is met, and
`(e) in all the circumstances of the case, it is reasonable for him to make the disclosure.'
192 By sub-section (2), the conditions referred to in sub-section (1)(d) are:
`(a) that, at the time he makes the disclosure the worker reasonably believes [256] that he will be subjected to a detriment by his employer if he makes a disclosure to his employer ...
`(b) that, in a case where no person is prescribed for the purposes of Section 43F in relation to the relevant failure the worker reasonably believes that it is likely that evidence relating to the relevant failure will be concealed or destroyed if he makes a disclosure to his employer, or
`(c) that the worker has previously made a disclosure of substantially the same information -
`(ii) in accordance with Section 43F.'
193 In determining whether it is reasonable for the worker to make the disclosure, regard is to be had in particular to: [257]
`(a) the identity of the person to whom the disclosure is made,
`(b) the seriousness of the relevant failure,
`(c) whether the relevant failure is continuing or is likely to occur in the future,
`(d) whether the disclosure is made in breach of a duty of confidentiality owed by the employer to any other person,
`(e) in a case falling within sub-section (2)(c)(i) or (ii), any action which the employer or the person to whom the previous disclosure in accordance with Section 43F was made has taken or might reasonably be expected to have taken as a result of the previous disclosure, and
`(f) in a case falling within sub-section (2)(c)(i), whether in making the disclosure to the employer the worker complied with any procedure whose use by him was authorised by the employer.'
194 It follows that, under the PIDA, disclosure must be made in the first place to the employer, or to a Minister of State or to a prescribed official. It may not be made to any other person, and still retain the quality of a `protected disclosure', unless the conditions in Section 43G are met. They speak for themselves, but it needs to be emphasised that the provision that the disclosure should be made `in good faith' means (as the requirement of good faith always does in a statute) `in the absence of bad faith'. Thus where a worker has mixed motives for making a disclosure (personal pique, pursuance of a political objective, or mischief-making) the disclosure may not qualify. Mixed motives may be very easy to attribute to any potential whistleblower, and would prevent protection under this section.
195 Moreover, the belief must be `reasonable'. That implies an objective standard in addition to the subjective belief as to the truth of the information. Applying this analysis of the recent developments in the law to the events in Bristol, it is not clear whether any disclosures would have been protected even under the newly enacted law.
Healthcare professionals in management
196 Doctor-managers remain subject to the GMC's jurisdiction, even while acting in a managerial or administrative capacity. The view of the GMC in this regard was upheld by the Privy Council in Roylance v General Medical Council. [258]
197 Nurse-managers similarly remain bound by their professional code of conduct:
`They [managers] are absolutely bound by the code whilst they maintain their [UKCC] professional registration.' [259]
`... we [UKCC] see cases where we have managers who also hold nursing registration who are reported to us for failing to act on concerns that have been made known to them.' [260]
198 The Privy Council rejected the view of Dr Roylance, which is, perhaps, exemplified by the following exchange:
`Q. Did you, being a doctor, have any responsibility, as you saw it, for the best interests of the patient?
`A. I had a responsibility, but I had no ability to determine what was in the best interests of the patient.' [261]
Team-based standards
199 One trend in professional standards has been the move from standards based on individual responsibility to team-based standards. According to Sir Donald Irvine, as has been seen:
`The concept of collective responsibility in clinical teams did not sit easily with such individualism' which `... flowed from, and was reinforced by ... the concept - in most doctors' minds - of accountability primarily to the patient and peers.' [262]
200 Sir Donald identified `The move towards more clinical teamwork and the concept of collective as well as personal responsibility' [263] as a trend since 1984. By contrast, the recent [264] report `The Regulation of Nurses, Midwives and Health Visitors' [265] suggests that collective responsibility was the norm, but is being built upon:
`Nursing is going through a period of significant change and professional development. Changes in nursing roles and practice include ... nurses becoming individually accountable for their practice'. [266]
