Examination of Witnesses (Questions 80
WEDNESDAY 28 MARCH 2001
80. We can explore that with the Department.
(Mr Buckley) The regulations make it clear that the
GP is responsible for whatever care is provided to his or her
patients, unless, which one may find out later, it is provided
by an independent GP principal. Therefore, under the system, complaints
have to go to the GP on whose list the patient may be. In one
particular case the GP dealt with it by having the patient removed
from his list. It is unfair to blame Healthcall for that.
81. I was not going to go on to blame Healthcall
for that at all! I was surprised that perhaps Healthcall were
not aware that there had been that consequence in one case. I
suppose, assuming that you were aware of it, my question was going
to be whether you had made any representations in that case to
the GP on behalf of the complainant. It is not that you would
have the responsibility to do that, but nevertheless we now have
the situation where the patient does not have a doctor and must
find another GP.
(Dr Dun) We genuinely were not aware of that. I have
been in conversation with some of the Ombudsman's officers on
the whole area of how out-of-hours services fit in with a practice-based
complaints procedure. That is the vehicle by which primary care
manages complaints and has been since 1996. It is at times confusing.
I do not believe that is just for deputising services; I think
that is an issue for NHS Direct and other out-of-hours providers.
We have done some work on this and we have corresponded on it.
We really would like to play our part in how we fit in with a
practice-based complaints procedure.
82. In terms of the operators and the guidance
that you give to the operators, how often do you review that?
Would that be when an incident occurs or would you review it on
a regular basis?
(Dr Dun) We would review it on a regular basis. We
have established a clinical standards group to review all clinical
guidelines and protocols. That is not to say that we do not have
a significant event policy, which we have introduced within the
last three months, so that if, as the result of an individual
event, something came to light outwith the normal work of the
review that meant the procedures needed to be reviewed, it could
be picked up. Yes, we do have the opportunity to review things
if an individual case occurs that warrants it.
83. Bearing in mind the number of areas that
you cover with 31 bases and 60 satellites, how do you convey that
across the network? Would it be through this bulletin that you
(Dr Dun) The bulletin is aimed for the duty doctors
and as a clinical information tool. It might say, "Here is
something where we did not do so well and there are opportunities
for learning". If we were going to alter policies and operating
procedures, we would do that through the network of operational
managers and local medical directors in each of the branches.
84. In terms of the branches themselves, how
do you determine how many doctors you require for an area? Is
that done per number of the population?
(Dr Dun) There is an number of variabilities; for
example, how the service is delivered. We still have a range where,
in some of our branches, 30 per cent of calls are responded to
by a home visit, whereas in others we are at 10 per cent. Obviously
the configuration of how many doctors are needed varies. Rather
than X per 100,000and this makes sense going forwardswe
measure our response times against the various priority categories.
The ability to be able to flex the workforce and to hit the target
which the out-of-hours review team has set down as a minimum is
the way that we do it and 30 years of experience helps in forming
rotas. That is how we measure if the numbers are working.
(Mr Burns) May I add that some branches with very
similar GP customer bases actually have very different call volumes.
That is partly socio-economic and partly the age and profile of
the population. We also measure call volumes to make sure that
we are properly covered. A branch with 600 GP customers can have
a varying call volume coming in and we need to make sure that
we cover base on the demand that comes through.
(Dr Dun) It is interesting that our South Wales branches
have two and a half times the call rate of Nottingham, for example.
It is not easy to understand why that should be.
85. In terms of when a doctor on-call in the
evening gets a call-out, would he or she drive himself or herself
to the patient or do you have a system with a driver to take that
doctor around the areas?
(Dr Dun) In every case there is a driver. In a number
of branchesand we need to evaluate this more fullythere
is the concept of patient transport. We use Ford Galaxy type vehicles
to bring patients who are medically able to travel but who do
not have transport to get to us. Obviously we are not asking people
to come when it is clinically inappropriate. We are looking at
various ways of being able to use our centre-based care rather
than home visits if possible.
