Examination of Witnesses (Questions 40-59)
24 JUNE 2004
DR JOHN
CHISHOLM, DR
RUTH LIVINGSTONE,
PROFESSOR DAVID
HASLAM, DR
MARK REYNOLDS,
DR MIKE
SADLER AND
MR MARTIN
SHALLEY
Q40 Mr Amess: One final question. Other
than this chief executive who walked the walk, why would you say,
Dr Sadler, that people like working for your organisation, because
you do not seem to have too much difficulty in recruiting and
retaining people?
Dr Sadler: May I, Chairman, respond
briefly to Mark, and then come briefly to that question.
Q41 Mr Amess: Get your bit in against
him?
Dr Sadler: I will not accelerate
the fuse. There are several areas where the co-ops and Primecare
actually work together, where they provide services for parts
of the day and we provide services for other parts of the day.
I think the best models are a mix and match of where you are getting
some economies of scale in terms of telephony and triage in the
way that we have demonstrated in our evidence, but then you do
have local services and the need for local integration and relationships.
So as we in one of our appendices put the details of the Cleveland
PCT model, we are providing services locally there that do have
the resilience and back-up with the centralised pool and telephony
so that if there are local problems in demand, local surges in
demand, we are able to back that up. It is one thing I hope the
Committee will come on to, which is up to now there is a built-in
safety net in the existing GP contract that will actually be lost
when the new contract comes in—and perhaps when I am not
interrupted by that bell I may return to that. In terms of your
specific question about why people work for us, I think I covered
some of it earlier. The first thing is that out-of-hours work
is actually quite challenging; we do see a different case mix.
I think a lot of people find it often a more exciting end of medicine
to be in, so we have always found doctors who work preferentially
in out-of-hours services. The second thing is the environment.
If they feel they are part of a service that is supportive, that
is achieving good care, that does not put too much pressure on
them, and that they can work in their own environment, perhaps
in the home, as we have talked about earlier, they will also continue
to want to provide services out of hours. The third issue, obviously,
is remuneration, and you have to ensure that you are giving people
the appropriate remuneration for them to wish to carry on working.
So it is a range of factors really, and I think we hope and expect
to continue to provide clinicians where they are needed. The other
thing we have done recently is started to use some resource planning
software to look at how many doctors, nurses and others you really,
truly need. I think often in the out-of-hours services there has
been a tendency to have five doctors on on a Saturday because
that is what we have always done. By looking at the actual volume
of calls coming in, and when those calls come in, you actually
find that you probably needed six, three hours earlier, but only
two later on. So we actually find you can use your clinical resource
more effectively by looking very carefully at the volume of calls
coming in, and when that is at a peak.
Q42 Dr Naysmith: Do you have any record
of how many of the doctors that you employ are retired doctors?
Dr Sadler: No, I do not. What
I would say is that all the doctors who work for us are either
GP principals or eligible to be GP principals, so they are on
the supplementary list of a PCT. What I do not have is a set of
records to see how many are still providing services as a principal.
The last time I looked at that, out of the 1,600 doctors who provide
work for us on occasions or more regularly, 1,500 of them were
still principals in practice.
Q43 Mr Bradley: Another player in this
business is NHS Direct, and that from the Department of Health
point of view has been well invested in. However, in one of the
memoranda one of the GP co-operatives said they would not use
NHS Direct because they feared the outcome of the patients. Do
you share those concerns or do you have some general views about
how NHS Direct should be used in the integration of the service
for out-of-hours services?
Professor Haslam: I have little
doubt that NHS Direct has been a popular and well-used service.
The main question relates to both capacity and impact on the rest
of the service. From a capacity point of view, as far as I know
NHS Direct currently deals with six million calls a year, which
is very impressive. British general practice deals with one million
calls a day. So it is very difficult—and I have been trying
to find out before this meeting—and maybe some of my colleagues
may be able to say what the total national throughput of out-of-hours
telephone calls to all our organisations would be. I do not know
what those figures are, but I would find it very difficult to
imagine that NHS Direct would be able to cope with that. Secondly,
as far as I can see from the research evidence, there is very
little evidence that NHS Direct has either changed consultation
patterns in general practice or in A&E; that it is an additional
service and a very welcome one for people who are worried, but
it does not seem to be reducing anything. That is not to denigrate
it; it is just that if that is what it was intended to do, it
is not doing it. The third one is just to come back to the question
of local against national. I really think there is a tremendous
logic in maybe patients having a single very simple number for
emergency healthcare and less emergency healthcare. I think there
is a logic in that, but somehow we have to build local knowledge
into that, because what you do in Rutland and what you do in East
Grinstead and what you do in Peckham are fundamentally different.
