Examination of Witnesses (Questions 1-19)
24 JUNE 2004
DR JOHN
CHISHOLM, DR
RUTH LIVINGSTONE,
PROFESSOR DAVID
HASLAM, DR
MARK REYNOLDS,
DR MIKE
SADLER AND
MR MARTIN
SHALLEY
Q1 Chairman: Colleagues, could I welcome
you to this session of the Committee and welcome our witnesses
and express the Committee's thanks for their willingness to join
us today to give evidence. Before you introduce yourselves, could
I say that we are hoping to conclude this session in time for
us to get into the Chamber for the statement on the NHS White
Paper. I anticipate we will conclude probably around 12.15. One
of the consequences of that is that the session will be a bit
briefer than normal. It would be helpful if witnesses did not
feel they had to answer every specific question. Obviously there
will be some you will want to answer and some not. I am sure you
understand what we are hoping to do. Could I ask you each briefly
to introduce yourself to the Committee.
Professor Haslam: I am Professor
David Haslam. I am the Chairman of Council of the Royal College
of General Practitioners.
Mr Shalley: I am Martin Shalley,
President of the British Medical Association and Consultant in
Emergency Medicine at Birmingham Heartlands and Solihull.
Dr Reynolds: I am Mark Reynolds.
I am Chairman of the National Association of GP Co-operatives
and Joint Medical Director of On Call Care, which is the first
of the new mutual Community Benefit Society out-of-hours' providers
to be registered.
Q2 Chairman: Are you still practising
as a GP?
Dr Reynolds: I am a full-time
GP, yes.
Dr Chisholm: I am John Chisholm.
I am currently the Chairman of the BMA's General Practitioners'
Committee.
Q3 Chairman: In your spare time, you
do a bit of practising as well.
Dr Chisholm: A bit!
Dr Livingstone: I am Ruth Livingstone.
I am representing the NHS Alliance. I am a GP and I am also PEC
Chair of a PCT.
Dr Sadler: I am Dr Mike Sadler.
I am the Medical Director of Primecare, which is the largest single
provider of out-of-hours services in the UK.
Q4 Chairman: Is your background as a
GP?
Dr Sadler: Yes, it is.
Q5 Chairman: Obviously this inquiry is
looking specifically at the current situation and concerns about
the future situation in relation to out-of-hours cover. It would
be helpful from my point of view, probably from the point of view
of one or two of the members, if one of the witnesses was able
to paint a bit of a history as to how we have got to where we
are now. Obviously, there has been an evolution and different
forms of provision over the years since we have had a national
health service. Does anyone feel able to give us a brief, colt-sized,
potted history as to how we have got to where we are now?
Dr Chisholm: Shall I have a go?
Traditionally, certainly if you look back to 20 years ago, general
practitioners did their own out-of-hours work, either, if they
were single-handed, literally doing it themselves, or, more commonly,
if they were in a partnership, doing it in rotation with their
partners or sometimes in an extended rota with perhaps another
practice or two. However, from certainly the mid-sixties onwards,
there were significant numbers of general practitioners who made
use of a commercial deputising service which historically was
the predecessor of Primecare. From the early eighties there has
been a development of GP out-of-hours co-operatives, which were
small in number until the early to mid-nineties, when, particularly
as a result of developments in Kent—the original co-operatives
had started off in the North-West of England—there was a
great burgeoning of co-operatives, helped particularly by major
negotiations that took place in the mid-nineties which ended up
in the establishment of an out-of-hours development fund to help
the local primary care organisations and GPs develop alternative
models of provision. There was a major trend towards care delivered
by organisations above the level of the individual practice and
also towards more premised-based care, so that when somebody rang
asking for help out of hours, they would either receive advice
over the phone or be asked to come down to a primary care centre
to be seen or be given a home visit if that was what they required
or be referred directly to hospital by an emergency ambulance.
