Examination of Witnesses (Questions 100
- 119)
WEDNESDAY 28 MARCH 2001
DR DAVID
CARSON, MR
ANDREW PALETHORPE
MR R THOMPSON
AND MS
C HEANEY
100. Did you say "a decision algorithm"?
(Mr Carson) Yes. That is a series of questions which
are designed to identify those patients which require an immediate
response by the nature of their clinical condition.
101. That is interesting. I am not quite sure
how that is going to crack all this. We have the beginning of
the process. Take us through the rest of it.
(Mr Carson) We have laid down a service model, a set
of quality standards and a process by which those standards will
be monitored and organisations will be held to account to deliver
against those standards. We have brought forward in the Health
and Social Care Bill a clause—clause 25—which will
give health authorities the power to accredit out-of-hours providers,
which will include commercial deputising services and GP co-ops,
and to accredit those to provide services to NHS GPs and their
lists. Stemming from that power of accreditation will be the requirement
that the organisation meets, and continuously meets, the quality
standards. The quality standards have been provided in a response
standard, which is an access standard. We have also looked at
standards that really refer to the organisation being fit for
purpose, that it demonstrates that it has enough personnel, that
its systems are safe and appropriate, and that it has the wherewithal
to deliver the service to the standard that the NHS has laid down.
So we have in effect recommended that the planning, commissioning
and monitoring of the delivering service is all held to account
by the NHS.
102. That is a standards framework that produces
accreditation which can be removed and I presume that Healthcall
at the time that we are talking would not have passed that test
and would not have been accredited?
(Mr Carson) On the evidence that we have, the responses
in the specific cases fall well outside the standards we have
recommended in the reports.
103. Can I pick up the point that David Lepper
raised with the previous witnesses, and others may want to return
to it, too. That raises the issue of complaints which you have
invited us to explore with you. Is it not extraordinary that not
only does a complainant in one of these dreadful cases have to
suffer the consequences of the case itself but then is advised
that the only complaint that he can make is not to the deputising
service itself but to the GP who is formally responsible for the
care of his patients and therefore that service? He does not want
to complain to the GP, with whom he has no complaint, but he does
complain, after being so advised, and within 24 hours is struck
off by the GP. It is the most extraordinary situation.
(Mr Carson) Since 1997 a GP can delegate his out-of-hours
responsibility to another principal on the list. That means that
the responsibility not only for providing the service but also
for responding to patient complaints associated with that service
passes from the host GP, the registered GP, to the GP who is covering
out of hours. We have recommended as part of accreditation that
that full responsibility passes to the organisation that is, in
effect, deputising for the GP out of hours, so that, as part of
being an accredited organisation, the out of hours provider would
have to respond properly to that complaint and have the systems
with which to respond and investigate to the complainant and not
via the host GP. In most cases we felt that was inappropriate.
The full responsibility for providing the service and also for
responding to the consequences of any actions should pass.
104. Before we lose the point, let us stick
with the striking-off issue for a minute. This Committee has been
worrying about this for some years now, again drawing on Ombudsman
investigations. We seem to be no further ahead with it. GPs still
seem able to strike people off as they want. This is the most
extraordinary case, as I say, but it is only an example of the
ability of GPs to do this without any reason being given or any
appeal procedure, which cannot be right.
(Mr Carson) That is, as I understand it, the current
regulation structure. Mr Palethorpe might be able to outline the
regulation.
(Mr Palethorpe) The current arrangements are as they
have been since the inception of the NHS, which is that it envisages
that the relationship between a GP and a patient is voluntary
on both sides to a large extent. The patient can withdraw from
a GP's list and register with another GP at will, but there are,
equally, occasions when the GP may conclude that the relationship
between the doctor and patient has come to a point where the friction
is getting in the way of an effective doctor-patient relationship.
However, it is the case that, despite guidance from the General
Medical Council in "Good Medical Practice" , if it comes
to that point, and preferably before then, the GP can actually
explain to the patient and give reasons. Certainly there should
be no question of things like economic considerations, which are
completely extraneous to a proper relationship between doctor
and patient, being taken into account. As you say, there are,
as the Ombudsman has observed, instances where there seem to have
been irrational, unfair removal of patients from the list. If
memory serves, the former Chief Executive of the NHS in evidence
to the Committee gave an undertaking to commission some research
work into the incidence of removals of patients from the list:
what was causing it and what was the underlying problem. He said
that the Department should do this work with the General Practitioners'
Committee of the British Medical Association. It is not a work
area with which I am directly familiar. That particular piece
of research, what stage it has got to and what consideration there
has been of the incidence, may already be in hand with evidence
given and work done into putting it into some form of action.