If you have a call centre in Edinburgh, because people like the
voices in Edinburgh, they are not going to know what those needs
are. So savings on one level in terms of delivery will be lost
in inappropriate healthcare provision.
Dr Reynolds: This is a difficult
question to give a good answer to, in a sense, but as an association
the jewel in the crown of NHS Direct is nurses' advice to worried
patients with illnesses that can be safely managed at home and
that should be very successful. However, what has not been made
public, as far as I am aware, is the evaluation of the exemplar
sites, which is where NHS Direct were the first point of contact
for urgent primary out-of-hours calls, and we are upset that we
have not seen that. Our understanding—and I am not entirely
sure about the exact figures—is that through NHS Direct
about 30% of out-of-hours primary care calls are finished off—a
rather unfortunate phrase—by NHS Direct; the episode is
completed. But in nurses employed by co-ops working side by side
with GPs, a team approach to this, with a different culture, experienced
nurses, sometimes working with decision support software, sometimes
working on the basis of careful training with access to paper-based
protocols, can successfully complete 60% of the calls that present
to a primary care service out of hours, when they have immediate
recourse to a GP working in the room next to them or at the end
of a phone. We believe that the filter that NHS Direct puts in
front of patients ringing for urgent calls out of hours only removes
30%, and delays perhaps 70%, and we would like to suggest that
the filter be re-thought, and that calls could be directed to
NHS Direct after initial assessment, perhaps not necessarily by
somebody clinically trained and bounced back to a clinician, if
needs be. Having said that, the NHS Direct review has the potential
to address many of the concerns that we have made right from the
point of the out-of-hours review, where we said in the out-of-hours
review model there is NHS Direct at the centre of all triage going
to it, and calls dispersed to all other services. We had a ferocious
argument with the out-of-hours team that that central box should
read "primary care/NHS D" (?) or "GP/NHS D"
so that there was a combined call filtering system at the centre,
not one service doing it. We still believe that that would be
the right way to go ahead. We do believe that the review gives
PCTs the chance to wield some financial influence on the structure
of NHS Direct to perhaps get them more locally responsive and
to perhaps have a system whereby local call sorting systems could
send calls to NHS Direct for very adequate response to the more,
frankly, without being denigrating—because their software
is so risk averse, NHS CAS—that it needs to be fairly self-limiting,
almost mostly reassurance issues that go to NHS Direct. The other
calls could go through to the services on the ground for clinicians
to sort out at that area. Having said that, there are some areas
where NHS Direct has worked well, and in the areas where it has
worked well it has been because there have been motivated local
clinicians of various colours working as a team behind it, and
in some areas the figures are better than that which I have said
previously. We at the moment would see NHS Direct—I share
Dr Haslam's comments—as a popular and well-liked service
that the patients appreciate, to call it, but in terms of clinical
effectiveness and money well spent I think the jury is well and
truly out, and we would like to see the pool of NHS Direct nurses
given more freedom, perhaps more senior nurses, and the NHS CAS
software radically changed to allow it to take more risks, with
the suitable safety-netting that occurs, to get the resolution
rate significantly raised and to have the nurses with access to
GPs so they can work as a team in solution to dealing with what
is essentially primary care work. That would be our suggestion.
Chairman: We have about half-an-hour
left, and a number of areas to cover in some detail. Could I appeal
for sharp questions and sharp answers as well.
Mr Bradley: I will not carry on.
Chairman: It is not pointed at you.
Q44 Dr Naysmith: We are beginning now
to touch on things that have already been touched on before, so
it should be easier to get sharp answers. This a question for
Mr Shalley. In the evidence of your organisation you said that
you feared that these changes would have an impact on Accident
& Emergency departments, and have already touched on the fact
that whether we have had these changes or not, things are getting
very pressured for Accident & Emergency departments, with
huge increases. Do you really have evidence that this is likely
to make that worse?