From the mid-nineties onwards, the great majority of general practitioners
have either been members of a GP out-of-hours co-operative or
have used a commercial deputising service, and only a relatively
small minority of doctors have, either by choice or because of
geographical isolation, continued to provide a practice-based
service. That really takes us up to 1 April this year, when the
possibility of transferring out-of-hours' responsibility to the
primary care organisation became an option, and sometime between
1 April and 31 December, except for a very small number of doctors
in very isolated and remote communities, doctors will be able
to transfer the practice's responsibility by agreement with the
primary care organisation if that is their wish. The reason that
change was made was because, in negotiating the new GP contract,
all the negotiating parties, the NHS Confederation, ourselves
and the health departments came to perhaps the rather sad realisation
that one of the things that was putting young doctors off coming
into general practice, becoming general practitioners, was the
24-hour responsibility. Therefore, if that could be addressed,
we might be able to get more of the general practitioners we need.
Q6 Chairman: That is very helpful. Does
anybody want to add to that at all?
Dr Sadler: As Dr Chisholm suggested,
some doctors sought to contract out-of-hours care nearly 30 to
40 years ago and it is fair to say the majority of the cases in
which that happened were in urban areas, often with quite high
levels of deprivation and quite high health needs, and, as you
will see from our written evidence, we continue to provide care
most often in those urban areas where needs are highest.
Professor Haslam: I think it is
important to stress the real workforce recruitment crisis that
has faced general practitioners. As I hope and expect the Secretary
of State will make clear today, primary care is absolutely central
to the future development of the health service, and yet, for
the last five years at least, the General Practitioners Committee
and the Royal College have made repeatedly clear that there is
around a 10,000 shortfall in the number of GPs required to offer
the sort of standard of service that the nation's patients deserve
and it is very clear that the responsibility of the out-of-hours
care—not necessarily the doing of but the responsibility
of—was a major turnoff for two main reasons. One is the
demographic changes in the workforce, an increasing number of
women doctors and male doctors who wish to work part time. That
is my second point as well: that it is not just the women but
it is the fact that the men want as good a life—in fact
a life—that has changed recruitment fundamentally.
Q7 Dr Naysmith: The actual change is
not as fundamental as it seems to most people outside of your
profession, because, as you describe it, Dr Chisholm, in fact
most GPs are already not directly fulfilling their role out of
hours. Although they remain responsible for 24 hours, that responsibility
has now been taken away, but it should not make all that much
difference in all that may different places.
Dr Chisholm: For a patient using
the service, they will not notice a great change. If anything,
the greater change occurred particularly in the mid-nineties.
Q8 Dr Naysmith: That is what I am saying,
it has already occurred. This is kind of marking by financial
responsibility measures being introduced.
Dr Chisholm: Yes, indeed. The
chances of a patient seeing their own doctor out of hours—they
still sometimes do by chance—are really now quite low and
have been for a number of years.
Dr Reynolds: I think in fact there
is an enormous change in the culture of responsibility that is
occurring because of the new GP contract. I would wish it to be
the case, as you put it, that in fact, in 70% of the country—the
more difficult to cover areas, the more rural areas, perhaps the
more expensive areas, where GP co-operatives are working—the
24-hour responsibility has been the glue that has held those organisations
together: one GP working on behalf of another. With the transfer
of the responsibility to the PCTs, that glue has been removed
and it essentially becomes voluntary whether GPs choose to take
a turn in the out-of-hours' rota or not. This really is a paradigm
change in the responsibility and in the culture of out-of-hours
provision. In the areas where the GPS have bought services from
a commercial provider, there may be less of a change in paradigm
and in culture; in areas where it has essentially been voluntary
for them to turn up on each other's behalf, there is a big change.
