Examination of Witnesses (Questions 60
WEDNESDAY 28 MARCH 2001
60. Would it not have been more straight forward
to let the call go straight through to a clinician?
(Dr Dun) That is one of the crucial advantages of
NHS Direct. However, NHS Direct does not deliver calls straight
through to the clinician at all times. I do not have the figures
for NHS Direct but certainly at peak times even NHS Direct has
to operate a call-back policy in those centres where nurses are
not directly answering the call. That would be the ideal position,
61. When you talk about retraining the operators,
what actually do you do and what level of medical complexity do
you go into there?
(Mr Burns) To start with, they go through the basics
of what they have to do in terms of what information they have
to collect, how it is laid out and the essential terms of the
demographics and personal information. They then go through a
series of role-playing with a senior member of staff in another
part of the building. The role play is to make sure that the person
understands the mechanism and starts taking the correct details,
and not only that, but that he is sympathetic, et cetera, to the
patient at the other end of the phone. Once they have gone through
that process, they then move on to the system itself, going live.
Normally first they actually sit and watch a trained operator
so that they can get the feel for how this is done. Then they
go on under the supervision of a supervisor. At the moment the
training is a minimum of about 100 hours before an operator is
allowed to do that on his own.
62. Are you measuring how the system works?
(Mr Burns) Yes. We have an assessment process with
our trainers and assessors whereby we actually assess individuals
not only for how well they perform but also to encourage the promotional
aspects. As they become more skilled at becoming an operator,
there is an opportunity for promotion to the next grade and financial
remuneration for that. We do have an assessment. We monitor cases
and in clinical terms look at about 13,500 patients every year
as well. Any complaints or problems that occur can be identified
back to an operator who is then taken out and retrained so that
the process is continued.
63. Do you have difficulties in making contact
with the doctors now? Can you get your clinical expert the first
time every time?
(Dr Dun) One of the cases referred to the systems
that were operating in that branch and we have addressed that
by putting in additional back-up arrangements so that we do not
rely only on radio or mobile. If there is any chance of radio
failure, our doctors are given a bleep and in that particular
branch they all have mobile telephones as well.
64. Are you measuring this and can you be sure
that it works?
(Dr Dun) I am monitoring all the complaints we get.
Perhaps that is not quite answering the same question. I have
not heard of any problems where that communication has not happened.
Perhaps that is an issue that we should monitor more formally
to make sure that every communication gets through. We do have
safety loops whereby if an operator does not get hold of a clinician,
then there is a report. The system is then put in place to try
again and there are contingency plans.
(Mr Burns) Also, again as part of the out-of-hours
standards, there is what is called a comfort call. If a patient
has been told a doctor will be there in, say, two hours and for
whatever reason that doctor is delayed, there is another safety
mechanism: the patient must get a call to say that the doctor
has been delayed but will be with that patient. This call will
be made 15 minutes either side of the two hour point. There are
more checks and balances in the system than there were.
65. One would imagine that this system would
help with what once probably was occasional overload. In the old
single-handed days, I am sure one doctor could not be in two places
at the same time. Obviously now there is an ability to marshal
much larger resources. Do you have system overload from time to
(Dr Dun) Without doubt on busy Sunday mornings during
the winter the demand can be extreme. The Ombudsman has quite
rightly flagged that and inquired whether our escalation for contingencies,
our back-up arrangements, are robust enough. We have made a number
of improvements to those arrangements which are not just about
IT, so that we can, with a 31-branch network, divert calls to
clinicians in different parts of the network if need be. We have
worked hard to make sure that we have more robust back-up arrangements
for clinicians and clear escalation procedures so that if those
unexpected peaks in demand occur, we can respond much better than
we did in these cases in 1997 and 1998.
(Mr Burns) We have installed a call logging system
now and we can look at all calls coming into a branch 24 hours
a day, seven days a week. We can map these. Strangely enough,
each Monday, for example, the call volumes coming in are almost
identical. Now we know that there is going to be a peak at 5.30
or 9.30, or whatever. We can plan in advance to make sure that
we have sufficient operators and doctors on to meet those peaks.
Three or four years ago we did not have that sort of science behind
66. Do you record all the calls or some of them?
(Mr Burns) We record all of them.
67. I have one or two questions about primary
care centres. As I understand the system, every so often in the
country you have a centre which is effectively a surgery that
operates on-line. People ring up and are told to go there. They
walk in, get stitched up, or whatever. What percentage of these
are yours and what percentage are surgeries which you are renting?
How does this work? How many are just ordinary surgeries?
(Mr Burns) Currently we have 31 main branches which
are our own. We have 60 satellite surgeries, which by and large
are arrangements that we have with local general practitioners
and with A&E, where we rent the rent the room overnight. About
31 are our own buildings and approximately 60 we rent from someone
68. Of this totality, do you employ the people
who work there in all cases?