86. If there was a home visit, the doctor could
not get lost in an area because he would have a driver with local
(Dr Dun) Absolutely and the IT developments in navigation
systems will make that far better than currently.
(Mr Burns) We are about to pilot proven technologies
that the ambulance service and RAC use, which is satellite navigation,
which makes it that much easier because the system actually tells
them where to go. That will be on offer in the next couple of
months with a view to running it out across our fleet.
87. An issue that is identified in these cases
is of doctors not being supplied by you with mobile phones and
sometimes being out of radio contact when they are driving to
new areas, but all that has gone; you now supply them with mobile
phones and they are in contact all the time?
(Dr Dun) Yes, and it was particularly in the Manchester
branch that we had problems. We addressed those very speedily.
In all the other branches we have different back-up arrangements,
whether it be by bleeper or by mobile phone, to support the radio
system, which is still fundamental to the business.
88. Someone less generous than me might say
that you are basically a commercial organisation. You make your
money by having a lot of money going in and less money going out.
Is there not a permanent incentive there for you to have the least
number of your doctors available that you possibly can, otherwise
you are not going to maximise your income, are you?
(Mr Burns) I do not think that is the case. The fundamental
issue is that all our customers have a choice. If we do not provide
an excellent service that is good value for money to themand,
as we have discussed, most of them are on annual contractsthey
can quite easily switch to another provider. As far as I am concerned
as the Group Managing Director, the highest priority in this group
is clinical quality. If we do not provide a high quality service,
I do not believe we will have a service because people have a
choice and they will quite rightly go elsewhere. The overriding
priority for my group is the delivery of a high quality local
89. You say that 70 per cent of the people who
work for you are GP principals. Are they currently in-post as
(Dr Dun) Absolutely, and I have the figures here.
Currently just over 76 per cent of our clinical workforce are
current GP principals; just over 4 per cent are nurses providing
nurse triage with decision-based software; and 19 per cent are
qualified GPs that are not currently principals.
90. I wonder why GPs who want to offload night
calls then want to sign up to do them through you?
(Dr Dun) Often what happens is that in a partnership
of five or six doctors, there may well be two or three who may
well be passionately against doing any out-of-hours calls and
would like us to undertake all of that; within that five or six,
there are two or three who would like to earn money to offset
the bills that we send them every month. There is a variety of
factors, and obviously pay is one, for those GP principals who
want to work for us.
91. When you use rented transport to take people
to one of your centres, who pays for that?
(Dr Dun) We do.
(Mr Burns) Those are our vehicles.
92. And you charge the doctors?
(Mr Burns) That is part of it. We are evaluating whether
this is of use at the moment. We have it running in four of the
branches where there is probably a greater socio-economic reason
why we should try to provide transport. One concern, and we are
open about this, is whether it becomes a dependence and, once
people actually hear that there is transport available, everyone
then demands transport, rather than actually coming in to the
centre. The transport is the vehicle fleet and that is provided
by us as part of the service that we deliver to customers.
93. And that is included in the charge you make
(Mr Burns) Correct.
94. When you send an ambulance, that would be
paid for by the NHS?
(Mr Burns) Yes.
95. Thank you for coming along. By way of conclusion,
may I say that I accept what you say about the new management
team and that we are going back two or three years with these
cases but we should not lose sight of the fact that these are
the most dreadful cases. There was an absolutely appalling failure
of service by your organisation in relation these people. As it
happens, we discovered that there were systemic failures across
your organisation. We are very used in this Committee to having
new management teams coming in and tell is it was the old management
team that did all these things. We are not entirely persuaded
by that all the time. Thank you very much for coming and talking
to us in the way that you have. We hope that what you are saying
is the case but we shall look very carefully at what Healthcall
does in the cases that come through the Ombudsman's hands. You
will understand when I say: we hope very much not to be able to
see you again on an occasion like this.
(Mr Burns) I hope, Chairman, that we do not have to
come again to sit in front of you, though as we said right at
the start, these cases are indefensible. The cases were appalling.
They should not have happened. We hope we have put in train now
systems to ensure that does not happen in the future. I hope we
do not have to have the privilege of coming in front of you in