The good news is that we learned from our membership that on the
whole about 70% of existing GP co-operative members have indicated
a willingness to continue to work for their membership-based organisation
because they get some potential satisfaction out of it, because
of the benefit to their patients, and because they will be able
to earn a decent amount of money for doing so as long as the funding
streams are correct. But no one can really tell how this will
pan out a year into the contract, when actually GPs may decide
in fact, "I don't want to earn £150 for working tonight,
I would rather do some more insurance reports or fine tune the
practice to earn that money during the day." So the culture
and the environment in which GPs will be working in the out-of-hours
period in years to come is crucial. It has to be a fine balance
between appropriate remuneration and good working conditions and
a rewarding job, mixed with the rapid and urgent development of
skill mix and developing local healthcare networks to provide
an NHS-based solution to the evolution that must occur in primary
care out of hours. Our vision as an association is to build on
the success of co-ops—the local ownership, the local motivation,
the grassroots' enthusiasm to run a patient-focused service—to
provide something that we call a clinical service provider which
would be an organisation not-for-profit, NHS aligned, capable
of co-ordinating and pulling together ambulance, A&E, general
practice (by which I mean primary care in the broader sense of
other practitioners able to practice general practice apart from
GPs: properly trained paramedics, nurses and others) in a unit
that could have a variety of organisational structures, one of
which is this new one called the Community Benefit Society, others
could be companies limited by guarantee, others could be PCT-based
but hopefully at a hand's-length budget to allow innovation. One
of the great successes of co-ops has been that we have had enthusiastic
people, able to draw budget from the members and able to take
their income from the members. If they need another computer or
another car, the membership base—they are co-owners—recognise
the need to do it. Money is very rapidly in and out, not-for-profit,
so the money into the organisation less operating expenses goes
out to the members in payment. It is easily able to fine tune
the service—rapid, fleet of foot and quite innovative. We
think that culture is valuable, and really we are very keen it
should be promoted on to a new level where that culture crosses
the boundaries between primary and secondary care and pulls in
ambulances, A&E and others as well.
Dr Naysmith: I think we are planning
to explore co-operatives a little bit later on and we are probably
jumping ahead. The Chairman was trying to work out how we had
got from where we were to where we are now and where we are going.
I think Dr Chisholm and Professor Haslam have said that one of
the reasons for theses changes was that it was becoming difficult
to get young graduates, medical graduates, to come in to the GP
profession because of the 24-hour responsibility. What we are
doing now might well make it very, very difficult to get people
to fulfil the out-of-hours service and maybe we will explore that.
Q9 Chairman: What objective research
has there been into the impact of the different approaches to
out-of-hours cover over the years and the different approaches
that will indeed be taken with the changes that are occurring
now. All of us have anecdotal experiences of dealing with out-of-hours
cover. My work before I came in here was in mental health social
work, so I have had a lot of contact with different models of
out-of-hours care in the area in which I worked and I gained certain
impressions as a consequence of that experience. It is 20 years'
out of date, but I certainly have several memories of having to
get a black coffee out to some of the doctors I was dealing with
and on one occasion of sectioning an alcoholic when the GP was
in a worse state than the alcoholic patient to be honest with
you. We have these anecdotal experiences. Over the years, has
there been any objective analysis, independent of the organisations
that you represent, of what has been a more effective approach?
Mr Shalley: I am not aware of
any.
Dr Chisholm: I think there has
been a little bit of research from the National Centre for Primary
Care Research and Development in Manchester on out-of-hours provision,
and also from Bristol University. I am hesitant to summarise,
but in conclusion I think they have felt that the new models,
particularly looking at the growth of co-operatives, have been
positive and beneficial and well accepted by patients in delivering
a high standard of care. But that research of which I am aware
is itself a few years ago now.
Dr Sadler: Chairman, the same
is also true of the research which I was going to talk about,
which is looking at the use of nurses in out-of-hours services.
There was a lot of research six or seven years ago showing high
patient satisfaction and patient safety with the use of nurses
in telephone triage.
Chairman: We are going to touch on that
a bit later on.