(Mr Burns) The doctors work as GPs and 77 per cent
of our doctor workforce are GP principals with their own practices.
They are not employed but the operators, the drivers who drive
the doctors and the receptionists are all employed by Healthcall.
69. Do you have more control over the 31 branches
you own than over the 60 you do not?
(Mr Burns) No, I do not think so. We have arrangements.
For example, not all the 90 are open all night because a lot of
the time there is not the demand. In some we have the facility
to say, "We have hit a peak. The doctor can go there and
open up the surgery and see four or five patients". That
is more appropriate in many instances with regard to the clinical
environment in which to examine the patient; secondly, it is a
much better use of the clinician's time because clearly, where
appropriate, the patients are coming to the doctor rather than
the doctor having to drive around the country. If we look at productivity
levels, it takes a lot longer going from house-to-house, particularly
if it is not clinically appropriate to do so.
70. Who is paying for the time of the doctor
who is manning one of your centres at the moment?
(Dr Dun) The 8,500 doctors we have referred to effectively
pay us and we then engage the doctors.
71. Do you pay different rates in various parts
of the country for this?
(Dr Dun) We do, and there are different rates for
the hours people work for us. More is paid for the overnight shift
than the late evening shift.
72. In negotiation with either the single doctor
or the co-operative, you strike a bargain or set a period of time.
You enter into a contract to provide this service out of hours.
How long is that characteristically?
(Dr Dun) For the 30-odd years Healthcall has been
doing this, there have been annual contracts. Increasingly, in
the last year, particularly when PCTs and co-ops have been involved,
there has been an enthusiasm for customers to enter into longer
agreements, two and three year contracts. I would say that is
by far the minority, though. Most of our contracts are one-year
73. You have 31 branches. What sort of geographical
area in general would each one cover?
(Dr Dun) By and large, we tend to operate in the urban
areas but that is not exclusively so. An example that comes to
mind is in South Wales where we extend up into the valleys in
the rural areas. As a headline figure, we tend to be in the larger
74. I see, for instance, that you have a branch
in my area of Hove. Would that be mainly for GPs in the Brighton
and Hove area who would use your services or is it likely to cover
a wider geographical area across Sussex?
(Dr Dun) That branch in Hove would cover the local
75. The impression I have from the cases that
the Ombudsman looked at and that we have seen is that certainly
at the time those cases happened there appeared to be quite wide
variations between the way things were done in different parts
of the country. Would you agree that was true?
(Dr Dun) I would agree absolutely. As
a new management team, we have tried to introduce far more standardisation
and consistency across the whole network. This is not in any way
trying to be rude to our predecessor. Then there were far more
locally-responsive initiatives. You are right; that led to variability.
(Mr Burns) Now we have national standards
against which we measure. Those were very much in line with what
the out-of-hours review was recommending. Clearly we have adopted
some of the proposals to conform with the out-of-hours review.
As far as I am concerned, Healthcall is only as good as its weakest
link. I want universal, high quality standards to apply right
the way across our network, so that we give a patient in Southend
exactly the same service as a patient in Newcastle or in Wales.
76. Could you give us some clear indication
of how you ensure that that happens?
(Mr Burns) From an operational perspectiveDr
Dun will give you the clinical perspectiveon a regular
monthly basis we collect a large array of operational statistical
data and we can actually look at branches and their performance,
as Dr Dun has already said, in the operational periodshow
many calls are engaged, how quickly the phone is answered, et
cetera. We look at areas like complaints on a quarterly basis.
We undertake fairly extensive patient satisfaction through customer
satisfaction surveys. We monitor not only the operational side
but also the patient side. We do a lot on the clinical quality
side in terms of audit as well.
(Dr Dun) For me, one of the key challengesand
we have 1600 GPs working for usis to try to ensure that
we have consistently high quality across 1600 independent practitioners.
We have identified a core curriculum for the training which is
bespoke to out of hours and which we deliver nationally. We are
striving to ensure that we are meeting the training and development
needs of the 1600 doctors that work for us. That underpins the
77. So all of the GPs working for us will have
had to undergo that in-house training for Healthcall?
(Dr Dun) As I said, 77 per cent of our GPsand
that means 1200are GP principals. Now we are rolling out
a national programme. We have started with telephone advice training
and risk management training. That is quite difficult with duty
doctor resources being a problem for all out-of-hour providers.
We are offering and encouraging that to all our workforce with
a variety of sticks and carrots. We are not at the stage where
it is mandatory, although I do believe that will be coming.
78. Finally, on a different issue, in one of
the cases that we and the Ombudsman looked at the complainant
was directed to make the complaint to the GP with whom he was
registered. As a result, he was struck off the list of that GP.
(Dr Dun) Was that one of ours?
79. We were given to believe that occurred because
of the problem about to whom complaints are made.
(Mr Buckley) I think it would be unfair to regard
that as the responsibility of Healthcall.
(Dr Dun) I was not aware of that.