Certification of Death (Scotland) Bill: Stage 3

– in the Scottish Parliament at on 16 March 2011.

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Photo of Alasdair Morgan Alasdair Morgan Scottish National Party

The next item of business is stage 3 proceedings on the Certification of Death (Scotland) Bill. By this point in the session, members should know which documents they need in front of them, so I will not tell them again.

Section 2—Referral of certain medical certificates of cause of death for review

Group 1 is on the procedure for revoking orders that suspend the referral and review of medical certificates of cause of death. Amendment 1, in the name of the minister, is grouped with amendments 2 and 4 to 6.

Photo of Shona Robison Shona Robison Scottish National Party

Amendments 1, 2, 4 and 5 relate to the procedure that surrounds orders for the suspension of the review system during periods of epidemics or other similar emergencies. As the bill stands, to revoke such orders when the period of emergency is over, it would be necessary to use the same emergency affirmative procedure as applies to the making of such orders. The amendments will enable negative procedure to be used to revoke such orders, which we consider is more appropriate.

Amendment 6 is consequential on amendments that were made to section 28 at stage 2. It will simply remove a reference to “regulations” that is no longer relevant to that section.

I move amendment 1.

Amendment 1 agreed to.

Amendment 2 moved—[Shona Robison]—and agreed to.

Section 8—Review of medical certificates of cause of death

Photo of Alasdair Morgan Alasdair Morgan Scottish National Party

Group 2 is on conduct of review of medical certificates of cause of death. Amendment 3, in the name of Ian McKee, is the only amendment in the group.

Photo of Ian McKee Ian McKee Scottish National Party

I realise that section 8(2)(c) is rather a catch-all provision, but it is important that it be a little bit more specific. Accordingly, I have lodged amendment 3, because I think that interrogating relatives, carers or anyone who was involved in looking after the deceased in the final days of their terminal illness is important in ensuring the death certificate’s accuracy. Of course, in the vast majority of such instances, their evidence will corroborate the information on the certificate; nevertheless, even then, that confirmatory evidence will be welcome.

However, in a proportion of cases, remarks by such witnesses on, for example, the mode of death or the symptoms exhibited before death, or even just casual comments about medication that was taken or treatment given could prompt a medical reviewer to follow a new line of investigation that might result in a more accurate certificate at the end of the process. Such contact would also serve to reassure the relatives or carers that such matters are not treated lightly and might even allow them to come forward with concerns that would otherwise never be mentioned.

I move amendment 3.

Photo of Ross Finnie Ross Finnie Liberal Democrat

I have much enjoyed working with Ian McKee and wholly support the substance of his amendment 3. However, it is a pity that it is ungrammatical. Given that the subject of the sentence in section 8(2) is “the medical reviewer”, the use of the subjective pronoun “who” instead of the objective pronoun “whom” in the amendment is, I think, much to be regretted.

Photo of Shona Robison Shona Robison Scottish National Party

I have to say that I did not know that we had such grammar boffins in the chamber. One learns something new every day.

As amendment 3 might assist the reader of the legislation in understanding what can occur during the review process, I welcome it.

Photo of Alasdair Morgan Alasdair Morgan Scottish National Party

Do you wish to add anything, Mr McKee?

Photo of Ian McKee Ian McKee Scottish National Party

I just want to confirm Ross Finnie’s admirable point. I had a little help in drafting the amendment, but obviously one needs to look a little bit harder at any help that one receives.

Amendment 3 agreed to.

After section 23

Photo of Alasdair Morgan Alasdair Morgan Scottish National Party

Group 3 is on creation and content of medical certificates of cause of death and any pilot scheme under the act. Amendment 7, in the name of Richard Simpson, is the only amendment in the group.

Photo of Richard Simpson Richard Simpson Labour

Amendment 7, which follows on from the Health and Sport Committee’s stage 1 report and observations that I have made at each stage of the bill’s progress, has two interconnected purposes. First, I wish to test whether the minister has taken on board the need for urgency in moving from a 19th century paper-based system to a 21st century electronic system, and I hope that she will indicate either now or in the following debate progress in and the potential timelines for developing an electronic system. I believe that any hasty move to a set of paper pilots that would have to be followed by an electronic certification system pilot would be a duplication that we can ill afford and might indeed be counterproductive. That would be true in times of plenty, but these are times of austerity and the waste involved could be significant.