I cannot speak on that from my own knowledge.
105. You have certainly described the problem
again. The question is: what are you going to do about it? It
is not an equal contract if a patient who dares to make a complaint
to a GP is struck off. That is not an equal contract. There is
a guidance note from the BMA which can happily be ignored by a
doctor without consequences. I have taken this up in relation
to my own constituency with the health authority but got nowhere
with it because they have no powers. Surely the area of clinical
governance ought to be sorting all this stuff out? This is basic
natural justice, is it not?
(Mr Palethorpe) I tend to agree, Mr Chairman. I am
afraid that I cannot tell you from my own knowledge where we are
on actually incorporating these sorts of doctor-patient relationships
or doctor-patient partnerships within the clinical governance
agenda to ensure that the decisions are rational and fair and
that there is a more balanced relationship.
Mr White
106. I am slightly confused. This follows on
from the question about what GPs can and cannot do. If there is
a problem with the out-of-hours service, whose responsibility
is it to sort that out? Is it the responsibility of the primary
care trust, the individual GP, the GP practice, the Department,
the NHS Executive, the regional health executive or the health
authority? Where do you go? Is it everybody's responsibility and
nobody's?
(Mr Carson) I will outline the current situation and
then perhaps move forward to where we intend to get. The current
situation is that the GP principal is responsible for providing
care to his list of a type that is normally provided by GP principals
365 days a year, 24 hours a day. Under the regulations, GPs can
delegate that responsibility to another principal on the list.
107. Within their own practice?
(Mr Carson) Within their own practice or without.
108. Somebody can approach them, if they wish?
(Mr Carson) Yes. It has to be somebody who can respond
appropriately within the timescale obviously. The health authority
holds the contract of the GP for that list. That is the line of
accountability. That is where it lies for the patient on the list.
GPs can discharge their out-of-hours responsibility in a number
of ways: they can choose to do it themselves; they can join together
in a rota that may just be based in the practice; they may decide
that they wish to go into a larger rota that covers a number of
practices; or they may decide to take part in a larger organisation,
which may be a GP co-operative—and these are most commonly
companies limited by guarantee and GPs join together to provide
cover to a large number of GPs - or a commercial deputising service
such as Healthcall. If the patient has a complaint in relation
to the service, at the present time the patient can only direct
the complaint to two people: one is his registered GP and the
other the GP to whom he had delegated the responsibility. If that
GP was a principal who happened to be working for Healthcall or
another commercial deputising service, then it would be that other
GP who would be responsible for responding to the complaint. That
is how we understand the regulations stand at the moment. What
we have recommended for the future is that the responsibility
for dealing with complainants and for providing the necessary
standard of care when the GP delegates a patient is that of the
organisation, which then takes on the full responsibility for
providing not only the service but all the consequences that arise
from the provision of that service. We have also suggested that
the local primary care trust starts to have a role, not only in
deciding on the safety and the quality of the service but actually
in the provision of the service in relation to other NHS services
locally, taking into account matters such as the convenience to
patients and the location of the facilities, et cetera.
Mr White: I am not sure I understand but I will
read it afterwards to make sure.
Chairman
109. What Brian wants to know is: when he has
to advise a constituent on where to direct a complaint, what is
the answer to the question?
(Mr Carson) At the moment you should direct the complaint
to the GP practice. If the GP practice is shared by another principal,
they will point the complainant in that direction.
Mr White
110. Something you said earlier worried me.
You talked about using the algorithm that was very similar to
the ones that ambulance trusts use. I remember when I was working
in information IT, one of my friends was designing ambulance trust
IT systems and failing to deliver. There have been a number of
problems around ambulance IT systems. What confidence do you have
in being able to follow that ambulance IT system and even the
algorithm you talked about and that it is actually going to deliver
your aspirations?
(Mr Carson) We have to be careful to separate the
information technology aspects of it from the clinical aspects.
The information technology is merely a convenient way of delivering
the decision-making process to the desktop. Most of the algorithmic
approaches to decision support that exist within Healthcall have
been developed within a paper-based system and then have been
facilitated by the development of IT. The academic evidence around
the clinical safety of such systems is such that we are confident
that they are safe to use and that the number of problems associated
with them is small.
111. When all these cases happened, the NHS
was going through its dark days and all the problems that existed
at that time. One of the things that has happened since then has
been this number of changes. You have created NHS Direct. Why
do you not just move everything into NHS Direct and do away with
the out-of-hours service and have it all within the NHS with one
route and not these myriad of different providers all with different
standards?
