Examination of Witnesses (Questions 20-39)
24 JUNE 2004
DR JOHN
CHISHOLM, DR
RUTH LIVINGSTONE,
PROFESSOR DAVID
HASLAM, DR
MARK REYNOLDS,
DR MIKE
SADLER AND
MR MARTIN
SHALLEY
Q20 Dr Taylor: Presumably it only needs
a few GPs to opt out for a particular co-operative to go out of
business, does it?
Dr Reynolds: The average size
of co-operative currently is 80 GPs. That is the normal size up
to now. That is too small in the modern world. Most are pulling
together in order to be able to afford skill mix and to network
more effectively and to rationalise service provision. At present
the rota is compulsory essentially in co-operatives: you have
to turn out because if you do not the co-operative can turn to
the practice and say, "Right, no one has volunteered for
this shift, which doctor in your practice is going to go on duty
this weekend." With the new contract, that is changing of
course, but where there is a strong ownership and a mutual ethos
amongst the co-operatives and there is a real club spirit—which
is where co-operatives are at their best—our evidence is
that up to 70% of existing GPs who turn out at the moment all
wish to continue to do so in the near future and we hope that
can be built on.
Dr Sadler: If I may offer two
bits of optimism or reassurance to the Committee. To some extent
Primecare and its historical predecessors have been working in
the new contract era for 30 to 40 years. People who contracted
their services out to ours have not had to work for the service
and so we have a fair understanding of trying to ensure we have
sufficient clinicians in an era where they are doing it on a voluntary
basis. Our findings have been that if the work is stimulating
enough, if the environments are appropriate and remuneration is
appropriate, clinicians will work in the out-of-hours service
and find it intellectually satisfying and challenging. The other
reassurance being provided—because we last year put £1
million into an investment into home-tele consultation, whereby
we put all the technology and telephony and information support
that you need into clinicians' homes, so that they could provide
by telephone clinical assessment in the out-of-hours period from
the comfort and convenience of their own home—is that I
actually had 400 expressions of interest from doctors alone in
becoming involved in providing out-of-hours services through that
resource. So I think that further reinforced our view that if
you make the environment appropriate and the work challenging
and interesting you will still get doctors and other clinicians
to work in the out-of-hours services.
Q21 Chairman: One of the witnesses made
reference to the fact that some PCTs were struggling to respond
to this. I wonder if you have any thoughts on that. In particular,
where we have PCTs within a certain SHA area is there not some
collective thinking going on organised by the SHA, or is it everybody
kind of reinventing the wheel?
Dr Livingstone: I think there
is some collective thinking. I think we could argue that collective
thinking began a bit late in the day. However, I would like to
reassure the Committee based on a survey that the NHS Alliance
did in preparation for coming here to give evidence today, where
we e-mailed around our PEC chairs—who by and large are GPs,
fairly cynical people. I have their responses here—which
are nearly 50—and most of them reassuring. They are all
approaching it in different ways and I would like to stress there
is no one answer that suits every single PCT or every single locality.
If the Committee would be interested, I am happy to submit this
collection of documents.
Q22 Chairman: That would be very helpful.
Is it geographically representative? Is it a fair cross-section
of different parts of the country?
Dr Livingstone: It seems to be
a fair cross-section. I would have to say that that when the PEC
chairs submitted their e-mails they had no idea we would be submitting
their comments direct to the Committee, so I think I would only
be prepared to do this if you could promise to keep the identities
of individual PEC chairs confidential.
Q23 Chairman: We have a good track record
on that!
Dr Livingstone: On that reassurance,
I think it would be helpful for the Committee to see a cross-section
of responses. There are some PEC chairs who express concern but
by and large most of them feel at this moment that there are good
plans in place and that they should meet deadlines that they have
set themselves at various stages through the autumn to have a
service in place by 31 December, which is the ultimate deadline.
Chairman: That is very helpful. Thank
you.
Q24 Dr Taylor: Turning to patient involvement,
it was the Carson report that said services should be designed
from the point of view of the patient. I think it was the NHS
Alliance that produced a booklet about patient involvement, stressing
the necessity not only to train the patients but to train the
GPs as well. The Royal College I think stresses that there appears
to have been little patient involvement. Do you have any ideas
on how to improve this? With the Government threatening the Commission
for Patient and Public Involvement in Health and therefore patient
forums, what are your thoughts on improving patient involvement?
Professor Haslam: Our comments
in our written evidence were based upon our impression that there
seemed to have been little in the way of patient involvement and
I think it comes back to planning being patient-centred rather
than professional-centred.
