Examination of Witnesses (Questions 60-70)
24 JUNE 2004
DR JOHN
CHISHOLM, DR
RUTH LIVINGSTONE,
PROFESSOR DAVID
HASLAM, DR
MARK REYNOLDS,
DR MIKE
SADLER AND
MR MARTIN
SHALLEY
Q60 Chairman: Can we quote you in half-an-hour?
Is that okay?
Mr Shalley: We are all talking
about targets and time—quantity targets—but maybe
now is the time to start thinking more about quality, but not
to forget time as well, not to forget time.
Q61 Chairman: Dr Sadler?
Dr Sadler: Just a point about
integration, if I may, Chairman. I think what one of the things
the changes do provide is the opportunity to have more integrated
services. Mr Shalley mentioned having primary care centres in
A&E departments, and I think that is an appropriate response
to where patients will turn up for care; we have to make sure
they get the appropriate care. You mentioned the 48-hour access
target. We in one particular area already provide in-hour services
to help the PCT achieve that. So I think we probably have to look
at not such a strict demarcation between in-hours services and
out-of-hours services; there are patient needs throughout the
24 hours, and I would like to think the new contract will offer
us an opportunity to bring much more unity between so-called in-hours
and out-of-hours services.
Q62 Dr Taylor: Can we talk briefly about
community hospitals. I think many of us have been quite confused
by the Minister—I forget which one—telling us that
the changes had nothing to do with the community hospitals. We
are really worried about out-of-hours cover for community hospitals,
out-of-hours cover for community hospital MIUs. How does this
work at the moment, and how will it work?
Dr Chisholm: I am pleased that
you are worried, because I think you are right to be concerned.
I think traditionally—and particularly in rural areas—community
hospital work has been part of the job of practices, and has been
something that they have willingly accepted as part of their service
to the community, even though for a variety of historic reasons
they have often not been well rewarded for that part of their
work, have often been paid on quite a lowly-salaried rate. I think
because those practices, and almost all practices in the UK, are
now going to have the possibility of transferring their responsibility
for out-of-hours general medical services to the local primary
care organisation, and then make a choice individually, as individual
doctors, whether they are going to do any out-of-hours work themselves,
there are large numbers of practices that are now thinking again
about whether they wish to continue community hospital work. We
certainly have heard of many reports in many parts of the UK of
practices giving notice to the community hospital of their intention
to either cease any community hospital work or only provide in-hours
community hospital work. I think it is a very serious threat,
and I think it is a threat that primary care organisations will
be worried about, because it is part of their overall provision
of emergency care, the community hospital. In Wales, the Welsh
Assembly government does seem to have got a grip on the urgency
of the issue, and discussions are quite well advanced; they are
not yet concluded, but there is at least a willingness for the
government and the NHS Confederation and the Welsh General Practitioners'
Committee preferred that there would have been UK negotiations
on the issue, but in England in particular both the Health Department
and the NHS Confederation have been disinclined to engage in national
negotiations, or have said that they can be part of the negotiations
about staff and associate specialists. Those negotiations are
about to begin. Looking at the three big recent contractual negotiations,
I would expect those to take a couple of years at the least, by
which time the community hospital problem may have got out of
control. So we would welcome any help that you can give to instil
in all the UK governments an appreciation of the urgency of addressing
this issue so that we can ensure that practices do not pull out
of community hospital work. Hopefully if the progress that has
been made in Wales in recent weeks is satisfactorily concluded
in the next week or two, that may be an example that people can
use in terms of what are appropriate payment arrangements, what
are appropriate arrangements for dealing with in-patients, what
are appropriate arrangements for dealing with minor injuries,
and recognising that actually GPs and practices and nurses working
in community hospitals have been taking the pressure off district
general hospitals and providing an enormously valued service to
their local community. We really are at the eleventh hour, because
by 31 December perhaps 90% of practices in the UK will have chosen
to transfer responsibility to out-of-hours providers to transfer
the responsibility to the primary care organisation; and I think
that unless something is done, we are doing to see in some areas
meltdown of the community hospital service.