Q10 Dr Taylor: Could I go first to Professor
Haslam, and then I am sure Dr Livingstone, as a PEC chair, will
want to come in. In your evidence you have suggested there was
a lack of understanding among PCTs about the needs for out-of-hours
care and also that there were some adversarial relationships between
PCTs and GP co-ops. Could you expand on that?
Professor Haslam: I think there
is a general underestimate of the complexity of what goes on in
an out-of-hours consultation. There is a huge amount of safety
and risk management done by general practitioners. Obviously to
become a general practitioner requires an absolute minimum of
nine years' training and usually more. I must stress that the
Royal College strongly supports skill mix and developing the team
with the use of nurses and paramedics but you cannot substitute
a paramedic with an additional 12-week course for a general practitioner
with a nine-years plus training plus many years of experience.
If you do substitute with the less experienced/less trained people,
you are inevitably going to have less ability to absorb risk,
uncertainty, and a more rapid default to, "You had better
go to hospital." One of the real concerns—and I am
sure it will be shared by my colleague on my left—is the
increase in referral through to A&E, either because someone
feels uncomfortable handling the case or because the patients
recognise, "Actually, if that's all I'm going to get, I might
as well go to A&E and see a doctor." So there are real
issues there. With regard to primary care organisations, I think
they are extremely variable and I feel extremely sorry for them.
I am sorry if that sounds patronising, but they have so much on
their plate at the moment, with the new GMS contract and with
the out-of-hours and everything else that is happening to them
in a very rapidly changing and expanding and improving health
service, that I am not entirely sure that this has been the highest
item on their agenda and yet it is in credibly important to the
safety and health of patients.
Q11 Dr Taylor: Could we have the PEC
perspective?
Dr Livingstone: I endorse some
of what David has said. I think for PCTs this has been a tremendous
challenge and some have risen to the challenge faster than others,
I think, organising out-of-hours properly. And I would actually
contest whether it has ever been organised properly, because out
of hours we should have a full range of multidisciplinary skills
available just as we have in hours: at six o'clock patients' needs
do not change. I welcome this opportunity to put right what has
currently been going on in out-of-hours—not to imply there
has been anything terrible going on in out-of-hours, but it is
a real opportunity to work better and to work more cohesively
and to have the proper professional skills in out-of-hours that
we desperately need. PCTs have an immensely difficult job, because
we have a very fast-changing agenda with lots of targets, with
lots of focus on secondary care up until now, and I think those
PCTs that have grasped the nettle and done a lot of work on this
have realised how immensely difficult this is going to be, particularly
in areas where there is a terrible shortage of GPs.
Dr Chisholm: I would agree with
what Dr Livingstone has said about the opportunity here for the
primary care organisation to think strategically about reforming
emergency care. As Mark Reynolds was saying, it is important that,
in doing that, all the contributors to out-of-hours care are brought
together so that the response is a more integrated one than it
has been in the past. That does mean bringing together the ambulance
service, accident and emergency departments, community nursing,
social care, NHS Direct or NHS 24, as well as GP out-of-hours',
which is really just commissioning what is already there. I think
there is a real opportunity here actually to produce something
that is potentially better.
Dr Reynolds: May I briefly add
that there is a real opportunity but our fear has been that there
has been, to an extent, a parallel universe. There have been people
in the PCTs taking this job on with no experience really, thinking
it is all going to be fine and reporting up the line that everything
is fine; whereas on the other universe there are people doing
the hard-edge of the provision, knocking up against financial
constraints and misunderstandings and not confident in many areas
that everything is fine.
Q12 Dr Taylor: What should we be recommending
in our report in regard to making PCTs more aware of the problems,
that they have one particular specific lead who really knows what
is going on.
Dr Reynolds: I think there is
a key and it is the engagement of senior people at PCT level.
