Examination of Witnesses (Questions 43
- 59)
WEDNESDAY 28 MARCH 2001
MR ROBBIE
BURNS AND
DR ANDREW
DUN
Chairman
43. Could I, on behalf of the Committee, welcome
you this afternoon. As you know, the Committee looks at cases
arising out of Ombudsman's reports, which is why we have invited
you from Healthcall to come along and look at some issues arising
out of a number of complaints about Healthcall. I think it would
be helpful if you were able to say a few words by way of introduction,
although before that it would be even more helpful if I asked
the Ombudsman to introduce and remind us of the cases that we
are talking about.
(Mr Buckley) As you say, my office has
investigated a number of complaints involving organisations providing
deputising services for GPs. Several of them have involved Healthcall
Limited. Besides the special report on cases like E.515/97-98,
published in March 1999, and which I should in fairness say was
mainly concerned with the actions of the deputising doctor himself,
I published three cases in full in the volume of Investigations
Completed between October 1999 and March 2000. The case references
are E.1927/98-99; E.1329/98-99; and E.516/99-00. In addition,
I have published in summary form two cases involving other deputising
services: the references are E.389/99-00 and E.3891582/99-00.
I understand that the Committee is not so much concerned to discuss
the details of individual cases as to explore the common themes
which have emerged from them. These include: (a) extended periods
between the time a doctor was called and when he or she actually
visited the patient; (b) the quality of care provided by the doctor;
(c) inadequate procedures that meant information was not passed
quickly to a person with the qualifications to make an assessment
of clinical need and priority; (d) occasions when too few deputising
doctors were stretched across a very large geographical area,
which contributed to delays; (e) procedures for calling upon more
doctors either did not exist, or were not activated; (f) inadequate
communication between the commissioning and deputising GPs. I
welcomed the deputising agencies' assurances that those matters
would be addressed and noted planned changes to induction, training
and other procedures. My staff have had helpful discussions with
Healthcall's Medical Director. Another general cause of concern
was the arrangements for monitoring the quality of deputising
services. Before April 1997, Health Authorities were responsible
for this, and were required to have a Deputising Services Sub-Committee.
Since 1997, the responsibility has passed to GPs, who are required
to take all reasonable steps to satisfy themselves that any deputising
services they use provide services which are adequate and appropriate.
I believe that change is under consideration and you may wish
to ask the Department of Health witnesses for an account of where
we are. It became clear in the course of the investigations I
have mentioned that some GPs monitored the quality of the service
provided by those deputising for them, but others did not. In
fact, the arrangements for monitoring out-of-hours services, whether
provided by independent sector organisations like Healthcall or
the GP-managed out-of-hours co-operatives, seemed to vary considerably.
I therefore welcomed the opportunity to contribute to the Chief
Medical Officer's review of out-of-hours services and the proposals
that emerged from that review. Finally, there has been a more
recent complaint which revealed some apparently widespread confusion
about which of the parties to a complaint—the commissioning
doctor, the deputising doctor or the deputising service—should
respond to the complainant. Since this appeared to be an immediate
concern, I drew the issue to the attention of the Department of
Health, and I understand that the matter is receiving consideration.
Finally, Chairman, although, as I say, I understand that the Committee
does not wish to examine the detail of individual cases, may I
nevertheless, through you, repeat the usual warning regarding
the confidentiality of individuals who were involved in the cases.
44. Thank you for that. Let me turn to Healthcall
and ask perhaps Mr Burns, the Group Managing Director, whether
he would like to say a few words by way of initial response.
(Mr Burns) May I take the opportunity initially to
introduce ourselves. My name is Robbie Burns. I am the Group Managing
Director of Healthcall. I have been with Healthcall for about
15 months and assumed the role of Group Managing Director in February
2000. I will ask my colleague to introduce himself.
(Dr Dun) My name is Dr Andrew Dun. I joined Healthcall
at the end of 1999, at about the same time as Robbie Burns. For
ten years prior to joining Healthcall, I was a GP in a partnership
in western Wiltshire.