Q63 Dr Taylor: Would GP co-operatives
think of taking on care of in-patients out of hours in community
hospitals?
Dr Reynolds: Yes, is the short
answer, as long as the medical staffing and the financial streams
can be sorted out.
Q64 Dr Naysmith: This is a huge question,
if we get into it, but a lot of the memoranda that we have submitted
to this Committee have mentioned a potential shortfall—millions
of pounds in some local health economies. Apart from my feelings
of surprise, given that the National Health Service is getting
more money at the moment than it has ever had before, do you think
this is a realistic picture of what is happening around the country,
that there are potential shortfalls of millions of pounds which
are going to have an impact on possibly this change?
Dr Livingstone: From our canvassing—you
have to understand that there is always doom and gloom about finances
which at this stage we have to take with a pinch of salt—but
certainly putting in place alternative arrangements is going to
by and large prove more expensive than the funding available to
do it. Dr Chisholm talked about the £6,000 per GP, and then
there is a top-up of about £3,000 per GP which would go into
the new out-of-hours arrangement; but most of the new out-of-hours
arrangements are going to cost more than that, so I think there
is understandable concern. We have had responses which suggest
anything between that we are going to break even within the budget
we have, to we are going to have a £400,000 shortfall on
out-of-hours alone.
Q65 Dr Naysmith: What will happen if
this shortfall is not addressed?
Dr Livingstone: PCTs will tend
to do what they have always done, which is desperately scramble
to balance the books at the end of the year, and broker payments
between each other to try and make the total books balance.
Q66 Dr Naysmith: I understand that has
now been outlawed, this sort of brokerage idea. The last time
we had the chief financial officer of the National Health Service
here he told us this was no longer going to be allowed.
Dr Livingstone: I think that would
worry PCTs greatly.
Dr Reynolds: I think this is the
nub of the problem, in that out-of-hours providers have little
choice but to continue in a similar fashion at present until skill
mix is ready, know how much it costs to provide a service. If
they are faced with a cash-strapped PCT that says there is only
X amount to do it, and they know it is going to cost Y
to do it, they have a choice of either diminishing the quality
of the service to the patient or saying "No, we're not going
to play any more, because we know we can't deliver a service for
that much money". It is a real problem. Our best guesstimate
is it is £200,000 to £300,000 per PCT across the country
short. Especially in rural and semi rural areas. The reason for
this is the culture change of GPs essentially doing out-of-hours
as part of their professional obligations for free until this
new contract has come into place.
Q67 Dr Naysmith: The final question is:
the NHS Confederation suggested that it might be a good idea to
have one global fund which would cover all unscheduled care. Obviously
that is GPs, out-of-hours GPs, in-hours services, Accident &
Emergency, emergency care, maybe even walk-in centres, minor injury
units and community hospitals. Do you think that is a feasible
or possible suggestion? I do not know who is best to answer that.
Dr Reynolds: We have been pushing
for some time for PCTs to think out of the box and to merge the
budgets that deal with unscheduled care, but it is a complex change
in thinking, in organisation, and there is no doubt that there
is a short-term financial shortfall.
Dr Chisholm: It is certainly a
feasible solution, and I think there has been a debate in recent
years about whether to give people overall budgets within which
at local level the primary care organisation makes its own decisions
about how to allocate resources, or whether you should earmark
resources for particular purposes in order to protect expenditure
in that area. There are arguments in both directions. Certainly
the big change in GP out-of-hours services that occurred in the
mid-1990s was enormously facilitated by the availability of ring-fenced
funding for out-of-hours development. As a personal view I think
the NHS Confederation's suggestion is quite a sensible one, of
having an overall fund for unscheduled and emergency care, and
trying to integrate primary and secondary care more, because that
really is what needs to be done in terms of moving forward in
reforming emergency care. Whether that is identified as a separate
resource, separate from their unified budget, given the pressures
that Mr Shalley has reported, I think perhaps having some dedicated
resources for emergency and unscheduled care might be a wise move.