The second purpose of amendment 7 is to point out that this is an opportunity to modernise the certification process not only by making it electronic but by ensuring that the data can truly inform our health planning. Despite certain doubts about the potential to analyse certification in electronic form, I believe that individual doctors could be shown to be outliers on the basis of the cumulative analysis of their certificates.

At present, the ability to link data from such sources to 2001 census data is inadequate, and I hope that the minister will take note of the difficulties in that respect for future reference. Cumbersome bureaucratic elements make that linking difficult to deal with. That is important, because the 2001 census is one of the main sources of ethnicity data, and we know that we will be able to plan our services better if we have good recorded ethnicity data.

I will give an example that was given in a debate that the minister, Ross Finnie and I were involved in last night. According to research, there is a much higher level of diabetes in the south Asian community, but we do not know whether that finding is valid in a Scottish context. If we had good electronic data in which ethnicity was always recorded, we would have the opportunity to examine that matter.

Another issue is health care acquired infection. Having notes on death certificates that say whether health care acquired infection was present and whether it contributed directly or indirectly to the death is important in ensuring that the excellent progress that has been made in dealing with MRSA and Clostridium difficile is maintained in dealing with VRE, NDM-1 and all the other new challenges that are now coming along and rearing their ugly heads. Things can be done much more easily on electronic forms. It would simply be a matter of saying whether there was or was not infection; if there was, there would be further drop-down boxes for answers. That is difficult to do with paper.

The consent of next of kin suggestion is to ensure that, in the reduced review climate, which remains one of the committee’s concerns, the next of kin acknowledge that they are content with the death certificate. Such an approach would be welcome. I realise that there is the opportunity in the bill for kin to require or request a review, but the proposal would go further than that—it would trigger the next of kin to think and to indicate whether they were content. They might not have thought of the matter, but if they were asked to think of it they could say, “Well, now you come to mention it, actually we’re really not that happy because something has been omitted from the death certificate.”

The final proposal would allow ministers to add any information that they thought was useful. Familial screening is mentioned. If there was electronic linkage, there would be the ability to ensure, for example, that familial hypercholesterolaemia, which is currently poorly screened for, was screened for. We could have a system that automatically sent a trigger to the general practitioner when a person with a condition for which familial screening was appropriate had died, to suggest that family members be contacted and screened.

I would make it an absolute requirement that the community health index number be entered. That is fundamental to the data linkage system that we must have in Scotland. Without a CHI number, a big piece of the jigsaw is missing. Requiring it is of great importance. I recognise that there is a difficulty with that, as the hospital side is not yet 100 per cent using CHI numbers and junior doctors are filling in things. Nevertheless, having access to the emergency care record that every doctor should have access to, that should be available for every patient, and that should have the CHI number recorded on it will allow us to have a modern, 21st century system.

As I will say in the final debate, I remain disappointed by the bill. It was introduced as a result of Shipman, for many good reasons, but by moving so quickly to a paper-based system we have failed to take the opportunities that we need to take.

I move amendment 7.

Photo of Shona Robison Shona Robison Scottish National Party

I do not support amending the bill to introduce discretionary powers to create electronic medical certificate of cause of death forms for use during the test site phase. That would be unnecessary, and would be likely to delay the start of the test sites in the new system. I have already made a commitment to exploring the feasibility of electronic MCCDs. Such a feasibility study would examine various options, including the different information technology solutions that are available and the different methods of verifying the identity of the certifying doctor.

As we all know, devising IT systems can be complex, costly and time consuming, with long lead-in periods. We are talking about a new IT system for which the business case has not yet been made and the costs, practical considerations and timescales have not yet been fully explored. I do not wish to jeopardise the implementation of the new death certification system. It is fair to say that the new processes that the bill will introduce mark a significant departure from current practice. There is a risk that trying to test the operation of a completely new process at the same time as introducing a new electronic system would be overly complex and that the operational difficulties of one might have a negative impact on the other. For that reason, we think that it is sensible to test the operation of the system outlined in the bill first. Only then will we be able to judge whether it is necessary to introduce electronic completion of MCCDs. However, as I have said, I see the potential benefits of electronic completion of MCCDs and I undertake to consider the feasibility of introducing such a system.