Mr Shalley: The attendance levels,
yes, just a huge jump in 12 months, which we have not seen for
the past four to five years.
Q45 Dr Naysmith: And the changes have
not really taken place yet.
Mr Shalley: It is public perception,
I think, that is the main driver. What is available, that is what
is driving attendance at emergency departments.
Q46 Chairman: In your figures that you
are using, is there any analysis of the nature of the presenting
problem at A&E, that you are dealing with.
Mr Shalley: The evidence is that
admissions are pretty much the same, so what we are seeing is
a bigger percentage increase in what we would like to call our
urgent care cases—walking wounded, or walking ill patients.
That seems to be our biggest increase at the moment. There will
not be a simple "yes"—we do not believe in categorising
people as inappropriate attenders, as David said; that is not
our role. What we would like to see in urban areas is to have
primary care actually located as part of the emergency department,
with a single triage point to make sure that patients get sent
to the right specialist—and I am calling primary care people
specialists, because they are. I think we need to have it as part
of the department, because we should not be turning people away.
We need to actually keep them and get them seen.
Q47 Mr Bradley: Just relating back to
NHS Direct, do you keep any statistics about who has advised people
to go to A&E? Is it that because of contacts with organisations
like NHS Direct, who may encourage them because of their own uncertainty,
to go to A&E?
Mr Shalley: We do not think that
NHS Direct has had a great effect on increasing attendance; it
certainly has not dropped attendances; but the default position
must be "seek medical care", and we are very happy with
that as an organisation.
Q48 Dr Naysmith: It may be the position
that you do no not say there is such a thing as inappropriate
referral, but I speak frequently with friends of mine who happen
to be medically qualified, and when they are not talking in public
they will tell you that lots of people turn up either at their
surgeries or their Accident & Emergency departments who really
should not be seen and should not be there at all.
Mr Shalley: I think patients need
to access medical care, and the patient will go where they think
they can get it.
Q49 Dr Naysmith: I think what they need
is appropriate advice, good advice, on where they should go. Is
that not fair?
Mr Shalley: I think that is entirely
reasonable, but I do not think we should be turning people away
from healthcare at all.
Q50 Dr Naysmith: Your question about
your fears of what the effect of this will be on Accident &
Emergency departments is positing the idea that somehow or other
we are not going to get through this crisis and we are not going
to solve it, and things are going to get worse. But if, as has
been suggested today, things do get better, we do provide a better
service, then I do not see that that in itself should have any
effect on Accident & Emergency departments, other than other
changes that might be happening in society, even such simple things
as the use of mobile phones, which is getting police and ambulance
services lots and lots of calls that they never used to have.
Mr Shalley: Like other people
have said, I think there is a tremendous potential to make things
better, but I do not think we should forget the risks that may
happen if we are not all up to speed here. The other thing, just
to say that our other major concern is that because of the new
GP contract many of our staff grade and associate specialist doctors
who provide a substantial proportion of our service are now leaving
emergency medicine to join primary care, and this is having a
major effect on recruitment nationally. That is another major
concern that we have.
Dr Naysmith: It is interesting. We hear
about GPs having difficulty recruiting, now it is emergency care
specialists who are leaving that branch of medicine to go and
work for GPs.
Q51 John Austin: It is just this perception
of reality again. You referred, I think, to a 15% increase, et
cetera. When? We are talking about a new contract which came in
on 1 April. Surely your figures for that increase pre-date those
changes? So they are not as a result of changes on the ground;
they may be as a result of a different perception that certain
things are not available.
Mr Shalley: Yes.
Q52 Chairman: Can I just press you, Mr
Shalley. You have made the point about not turning people away.
I referred in the debate we are having in the Chamber this week
to my experience of spending a night with my daughter about six
months ago in a Casualty A&E unit. It was a Saturday night/Sunday
morning, which indicates the nature of the business that was under
way there, and some of you will know the kind of thing I am talking
about. It did strike me very strongly that there were some genuine
people there who needed help, and their ability to gain help was
affected by the presence of people who, frankly, could have been
dealt with elsewhere. Any city centre A&E on a Saturday night/Sunday
morning has a certain kind of people who are drunk, vomiting,
have been fighting. I would have thought that there was a more
appropriate response outside A&E to that type of situation.
