Select Committee on Public Administration Minutes of Evidence

Examination of Witnesses (Questions 60 - 79)



  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, yes.

Mr Trend

  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 time?
  (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 us.

  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 else.

  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 arrangements.

Mr Lepper

  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 urban areas.

  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 area.

  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 perspective—Dr Dun will give you the clinical perspective—on 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 periods—how 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 challenges—and we have 1600 GPs working for us—is 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 audit.

  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 GPs—and that means 1200—are 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.

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