Q25 Dr Taylor: How do you make that happen?
Professor Haslam: I think fundamentally
it comes down to a mindset but you do have to have good patient
involvement in the planning discussions. It comes back to what
I was saying earlier, the old comment about inappropriate attenders
here, there and everywhere is an inappropriate mindset. We have
to look at the reality of what is going on and then try to address
it. The comments that have been made—and I agree—that
the use of the ambulance service is genuinely inappropriate, but
that is telling us something about perceptions. So there has to
be, either at a national or a local level, a very clear patient
input into the process. That is not an incredibly specific answer,
I agree, but to me these things come down to mindsets.
Q26 Dr Taylor: Do you think patient forums
have the potential to put the patient's point of view across?
Professor Haslam: One day.
Mr Shalley: It has to be much
more general than that. There has to be a media campaign to let
patients know what is available, where it is available and what
they are going to get.
Q27 Dr Taylor: You are talking about
it the other way round. You are talking about doctors education
the patient on what is available.
Mr Shalley: No.
Q28 Dr Taylor: I am trying to get at
patients saying what they think ought to be available.
Mr Shalley: I think the fora are
important for that, but it must just not stop there. It then has
to be devolved to the public, so the public know what is available
and where to get it.
Professor Haslam: I want to reinforce
the point Martin Shalley is making, that there is uncertainty
out there, and, in particular, I think there is uncertainty for
members of the public. Of all the changes resulting from the new
contract, one that has the potential for being reported in a way
that could cause alarm is the change in out-of-hours provision.
As we talked about earlier, in fact as far as the service available
to the patient is concerned, there is not gong to be a huge change,
except perhaps in the sense of a more multidisciplinary response
over time, with a greater use of nurses and paramedics and pharmacists
and social care staff as well as general practitioners, so that
general practitioners give the care that GPs can give best, and
they are always available to patients who need a GP, but that
we make better use of the skills of other professionals. Now,
I think there are two levels at which the messages about the out-of-hours
changes need to be got out—and the importance of this is
something we have certainly discussed with the NHS Confederation
and the health departments. There is a national message which
I hope is a reassuring message that this is not a change that
is going to threaten the safety of patient care, far from it,
but also very importantly there is a targeted local message at
the time in the run-up to local change, so that through using
local newspapers, local radio stations and so on, the public is
well informed about the nature of the local changes, which, as
has been commented earlier, are going to be different depending
on the part of the country that you are in.
Q29 Mr Jones: I was going to ask some
questions about the role of GP co-operatives, but in the evidence
Dr Reynolds has given quite a few of those questions have already
been covered, so I will be briefer than I would otherwise be.
In the evidence to our inquiry the National Health Service Confederation
expressed the view that renewing the contracts with existing GP
co-operatives is "clinically unnecessary, maybe financially
unviable and goes against the grain of systems' integration."
What view do you have on that comment, Dr Reynolds and Dr Livingstone?
Dr Reynolds: I think it is unhelpful
and probably misguided. I think it has to be accepted that the
costs of out-of-hours provision are going to rise, and, indeed,
the Department of Health and the Government have recognised that
with some additional investment, although there probably is not
quite enough in each area. GP co-operatives must change. They
practically all realise that they must evolve. All GP co-operatives
are not perfect—I would be the last person to say that.
GP co-operatives have had to work up to now in isolation, run
by GPs for GPS. Breaking down the barriers into the rest of the
NHS has been very difficult. Gaining access to skill mix, gaining
access to influencing other areas of the NHS has been difficult
because it has been in part a choice of its own but also because
it has been so separate and poorly understood elsewhere and it
has been very difficult to achieve. There is a new opportunity
of re-engineering, providing local experts and enthusiasts with
the ability to build a wider network. I think that is exactly
the right way to go and co-op successor organisations or the teams
involved that have been running services successfully for the
last five, maybe ten years in an area, largely unwatched by the
rest of the NHS—simply getting on with it, with high levels
of patient satisfaction—provide a very good starting point
for producing this. I think the NHS Confederation evidence makes
the assumption that other professionals working in the out-of-hours
environment may be cheaper. I am not sure that is the case, because
generally speaking other professionals work more slowly and you
have to have more of them to replace the single general practitioner.
General practitioners could be criticised for working too fast
in the out-of-hours period. Quite where the truth lies there,
I do not know, but I am not at all convinced that skill mix will
necessarily be cheaper, certainly in the short to medium term.