(Mr Burns) May I tell the Committee a little bit about
Healthcall? We are a health service provision company. The vast
bulk of the business, the core business, is the out-of-hours deputising
service. Currently we have just over 8,500 GP customers. We look
after approximately 15 million patients every night across the
United Kingdom from Scotland through Wales and into the south-west
of England. I do not particularly want to say anything on the
specific cases but, if you would like to go into some of the details
of it, Chairman, we are more than happy to take questions.
45. Thank you very much. Someone who reads their
way through these cases, because obviously we start with the cases,
I think is appalled by what happened with people being kept waiting
for hours before anyone came and in two cases people died. We
do not know about the cause and effect. That brings home the severity
of this. The Ombudsman in one of the reports talks about fundamental
failings of Healthcall in relation to the issues. What do you
think those fundamental failings are?
(Dr Dun) Undoubtedly, the cases that the Ombudsman
referred to in 1997 and 1998 showed a number of fundamental failings
where we wholeheartedly agree with the Ombudsman. From the clinical
perspective I think perhaps they could be summarised in terms
of having inadequate prioritisation early in the proceedings.
One of the comments which the Ombudsman and his team have referred
to has been using operators—non-clinicians—to prioritise
calls, which I wholeheartedly accept is not appropriate to modern,
high quality out-of-hours care. We have put in place changes to
remedy that. I think undoubtedly there were some failings in our
organisational proceedings for passing calls swiftly from control
centres out to clinicians, whether they be within the centre or
out in the field. I think one of the other things which underlies
much of the criticism which is absolutely right is that we were
perhaps delivering at that time an out-of-hours service that required
modernising. If I may elaborate on that, in the mid-Nineties,
and certainly in 1995-96, Healthcall delivered primarily a home
visiting service. I think it has become only too apparent from
some of the developments in GP co-operatives—and, I am pleased
to say, some of our changes—that modern, out-of-hours, primary
care does not actually require a home visit to be delivered for
all patients. There are other mechanisms of delivery such as clinical
telephone advice and inviting patients, when it is clinically
appropriate so to do, to come to primary care centres and hence
to use initially working out of hours far more effectively. I
wholeheartedly accept that there were some fundamental issues
that the Ombudsman identified, which we feel, without in any way
being complacent, we are working hard to change.
(Mr Burns) To carry on from where my colleague left
off, in the last year or 15 months we have introduced a number
of changes to improve not only the clinical delivery of the service
but also the operational delivery, both in terms of organising
the technology and telephony we actually use and also fundamentally
to retrain our operators in how to handle calls and the issue,
as Dr Dun has stated, of making sure that those calls are passed
swiftly to a clinician to undertake the prioritisation. We wholeheartedly
accept the criticisms that are levelled in these cases but we
believe we have made considerable progress in improving the delivery
service that we offer our patients and our customers.
46. The picture that we have here is of a service
which sometimes takes calls inadequately and in one case did not
understand the severity of the conditions; those calls are held
for a long time by a non-medically qualified operator who fails
to transmit those calls in any decent time to a medically qualified
person; and that that medically qualified person, as we are told
in some of these cases, may even not be in radio contact. In your
view do none of those things apply?
(Mr Burns) We have addressed all of those issues.
We have undertaken a retraining programme of our operators; new
operators that come in have a minimum of 100 hours training before
they are actually on their own taking calls. Dr Dun can comment
on the clinical prioritisation we have undertaken after consultation
with our local medical directors, and we believe that we have
come an enormous way since 1998-99. There is always going to be
an instance when something unforeseen happens. We have an environment
now in which every complaint is examined; we use that as a learning
tool so that if there is an issue we make sure that is addressed
so that we can actually ensure that we do not repeat the mistakes
that were made in the past.
47. Before my colleagues come in, can I press
you on this because it is a fundamental issue. If there are system
failures which you have identified in these reports, can you tell
us, hand on heart, that they have been corrected now so that cases
like this cannot happen again?