Amendment 7 would require additional information to be added to the MCCD for use during the piloting of the test sites. I cannot support that. Again, there is a risk that making the inclusion of that information mandatory would result in complications and cause delays during the testing of the new system. For example, in cases in which the deceased was to be cremated, the amendment would require the recording of the next of kin’s acceptance that the information on the MCCD form was correct. Delays could quite easily result if there were difficulties locating the next of kin or it was not known at the point of completion of the MCCD whether the deceased wished to be cremated.

Further, it would potentially be insensitive to pressure the next of kin to make a decision about the adequacy of the MCCD so close to the death. That is why we have provided an opportunity in the bill for certain family members to apply within three years of the death to have the MCCD reviewed by an independent medical reviewer.

Also, we do not think that it is appropriate to require the other additional information to be included in every MCCD used during the piloting of the test sites. That would make completion of the forms more complex and time consuming, which might have a negative impact on the main objective of testing the system that is set out in the bill. The bill makes provision to allow additional medical information to be included in MCCDs. The General Register Office for Scotland has recently consulted on that issue. There is therefore no need for that information to be added to MCCDs for the purposes of the test sites. The results from the test sites may lead to some of the changes that Richard Simpson is arguing for today.

For those reasons, I oppose amendment 7.

Photo of Mary Scanlon Mary Scanlon Conservative

I understand the minister’s response and appreciate what she said at stage 2. None of us would wish to delay funerals, which would be difficult for families. I also appreciate what the minister said about the proposals being costly and complex and having a long run-in period. However, we had 100 years prior to the bill to change practice. This is the first change in 100 years. We have had 12 years of a Scottish Parliament. Perhaps Richard Simpson has a good point.

I also have a more general point, on an issue that the Health and Sport Committee has considered over the years. Generally speaking, the national health service is extremely slow to adapt to e-health, telehealth, clinical portals and any other electronic system. I still have to write a letter to my doctor or turn up in person at the surgery in order to get a prescription—something that for many years could have been done electronically. Even the electronic bed management system is operated differently in different health boards.

While I have sympathy for Richard Simpson’s point, I understand the minister’s response. When we are faced with legislation in future, surely it is incumbent on the bill team, ministers and all of those who prepare bills to ask themselves, “Can we introduce technology at this point that would make things better now and in future, and that could be utilised to the benefit of all?”

My final point is one that I will also mention in my summing up. I am not yet sure that we have secured the provision of full and accurate information on the death certificate, although that is a proposition of the bill. It would be helpful if an electronic system managed to integrate information on hospital-acquired infections, as well as any other information that is useful to future public health planning.

Photo of Richard Simpson Richard Simpson Labour

I am slightly disappointed by the minister’s response, but I will seek to withdraw amendment 7. Subsection (1) of the amendment states:

“the Scottish Ministers may provide for medical certificates of cause of death to be created in an electronic form.”

We already have an electronic form—we are not starting from scratch. ISD Scotland enters the data in an electronic form. The Health and Sport Committee received evidence from Colin Fischbacher that he must make 2,000 inquiries a year about deaths, although he does not get information back, because there is no compulsion to change the current paper reporting, which is bizarre. Nevertheless, a system exists that ends up with an electronic form.

Given that we start from that point and given—I assume—that all deaths will have to be coded, it does not seem that we should not make progress. That is why I am disappointed. In rejecting my amendment, the minister used words like “will” and “can in the future look at”. The committee said clearly in its report, which was published on 21 January, that technology was important for the future. I believe that the minister should have said, “We have already commenced the process of examining the issue.” However, I will seek to withdraw amendment 7.

Amendment 7, by agreement, withdrawn.

Section 28—Orders and regulations

Amendments 4 to 6 moved—[Shona Robison]—and agreed to.

Photo of Alasdair Morgan Alasdair Morgan Scottish National Party

That ends consideration of amendments.