Dr Livingstone: I think the emphasis
has to be on the provision of a good service for patients, and,
where we have well-established co-ops that have shown themselves
to be limited and to rise to the challenge, I have no hesitation
at all in saying that is certainly the right model for those areas.
I would say there is no single model, so a lot of areas do have
the advantage of having well-established co-ops or have co-ops
who are not prepared to change and who have seen their membership
gradually lose interest in out-of-hours as the realities of a
new contract have begun to come home. In those circumstances,
the primary care organisations will have to do that networking,
produce those multidisciplinary teams and run the service. So
I think it is a mistake to think that is the right way of doing
it or that is the wrong way of doing it; I think we will just
have to grasp what we have and turn it into something bigger and
better.
Q30 Mr Jones: I am sure everybody would
argue that we need a good service, but I also think people would
probably argue that we need a cost-effective service as well.
Dr Livingstone: Certainly we do.
Q31 Mr Jones: What are your views—and
I am not sure to whom this is best addressed—on the new
mutual models that are being proposed? How do you see those working?
Your role up to now seems to be defending the existing model and
I was trying to extend it.
Dr Reynolds: I was medical director
of the fourth co-op in the country many moons ago and it felt
like a very exciting development, pulling together a community
and producing a useful, cost-effective and patient-friendly service.
After a period of gloom for the last year or two and trying to
make sense of the changes, this new organisation feels equally
exciting in terms of the opportunity that it creates to build
something genuinely new and exciting, involving a wider NHS solution
to this problem. I am deeply biased, I am personally in favour
of it. I am a joint medical director of the first mutual society
that is now up and running, incorporating four co-ops across the
south-east, in Maidstone, Tunbridge Wells, Sussex and East Sussex,
covering three quarters of a million population, one thousand
square miles roughly. We are up and running now, busy pulling
together the four co-operatives, and we are just beginning to
pull together the Advisory Council on which we hope to represent
the powers and members of the public. In theory, public involvement
in these organisations is as open as it is in foundation trust
hospitals, because the rules of the society are similar to that.
The difficulty with involving the public is that they only use
the service once every five or six years on average, so a campaign
simply raises awareness that there is something out there. My
own feeling is that as well as some information there has to be
what we call patient triage, "phone before you go",
with calls dealt with on the basis of assessed clinical need.
We believe that is best served not by remote call centres but
by people staffed and embedded in the local health economy. We
hope that these new Community Benefit Societies will pull together
and retain ownership, and a motivation not from just GP owners
and members, but nurses and administrative staff, pulling together
to provide a service, with the PCTs, A&E, ambulance and others
having a seat on the council of these organisations and able to
play a part in the strategic direction of the organisation. Open-book
accounting—the NHS can see exactly where the money is going—hopefully
providing a good working environment for all the professionals
within it, to motivate them to continue to turn out. There is
clearly a mutual benefit from working closely with A&E and
the ambulance services. You can begin to see it now—the
ambulance service is beginning to bring people to us. If someone
has just had a fit, for instance, the waits in our primary care
centres are 12 minutes, half an hour. A patient can be seen, turned
round and sent back again very quickly, which is of course of
enormous benefit to the ambulance service and is one less load
on A&E. We would like to get into trading with A&E. Where
we clearly on the phone have assessed somebody as needing direct
admission to hospital or 99% likely to do so, we would like to
have the quid pro quo of saying to A&E, "Right,
would you please deal with that. What can we do to help you?"
If A&E are on the board of these organisations, which they
will be, then we think this begins to break down the barriers
that exist between the existing NHS organisations and produces
a genuinely exciting possibility to facilitate truly integrated
services.
Q32 Dr Naysmith: Dr Reynolds has just
touched on what I was going to ask: Is it not true that there
are co-operatives developing now which started off doing the out-of-hours
service but are now beginning to provide other services.
Dr Reynolds: Yes.
Q33 Dr Naysmith: I know one in London
which is doing all sorts of things, clinics and things. They started
off as an out-of-hours service and are now spreading out to do
other things, and doing what you said, providing community service.