(Mr Burns) They have been corrected. I think it would
be foolhardy of me to say that they will not ever happen again
in the future. We believe we have put the checks and balances
in train to ensure that that risk is minimised right down to a
level where, hopefully, it will never happen. I do not think I
could say that it will never happen again. We have dramatically
improved not only the training but also the telephony and the
systems we have put in train since 1998-99.
48. I am not sure you have quite got the point.
It is not that cases do not happen, otherwise the Ombudsman would
not be in business. The point is that, if cases are a consequence
of failures of systems, they can be corrected. Have you corrected
those failures in systems so that that dimension of these kinds
of cases cannot recur?
(Mr Burns) We believe we have. We are planning to
do more things. With modern technologies we believe we can take
that a stage further. We are constantly improving our systems
and making investments in the systems. Yes, those fundamental
issues we believe we have corrected.
Chairman: I am sure we will want to explore
some of those with you.
Mr White
49. I represent Milton Keynes, so it is interesting
that you are here! One of the things that has struck me of course
was NHS Direct. It seems to me there is a number of lessons from
your experiences that would be applicable to NHS Direct. Have
you offered those to NHS Direct so that NHS Direct does not repeat
the same mistakes you are making?
(Dr Dun) We have been pleased to be involved with
NHS Direct at both local and national levels and more importantly,
if I may add, with the Government out-of-hours review team, which
I believe has taken a wide range of opinions and experience, the
good and the bad from all out-of-hours providers. Now the Government
has a framework by which quality out-of-hours care, including
the role that NHS Direct plays in it, can be transparently measured
and there can be benchmarking between providers so that we can
see the good and the bad and share best practice. Yes, we have
communications at local and national levels with NHS Direct.
50. One of the things that came across from
reading the Ombudsman's report was the differing ways in various
parts of the country the out-of-hours service is provided. You
provide quite a number of services where there are local co-ops
and services by individual GPs. How do you co-operate between
you or is there competition? I could not understand how the system
works. Is that not one of the problems? It sounds as though there
are different standards in the contracts.
(Dr Dun) Without doubt competition has been rife since
the mid-Nineties between organisations like ourselves and particularly
GP co-operatives. I am not sure that that competition has always
worked in the best interests of patients. I do genuinely believe
that the core of the out-of-hours review initiative fundamentally
says that out-of-hours providers, including A&E, ambulance
trusts and GP providers, must work together and collaborate. General
practitioners of my generation and much younger are less keen
to work out-of-hours than they have ever been. We make sure that
we make best use of resources by working together.
51. One of the things, it seems to me, is that
the pressure on out-of-hours services is putting more pressure
on A&E departments. Does that not lead to some of the complications
we have seen in these reports?
(Mr Burns) One of the issues raised in the out-of-hours
review, which is absolutely appropriate, is that a lot of patients
presenting at A&E do not require secondary but primary intervention.
Therefore, there is a move to try and co-locate many primary care
centres alongside A&E departments and, as Dr Dun has said,
to share resources, so that we do not have patients travelling
across towns to get to their primary care centre but they go to
the one most convenient to them. We certainly welcome this initiative.
We already have a couple of primary care centres in A&E departments.
This momentum is now beginning. I am sure that, as the out-of-hours
review is implemented, we will see a much more comprehensive service
delivery framework for the patients.
52. With whom is your contact these days?
(Dr Dun) As we sit now, mostly with individual general
practitioners. However, during the last year there has been quite
a move towards primary care groups and trusts. Interestingly as
well, we do have a good number—between 10 and 20—of
formal contractual arrangements with co-operatives where we have
started to collaborate. That is not universal across the country
and it is mostly with GPs but there is a real move towards primary
care trusts.
53. If I phone up, I do not know who is going
to come and see me. Is that correct?
(Dr Dun) When you phone up your current general practitioner,
unless that call is routed to a provider that tells you who you
are going to get to come and see you, I think that is right, yes.
Chairman
54. Take us through Brian's call and through
the system so that we get a sense of this. Brian is having pains
in the middle of the night. He makes a call to his GP. The GP
has a contract with you. Take us through the system.