We have always thought it ought to be at least chief executive
or director of primary care involvement in this, rather than more
junior managers. The other thing is really to trust the people
who have been doing it on the ground and to build on the expertise
that is out here in the network already, rather than feel that
because there is not enough money in the PCT budget that it has
to be re-configured to a lower price rather than a quality level,
if you see what I mean.
Dr Sadler: If I may, I would make
two points. One is to support my colleagues in their assessment
that this is not an easy service to provide. We receive almost
60,000 calls a week and have made significant investment to achieve
the service improvements we have outlined in our evidence. I think
the second thing is that some of the decision-making processes
that primary care organisations have put in place to decide out-of-hours
services are not clear. I think the people involved are not clear
why the decisions made were made in that way and feel that perhaps
there is a lack of explicit criteria by which they might make
those decisions. There was some guidance issued by the Department;
it is not always clear to all of us involved that primary care
organisations are following that guidance in making their decisions
about out-of-hours services for patients.
Professor Haslam: Very briefly,
I would say that the mindset that is required is not just how
do we survive, but how do we thrive and develop. Far too often
it is just about how we get through this crisis when actually
there is the potential for really joined-up work. For my entire
professional lifetime—I should have added that I am a general
practitioner as well—we have complained about patients attending
inappropriately here, there or everywhere. That mindset is inappropriate.
We should be providing the services where the patients are likely
to be and make sure they are the right services. For instance,
there is very good evidence that general practitioners within
A&E departments reduce admissions because, again, of what
I referred to earlier, this skill at absorbing risk and uncertainty.
Instead, we frequently have in A&E departments junior senior
house officers or junior doctors who of course do not have that
experience. So it is an opportunity for improvement.
Chairman: Mr Shalley, I noticed that
you pulled a face at certain remarks. Do you want to expand on
that face-pulling?
Q13 Dr Naysmith: Could I just ask a question
of Professor Haslam. I wonder why you used the phrase "get
through this crisis".
Professor Haslam: Because I think
in too many PCTs it is seen as a crisis, that there is a deadline
looming, they are not sure who is going to do the work. I think
this comes back to what Mark was saying: in the past it has been
the clear mutual responsibility and mutual support of practices
for each other; that has now gone.
Q14 Dr Naysmith: It may be a difficult
situation, but when there is a crisis things are falling apart.
Professor Haslam: No.
Q15 Dr Naysmith: You are not saying that.
Professor Haslam: No. I think
for many people there is a feeling of potential crisis: "Who
is going to do this work?" That really is an issue and therefore
creates fear in every other branch of medicine as to where all
the work will end up—because, sure as anything, it ain't
going to go away!
Q16 Dr Naysmith: I have seen one or two
crises in my time, but I would not call this a crisis.
Professor Haslam: No, a potential
crisis.
Q17 Chairman: We are in a permanent crisis!
Mr Shalley.
Mr Shalley: From emergency departments'
perspective, I would like to corroborate what everyone has said
here. A lot of our members around the country are very concerned
about what is going to happen, and the word that keeps coming
to me from members of the association is that it is "patchy".
We are not sure what is going to happen throughout the country,
it is going to be different. There are various models, but you
will not get a model that will fit everyone or every area. In
emergency medicine we have found that our attendances in the last
12 months have increased by 13 to 15%: the hospital across the
river is 15% up; Kings College attendances are up by 25%. For
the past three to four years there has been only a very modest
1 to 2% increase, so something has changed. It may be that our
performances for our targets are so good now that patients are
saying, "Let's go to emergency department because we know
we get seen and turned around." It may be—and this
I think is important—that, from a patient's perspective,
many of them believe that primary care or emergency care in the
primary care setting does not exist outside of nine to five. The
other thing, just to get everyone straight, out-of-hours is two-thirds
of the week. As George Alberti says, this is a huge timeframe,
and our concern is the default position will be that patients
will come to emergency departments. As yet, there has been no
initiative, as has been shown, ever to decrease attendances at
emergency departments.