Dr Reynolds: The structure is
not that important. This type of network could be provided from
a PCT-base, properly financed, with an independent hands-off budget,
run by a team of enthusiasts. In some areas it would suit PCTs
to do it that way and there are good reasons for it—companies
limited by guarantee, the same company structure as a co-op, could
in theory do some of this. The actual company structure must serve
the function of the health needs in the locality rather than a
preferred structure be imposed on the health network until the
health network has decided the job that is to be done, but the
job that is to be done requires a leap of faith and some imagination
about pulling things together. We think the CBS is a very good
model, but in a variety of areas, for example Medway, the out-of-hours'
provider is also providing in-hour services, and the clinical
service provider network we could see assisting practices in the
day time with aspects of the contract that they wish not to do,
with coordinating nursing and other services, and providing access
to patients out of their area perhaps or, if a practice is overloaded,
seeing people in a primary care centre. There is lots of exciting
possibilities that with some imagination and vision could produce
a really useful local health service and addition to the health
service.
Q34 Mr Amess: This is the opportunity
now for some creative tension between our witnesses—but
if you could restrain from having a sort of Big Brother style
punch-up between yourselves. Dr Sadler you are strategically placed
and we have Professor Haslam at the other end. Some of your fellow
witnesses are not particularly enamoured with your organisation.
They seem to have it in for you. In fact they see you as a necessary
evil. According to Dr Chisholm's organisation, Primecare's "continuing
stability is a matter of concern" and the chief executive
of Nestor resigned recently over falling profits with the failure
of Primecare to secure the proposed 30 to 40% growth in out-of-hours
business that it was hoping for. Of course tragically, a fortnight
ago, Robert Wells, a police surgeon, was found guilty of rape
and sexual assault. If I turn to Professor Haslam, you said that
there are uncertainties around the role and performance of Primecare.
Could you explain to the Committee what exactly you meant by that?
Professor Haslam: We put out to
a number of our members basically the questions that you asked
us and this was one of the responses that came back. I personally
have no specific additional evidence to add to that. I certainly
would not wish to single out Primecare for any particular concerns.
Looking at the whole spectrum of care that is going to be available
for patients, what is needed is the thing that everybody in this
room has been trying to stress: reassurance for patients—that
it is going to be all right, that it is going to be safe, that
not only are we going to be all right but we are going to build.
That does require all the organisations involved to be long-term
viable. I think that is really all that came out of our consultation.
Q35 Mr Amess: I have failed miserably
to get sparks flying. You are going to get your chance, Dr Sadler,
after some questions. Could I ask generally what our panel's views
are on commercial deputising services.
Dr Chisholm: I think one of the
good features is that henceforward all provider organisations
are going to be assessed against nationally defined standards.
Now Mike Sadler and Mark Reynolds may want to comment on those
standards, but, I think, particularly after yesterday's announcements
by two of the political parties about plurality of provision,
it hardly behoves us to say that we do not welcome that. I think
what is important, as Dr Livingstone said, is the standard of
care that is received by the patient and we welcome any organisation
that is delivering very high quality service to patients whatever
the particular contractual status of that organisation. As Mark
has said, the co-op movement is, in a sense, going in a multiplicity
of different directions as far as structure is concerned. We are
much more concerned about function and outcome.
Q36 Mr Amess: Before Dr Sadler has his
say, does anyone else wish to add anything?
Professor Haslam: The document
The Quality Standards in the Delivery of GP Out-of-Hours Services,
which was produced by the Department of Health a couple of years
ago and which is really the measure, was commissioned from the
Royal College of GPs, so it was very much our work that went into
that, and I would very much echo what John Chisholm has said,
that it is the quality. It is not the who, it is the how and the
what that matters.
Q37 Mr Amess: Does anyone else have any
comments on commercial deputising services? I have failed miserably
here. Let's turn over to Primecare to sing the praises of the
company and particularly talk about what you feel you can offer
over and above the service offered by an existing GP co-operative.
Dr Sadler: I would start with
what I would have given in response to the previous question,
which is that I do not think it is the structure that matters,
it is the quality of care that you provide. We are still the single
largest provider of out-of-hours services in this country. We
take 60,000 calls a week, and that is substantially more than
any other out-of-hours service. Because of our position and the
way that we provide services, we have been able to invest over
£13 million in changing the way that services are provided,
both to meet the challenges of the Carson report, but also "Reforming
Emergency Care" a document published by the DoH, and then
the new GP contract as it came along. That has enabled us to invest
in centralising telephony, because I think there are some economies
of scale that you can achieve—and we do need to provide
high quality care within limited resources always. So we have
been able to achieve major improvements in service quality that
are in the appendix that accompanied or written evidence. I think
that size also enables you to be innovative. I have already talked
about having tele-consultation. We also have extensive experience
now in using nurses, emergency care practitioners, pharmacists
to provide services to patients in the out-of-hours area. So I
think there are several advantages to being a commercial provider
and being the size that we are and I believe that we have the
resilience and the structure to continue to provide those services
in the best way possible for patients in the coming years. There
are national quality standards now set out by the Carson report,
there is a national accreditation process. We believe we are closer
to achieving those national quality standards than probably many
other providers and would welcome the publication of comparable
data from all providers so that we can actually benchmark our
own performance, but the graphs that we have shown to the Committee
demonstrate how much we have achieved over the last 18 months.
