Select Committee on Public Administration Minutes of Evidence

Examination of Witnesses (Questions 100 - 119)



  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.


  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.


  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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