(Mr Carson) What we have recommended in the out-of-hours
review that we are looking forward to implementing is that in
time NHS Direct will provide a single gateway to all out of hours
healthcare. That will allow a national approach to be taken to
telephony standards and to the initial clinical assessment of
the calls. That will be a national standard across the country.
There is some way to go before NHS Direct can develop not only
the capacity but also the operational links to the existing GP
out-of-hours services. This year we are moving forward with this
series of exemplars to identify some of the operational issues
that will arise from linking those two services together. We have
to be mindful that the public is increasingly choosing NHS Direct
as their first point of access to the health service. We therefore
have a commitment in the NHS plan to which we are working to pass
all calls that go to NHS Direct to GP out-of-hours services without
having to re-dial and the development of the integrated NHS Direct
GP out-of-hours services on the same timetable.
Mr Trend
112. While Mr White was asking questions, I
was reminded that I was on the Health Select Committee when we
looked at the failure of the London Ambulance Service IT. That
must be a lesson that keeps you awake at night, or I hope it does.
That whole system collapsed overnight. It was absolutely monstrous.
I really want to ask you more about the review. Where has the
review got; i.e. how much of it has been published, have decisions
been made, what is going to happen next?
(Mr Carson) The review was presented to the Department
by the first review team in September and was published by the
Department at the end of October. The Department has accepted
the recommendations of the review and we are moving forward to
implementing the review over a three-year time period.
113. Who is monitoring that to see whether it
is done properly?
(Mr Carson) As I say, we are moving forward to implementing
it. The Ministers have accepted the recommendations. It is Department
policy and, as part of that, the quality standards that are included
in the review will start to be routinely monitored across the
system.
114. What were the main decisions of the review?
(Mr Carson) The principles that we adhered to were,
first of all, to look at the services from the point of the patient.
There was a lay member in the central review team. We were also
charged with developing a system that was clinically safe and
a set of quality standards and a means for their enforcement,
which includes the accountability framework that we have developed
and recommended. The first stage of implementing that quality
and accountability framework is clause 25 of the Health and Social
Care Bill, which gives health authorities the power to accredit
out-of-hours providers.
115. We understand also that there is an evaluation
study of complaints generally. Can you tell us how that is going?
(Mr Thompson) This was an independent evaluation by
York University and it was completed at the end of February. We
intend to consult on the proposals that emerge from that evaluation,
as well as to publish that evaluation, once the Health and Social
Care Bill has progressed through the Houses of Parliament. The
reason for tying the complaints procedures to parts of the Health
and Social Care Bill is that the Health and Social Care Bill itself
contains quite a sophisticated structure for public and patient
involvement in the NHS in the future. It is very important, we
feel, that the new complaints procedure is consulted within the
framework and is integrated within the new structures, which we
hope will emerge from the Health and Social Care Bill.
116. I find this difficult to understand. You
are waiting for the legislation which will include consultation
before you publish the evaluation?
(Mr Thompson) No. Publication of the evaluation and
the consultation will take place at the same time as the new structures
within the NHS.
117. This is after the Bill has been enacted?
(Mr Thompson) The Bill has gone through the Commons
and I think is now through the Lords. We do not expect it to be
too many weeks away—I choose my words carefully—and
we do expect that the Bill will contain a significant change in
the way in which patients and the public are involved and engaged
within the NHS and particularly in the complaints procedure. If
I can give an example to the Committee: each trust, each hospital,
for example, in the future will have a patient advocacy and liaison
service, which is intended to be a support to patients in resolving
problems on the spot but also a support to them in making a complaint
in the future. We think it would be unwise to consult on a complaints
procedure until we are clear what the new structures are. Once
those new structures are clear and they have been passed through
the House, we ought to move very quickly to consultation.
118. I still find it difficult to understand,
but not in the sense you originally meant. The evaluation study
has therefore been available to the Government drafters of this
Bill but not available to the legislators who have to vote on
it?
(Mr Thompson) Certainly the evaluation study was completed
only at the end of February. We have only had that particular
study for a matter of weeks. The Health and Social Care Bill was
drawn up some months ago. Yes, the two things have not been in
synchrony. We are very keen that they are synchronised in the
future and are very much integrated together.
Chairman
119. Can I try Michael's question a different
way? As it is only a review we are talking about, why on earth
can we not, given all the discussion about the problems with the
complaints system at present and again these other Ombudsman cases
we have touched on now, at least have the findings of the review,
never mind whether we then move on to a consultation about a change
to the system? I cannot for the life of me see why we cannot see
the findings of the review.
(Mr Thompson) The review is with Ministers at the
moment. Basically they will be publishing that review, as well
as that forming the basis of the consultation document.
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