In every place where our branches have been assessed, which is
now throughout the UK, we have passed the assessment process and
have become accredited providers, so from my point of view there
is more than enough work in the out-of-hours field for all providers.
The important thing is that we do meet national standards, that
we do provide high quality service to patients, and that the 250,000
calls a week that are generated in the out-of-hours primary care
service now are answered in the best way possible and in the most
cost-effective way possible and we believe we are extremely well
placed to continue to do that for years to come.
Q38 John Austin: You have referred to
the fact that you are a national organisation, running lots of
services and therefore you can only invest centrally, in your
Central Triage Pool, in your home-tele consultation. The question
is really to some of the others: Would it be possible, given the
localised nature of the out-of-hours service that is provided
either through co-operatives or through other ways, that it is
unlikely that the level of investment could be made that could
enable some of these modern technological developments to occur?
Is there, therefore, a responsibility on the Department to ensure
that there is funding available to ensure those collegiate responses?
Dr Reynolds: I wonder if I could
light a slow-burning fuse rather than a spark? In reply to that
I would wish to point out that there are two cultures really in
out-of-hours provision, and three-quarters of the UK's GPs have
been unable to gain access to Primecare or have decided that that
type of service is not for them. Mike said they are the single
largest provider, but the co-op type provision is by far and away
the majority provision of out-of-hours services in the country,
through reasons of choice of local GPs that they wish to do it
that way. Traditionally, that has been in areas where GPs previously
have provided their own services or have become dissatisfied with
the services provided by commercial providers historically and
have chosen to set up a co-op rather than to purchase services
from a commercial provider. There are differences in culture,
there are differences in emphasis and there are differences in
style. We believe there are not huge economies of scale to be
made from massive service provision. Sometimes the economy of
scale that can be talked about by call centre technology does
not translate easily into the provision of health. We are firm
believers in the local or semi-local provision of triage services:
"phone before you go" advice to local populations to
pick up the phone to decide, and to speak to the highly experienced,
relatively locally based commission on whether or not a trip to
A&E would be appropriate or an ambulance call is appropriate.
We are very keen to assist ambulance services in off-loading some
of their lower level calls to us to provide a locally-based service.
And a locally-based service definitely need not be more expensive
than a very large service, particularly given the fact that most
of the larger not-for-profit sectors have now become quite large—and
when you get too large the trouble is that you lose contact with
your edges and it is actually quite difficult to get a balance.
I am not saying there is one size that fits all by any means,
but on our side of the fence we genuinely believe that locally
owned, locally run, not-for-profit services provide the best compromise
solution in this really quite challenging area of health care
provision. We really believe that we can provide a high quality,
sustainable, organisationally integrated service, or facilitate
that service at semi-local level. I will not use the word "local"
any more. Co-ops used to be very local, based on a market town,
based on perhaps around a DGH hospital. I think there is a realisation
now that they need to be bigger, and many co-ops are now joining
forces to provide an economy of scale, the ability to employ skill
mix, the ability to cross-boundary cover with neighbouring providers
effectively so that patients do not fall between two nets. I think
one of the problems we have had with PCTs is that up to now in
some areas individual PCTs have felt that they wanted to provide
their own service at their own cost and have their own costing
process and have not in some areas worked as teams and have mitigated
a little bit against joined-up thinking in localities in some
areas.
Q39 Chairman: Dr Chisholm, do you want
to respond?
Dr Chisholm: Yes, I just want
to come in on the issue of what Mr Austin referred to in terms
of additional central resources for the out-of-hours service.
I think one reason that primary care organisations have found
the agenda quite challenging, and that there is still some uncertainty
in some areas about what the shape of the service is going to
look like, is because of the cost of providing the service. They
have the sums that practices are giving up in order to transfer
their responsibility, but those costs are very much less than
the total cost of providing the service. They have the out-of-hours
development fund. In addition in England there has been some targeted
additional funding, particularly for urban and rural areas, but
still they are worried that they do not have sufficient resources
to provide the high quality service that they identify patients
require. So I think the case for the necessary resources being
available is a tough one for the primary care organisation often,
and there may be a place for some additional central initiative.
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