201 However, Ms Lavin qualified that statement:
`Individual accountability has always been there. I think nurses are becoming more aware of what it means in practice ... .' [267]
202 The GMC essentially regulates individual doctors (it maintains a register of individuals) not clinical teams (such as units). It nonetheless now promulgates standards for teams, but:
`... [responsibility for] the implementation of this [guidance for collective responsibility] is not with us, it is with employers and this is where the overlap with institutions comes.' [268]
203 In addition, clinical teams are often multidisciplinary and responsibility is shared with managers (who might not belong to one of the healthcare professions):
`... the regulating bodies, be it for nursing, for medicine, have their prescribed responsibilities for the fitness to practise of the individual practitioner. But managers have always had a duty of care, responsible managers have always seen themselves as having a duty of care for those who come to their hospital or their practice for a service.' [269]
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Footnotes
[196] The editions of the `Blue Book' current during the Inquiry's period are at: WIT 0062 0127 (August 1983), WIT 0062 0145 (April 1985), WIT 0062 0165 (April 1987), WIT 0062 0183 (March 1989), WIT 0062 0201 (June 1990), WIT 0062 0220 (February 1991), WIT 0062 0239 (May 1992) and WIT 0062 0283 (December 1993)
[197] WIT 0062 0136 Mr Scott
[198] T48 p.90 Sir Donald Irvine
[201] WIT 0051 0075 Sir Donald Irvine
[202] T48 p.91-2 Sir Donald Irvine
[203] T48 p.93 Sir Donald Irvine
[204] WIT 0051 0075 Sir Donald Irvine
[205] WIT 0062 0175 Mr Scott
[206] WIT 0062 0210 - 0211 Mr Scott
[207] T48 p.93 Sir Donald Irvine
[208] T48 p.94 Sir Donald Irvine
[209] T48 p.95 Sir Donald Irvine
[210] T48 p.98-9 Sir Donald Irvine
[211] WIT 0051 0075 Sir Donald Irvine
[212] WIT 0062 0230 Mr Scott
[213] T48 p.96 Sir Donald Irvine
[214] T48 p.96-7 Sir Donald Irvine
[215] T48 p.96 Sir Donald Irvine
[216] WIT 0062 0250 Mr Scott
[217] WIT 0062 0294 Mr Scott
[218] `Good Medical Practice' is at WIT 0062 0309 Mr Scott (October 1995 edition) and WIT 0062 0374 Mr Scott (July 1998 edition)
[219] WIT 0062 0309 Mr Scott
[220] T48 p.97-8 Sir Donald Irvine
[221] T48 p.97-8 Sir Donald Irvine
[222] GMC Annual Report 1994, p. 20
[223] WIT 0051 0075 - 0076 Sir Donald Irvine
[224] WIT 0062 0305 Mr Scott
[225] WIT 0062 0307 Mr Scott
[226] WIT 0062 0310 Mr Scott
[227] WIT 0062 0343 Mr Scott
[228] WIT 0062 0360 Mr Scott
[229] WIT 0062 0328 Mr Scott
[230] WIT 0062 0314 Mr Scott
[231] WIT 0062 0315 Mr Scott
[232] WIT 0062 0316 Mr Scott
[233] WIT 0062 0317 Mr Scott
[234] WIT 0062 0318 Mr Scott
[235] WIT 0062 0384 Mr Scott
[236] WIT 0062 0398 Mr Scott; `Maintaining Good Medical Practice'
[237] 3rd edition, June 1992
[238] WIT 0052 0142 Ms Lavin
[239] WIT 0052 0341 Ms Lavin; `Employers have a duty to provide the resources needed for patient and client care, but the numerous requests to the UKCC for advice on this subject indicate that the environment in which care is provided is not always adequate. You may find yourself unable to provide good care because of a lack of adequate resources'. WIT 0052 0341 - 0342 Ms Lavin; `This [advice] will help to make sure that those who manage resources and staff have all the information they need to provide an adequate and appropriate standard of care. You must not be deterred from reporting your concerns, even if you believe that resources are not available ... this [communication] may require senior managers to justify their actions if inadequate resources are seen to affect the situation.'
[241] WIT 0052 0142 Ms Lavin
[242] WIT 0052 0341 Ms Lavin; `You may also have concerns over inappropriate behaviour by a colleague and feel it necessary to make your concerns known.'
[243] WIT 0052 0342 Ms Lavin
[248] Guidance to staff on relations with the public and media; EL(93)51 GMC 0006 0017
[249] WIT 0335 0016 Sir Alan Langlands
[250] Enacted 2 July 1998
[251] Section 42A, ERA 1996; defined in Section 43B
[252] Section 43D ERA
[253] In the case of the NHS: see Section 43E ERA
[254] HSE, for example: as at September 1999 no specific person had been proscribed in respect of the NHS (Section 43F ERA)
[255] See Section 43G ERA
[256] (Emphasis added)
[257] Section 43G(3) ERA
[258] 1999 `Lloyd's Law Reports' 139-52, PC
[262] WIT 0051 0003 Sir Donald Irvine
[263] WIT 0051 0002 Sir Donald Irvine
[264] WIT 0052 0275 Ms Lavin; the exact date of the report is uncertain but it is after January 1998
[265] WIT 0052 0183 Ms Lavin; conducted by J M Consulting Ltd for the UK Health Departments
[266] WIT 0052 0220 Ms Lavin