(Dr Dun) When Mr White makes his call, currently we
have some quality standards around how we should respond to that
call in terms of the chance of him hitting an engaged tone and
the speed of response. Obviously minimum standards have been set
down now nationally and one has to do that. If Mr White were to
ring Healthcall, he would be answered by a trained operator but
not a clinically-trained operator. At that stage, the operator
who is trained in taking some fairly basic information, demographic
information and symptom information, has a simple choice to make.
If there are potentially immediately life-threatening conditions,
we have in common with ambulance trusts identified the most commonly
presenting immediately life-threatening conditions that require
a 999 response. We are required to report centrally in the out-of-hours
review how many of those immediately life-threatening conditions
we identify within a minute.
55. Pause there for a second. Here is Brian
with these dreadful pains of the kind that MPs get routinely,
in the middle of the night, and he phones this person who is not
medically qualified. He describes the pains. Does this person
then have to decide if it is urgent?
(Dr Dun) No. There is a lay script that has been tested
with clinicians and ambulance trusts. High on the list of immediately
life-threatening conditions might be a heart attack if there is
central chest pain. The operator would be able to ask some fairly
basic simple questions and would instigate a 999 response for
Mr White. All other callers are invited to attend one of our primary
care centres or they are passed—which I believe is a fundamental
improvement from the case on which the Ombudsman comments - to
a clinician for a prioritisation decision. Then the outcome from
either that prioritisation decision or the operator's discussion
with Mr White would effectively lead to three mechanisms of delivering
a service to Mr White. He would be advised by, in most cases within
Healthcall, a qualified GP, although four per cent of our workforce
are triage nurses; and he would be advised on self-care and self-help,
perhaps rather similar to NHS Direct. He would be invited to one
of our primary care centres or surgeries or a home visit would
be arranged. Priority for the home visit would then be set, obviously
in negotiation with the patient, by a clinician and not, as in
the cases which Mr Buckley identified, by a non-qualified operator.
Mr White
56. I have a condition whereby I am allergic
to penicillin. If I took penicillin, it would kill me, which is
why I wear a medico bracelet. My doctor knows about that but how
would you know about it?
(Dr Dun) Currently we do not. One of the weaknesses
in the current arrangements, and perhaps until electronic health
and patient records exists, is that, unless your GP informs us—and
the classic example is in the care of the terminally ill where
all out-of-hours services ought to be providing better quality
care—or unless you told us the specific circumstances about
your penicillin allergy, we would not be aware of it until one
of our clinicians spoke with you and hopefully gleaned that information
from you. To conclude, the end point of Mr White's consultation
interaction with us would be either telephone advice by a clinician,
an appointment to come to a primary care centre or surgery to
see a qualified GP, or a home visit could be arranged.
57. How does that information get back to my
GP?
(Dr Dun) This is an area on which the out-of-hours
review has set down clearly that they expect us to make sure that
the next day by 9 a.m. your GP is aware: (a) that you have made
contact with us; (b) what you presented with; and (c) what we
did about it.
58. Would your statistics show that you have
achieved that?
(Dr Dun) In terms of getting information back, currently
in the branches that are computerised—and that is about
50-per-cent of our network—we deliver that every time. I
will get the information on the others back to you. I know that
we do not get there every time. That is an area we have to address
urgently to meet the requirements of the out-of-hours review.
Chairman
59. To wrap up that story, the key issue in
the case that we have looked at was the failure to get this information
into a clinician's hands over any tolerable time period. You are
saying now that although the initial call goes to a non-clinically
qualified person, it then goes straightforwardly and immediately
into a clinician's hands and he makes these decisions.
(Dr Dun) I would not in any way want to mislead you.
As with some of the NHS Direct centres when they do not have nurses
answering the call but operators, we endeavour to put calls through
to clinicians. I would have to say that on the majority of occasions
the clinician instigates a telephone call back to the patient.
I would not want to appear to be deceiving and say that the call
immediately goes through to an advising clinician. The clinician
rings the patient back in most cases. I believe that is pretty
normal for most out-of-hours providers, whether a deputising service,
GP co-operative or other.
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