I wonder whether you and your colleagues think that perhaps as
part of this process of change we ought to be looking at alternatives
to some of the responses that we give to people who have drink-related
problems, that do not really need to be queuing up at an A&E
department.
Mr Shalley: I think that is very
difficult. More and more emergency departments are being seen
as a place of safety by many organisations, including the police,
because these people are difficult; they do present challenges
both medically and socially. I think you are quite right in that
we do not have the right place to see and deal with these people.
Maybe something will come out of the reorganisation of out-of-hours
service and that is something that we should all look at for the
future. But, yes, I think they are a great challenge, and I do
not think we have the answer to that question.
Professor Haslam: One specific
and one general point. The specific one is that the difficulty
is that you only know that you did not need to see and treat someone
after you have seen them, so it is quite easy in retrospect but
quite difficult in prospect. There is an issue there, and I personally
believe that the answer is much more co-location of general practice
skills and A&E skills together so that very early on the right
person has dealt with it. I think an area that none of us have
talked about—and it is probably far too big to even get
into—is societal changes, in which society has become much
more risk averse: "If in doubt, let's see a professional".
A lot of that is driven by very understandable fears around things
like meningitis, and where the first signs of a cold and the first
signs of meningitis are indistinguishable, and you are a worried
parent with no family support, and no extended family support,
then your reaction is going to be fundamentally different. I think
that is probably one of the drivers of what is happening with
all of us.
Q53 Dr Naysmith: Can I ask a question
of Professor Haslam, and it has probably been touched on a little
bit. Are your members concerned that the changes in out-of-hours
provision are going to have a knock-on impact on regular GP during-the-day
services, and in particular do you think this could affect the
48-hour access target?
Professor Haslam: That is a huge
question. I think, as a number of people have said, actually not
much is going to change, because most of the big changes have
already happened. When I was first a general practitioner I did
all my own out-of-hours; I was seeing my own patients at every
hour of the day and night, I was completely exhausted. Over the
last five or 10 years I have been in a co-op, and that has handled
things in a completely different way to the way I would have done
it for my own patients, and far more has been—"You're
OK, you'll get through the night. See your doctor tomorrow",
which is actually fine. I do not think an awful lot of what is
going to happen in the next year or two is that much different
from where we are now. To me the biggest change is where the responsibility
lies, not where the delivery lies; and that goes back to where
we came in.
Q54 Dr Naysmith: One very simple way
that it might change is often it used to be a doctor from your
own practice who would be saying it, and that may not be the case
in the future. A doctor would say, if he or she saw you in the
middle of the night, "Come and see me in the morning and
we'll sort this out".
Professor Haslam: The thing is,
not only would that be the case in the future, it is the case
now. The chances are, now.
Q55 Dr Naysmith: That is right, yes.
Professor Haslam: So if you are
asking me what the concerns are, those concerns have already happened.
Yes, Monday mornings are very busy.
Q56 Dr Taylor: Mr Shalley, you have already
told us the workload has gone up tremendously. Has that affected
your ability to meet the four-hour waiting time target?
Mr Shalley: That is very interesting.
There are graphs that actually show that performance is dropping
off with increase in workload. There are four departments in the
country whose workload is decreasing. I think it would be good
to go and see them and find out how they are doing it. But, generally
speaking, with increasing attendance, four-hour turn-round times
are dropping.
Q57 Dr Taylor: Would you be able to tell
us which those four units are?
Mr Shalley: I wish I could. I
have the graph, but it is anonymised. I shall try and find out.
Q58 Dr Taylor: This is probably rather
academic, because in about half-an-hour we are going to be told
what the government's new targets are; but would you have any
suggestions about generic targets to help the whole out-of-hours
service?
Mr Shalley: I think that is very
difficult, for me to pontificate on primary care.
Q59 Dr Taylor: Not only you, the others.
Mr Shalley: I am very happy—I
think the four-hour target for emergency medicine has been a godsend.
I think it has actually focused everybody's thoughts on the emergency
patient. As you can imagine, from my speciality, that has been
a great change, and a great change for the good of patients primarily;
and because of that, for staff, departments and trusts. I think
it has done only good.
|