Q18 John Austin: I agree. I was talking
to the London ambulance service a few weeks ago, and I am not
sure of the precise figure but their assessment was that something
like 70 to 80% of the emergency calls they attend are not emergencies
at all. That would suggest that it is not the changes in the contract
but there is something already happening in terms of people's
perceptions about the way they get their out-of-hours service.
But, far from all the doom and gloom that has been talked, talking
up the use of the word "crisis" that Dr Naysmith picked
up on, all we have heard about the new contract and out-of-hours
has been doom and gloom, but the evidence which two or three people
have given is that this presents some real opportunity for the
first time to present a coordinated, seamless service for out-of-hours
services. Is it not time to be talking more about the opportunities?
If we are going to come on to the problems of lack of skill mix,
lack of resources and all the rest of it, nobody is pretending
that it is going to be simple, but would all witnesses agree that
this presents a real opportunity to prevent a seamless service
for out-of hours provision?
Dr Reynolds: I could not agree
more, there is a great opportunity, but there is also a highly
uncertain few months ahead where, essentially, voluntary bodies
and voluntary management teams are struggling to produce a service
specification that matches the PCT's financial constraints and
to begin to think about inter-linkages with other services. Those
essentially voluntary bodies, the medical directors of the co-operatives,
if they are not given the green light and an open door in localities,
have a choice to say, "It's not worth the hassle any more,
we are going to pack up and go home." I am hopeful that in
the last month or two the culture on the PCT side has changed
somewhat and the understanding of the difficulties of providing
an out-of-hours service has increased, but in many areas of the
country it is still highly uncertain whether or not the co-operatives
and management teams associated with them all wish to continue,
so I think the word potential "crisis" is strong but
there is certainly a very difficult period of uncertainty. But
there are things that can be done about it. One of the things
that can be done about it is to encourage PCTs to think out of
the particular financial box of just GMS service re-engineering
through the finance that is liberated from the new contract and
to think about the wider unscheduled care budget. We have to realise
that this may need some pump-priming. This work is so important
that if it is not done properly the consequences on colleagues
in A&E and ambulance services could, in parts of the country
where it does not work well, be very significant.
Q19 Dr Taylor: You have picked up the
point Dr Reynolds made a little earlier about the lack of incentives
for some GPs to go on providing out-of-hours cover and you reassured
us somewhat by saying 70% of co-operatives are prepared to continue.
That is right, is it?
Dr Reynolds: No. Forgive me. At
the stage at which we took our soundings, which is April, about
70% of GP co-operatives members, individual GP members, were prepared
at that stage to continue to take a turn at the wheel for the
early future (although the figure may have reduced). Our initial
figures suggest that a large percentage of co-operatives, possibly
30 or 40%, are thinking of becoming immersed in the NHS and becoming
part of the PCT; about 30%-ish are undecided—and these figures
are not exact because it is very uncertain out there—and
about 30 or 40%—although that probably does not quite add
up—are looking to remain as companies limited by guarantee
or to evolve into the Community Benefit Society. Department figures,
as one networked outside the door, suggest that in perhaps 50%
of the country the co-operatives, are thinking of continuing and
evolving their organisations, and the latest rumour is that 30
to 40% are thinking of going into the PCTs and becoming part of
the PCT. We are fearful that there is an inbuilt conflict between
PCT s being both provider and commissioner of services. We know
there is a cost to providing out-of-hours. We have a fairly good
idea of the range of costs rural to urban: generally speaking,
it is cheaper to provide services in urban areas; generally speaking,
it is a lot more expensive to provide services in rural areas.
We are getting a picture. It is muddled. We hope there will be
a thriving, independent NHS-aligned sector, and Primecare will
of course be there. I am unsure what their situation is at present
but Dr Sadler, I am sure, will elucidate on that. It is unclear
how the PCT-based services will really work and whether that conflict
can be resolved between them both having to fund it and provide
it themselves.
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