Q68 John Austin: I was going to ask a
question related to some evidence we had from the co-operative
in Cornwall, but I think in evidence most of you have said that
you fear that financial pressures on the PCTs may lead to some
effect on service provision. I think you also indicated that providing
a new system of care may be more costly than the way in which
it was provided before. Where do you see the key risk areas?
Professor Haslam: I think on a
very small level, one of the ways that out-of-hours care has survived
in the last two or three years, if not longer, is that the responsibility—and
we talked about this before—for instance, for next Saturday
night, lies with me, and I will try and sell that if I do not
want to do it. Actually, practically, if nobody else wants to
do it, the cost goes up and up and up and up until it is enough
money for me to be prepared to pay it and somebody else to be
prepared to do it. That has been a budget just between individual
doctors, effectively. Obviously from an NHS budget one cannot
have that degree of financial flexibility for what the cost of
a shift would be, so there feel to me to be concerns about just
what will happen. This is very much in Mark's area rather than
mine, but it is an observation that would concern me.
Dr Reynolds: I think the key risk
is providing a sustainable workforce adequately remunerated with
conditions of work that allow people to wish to come back to work.
At the moment if a GP has a ferociously busy Sunday morning shift
at the co-op, they still have to come up to the next one; but
if they have two or three of those in a row when they are on a
different basis, relationship, they may choose not to do so. So
I think the workforce and the conditions, the development of the
skill mix, are the key risk areas. The funding has to largely
go—actually the biggest cost is to the workforce-rather
than to the physical infrastructure. It is a very workforce-heavy
cost.
Dr Sadler: I think the biggest
risk was the one I started to refer to when the bell was going
earlier. At the present time, whatever provision a GP makes to
provide out-of-hours service, ultimately that responsibility is
his own, so if the service with whom he contracts or which he
uses to provide that service for one reason or another cannot
cope or provide that service, they can hand back that service,
because it is the GP's 24-hour responsibility to provide care.
As from 31 December that responsibility no longer applies, and
it is a concern to myself and some colleagues that in some areas
there appear to be new, not-yet-proven, untried models being put
into place as we come into the winter of 2004, without that back-up;
and where you have a relatively small, untried service, there
is to me a danger that if you get some fluctuations in demand,
an epidemic, they may not be able to cope with that and will not
have the back-stop of being able to say "Aha! It's actually
the GP's 24-hour responsibility, so let's hand it back".
I think from my point of view the biggest risk is the lack of
resilience in some of the new services that are being suggested
will be set up as we move into winter 2004.
Dr Chisholm: I think there are
four key issues which in a sense flag up risks. One of them is
to do with integration, that we want to see a service that actually
brings together all the different parties contributing to out-of-hours
care in a way that produces a much more integrated service than
we have at the moment, and co-location of services and working
together of providers is part of that. The second issue obviously
is adequate resources in order to continue to deliver the quality.
The third key issue is one that Mike Sadler has raised, which
is that henceforward the default will lie with the primary care
organisation, so the primary care organisation itself has to have
in place arrangements for managing the risk that could occur during
an epidemic, or whatever. The fourth key area, as Mark has emphasised,
is the workforce. I am encouraged by the results of Mark's survey
that 70% of doctors who are members of co-ops will continue to
do some out-of-hours work; I actually as a personal view think
that that may be quite shortly a rather optimistic estimate, and
that we might see perhaps only 40 or 50% of doctors, and that
is part of the workforce issue. We need to have enough doctors,
enough paramedics, enough ambulance staff, enough nurses and nurse
practitioners to provide the service that patients need. So integration
resources, the default position, and adequate workforce.
Q69 John Austin: In the past it is quite
clear that the responsibility was with the GP, and the buck stopped
there, but I do not think we should paint too rosy a situation.
It may have worked in some areas, but, to be frank, some of the
provision of out-of-hours service was pretty ropey, and there
have been some pretty dodgy deputising services in many parts
of the country. In your view are the standards for out-of-hours
service sufficiently robust, and are the mechanisms for audit
and monitoring adequate?
Dr Sadler: I think the standards
are robust. I think what we would like to see is people monitoring
more closely, and some national publication of people's performance
against those. We would welcome that, and I think it would make
explicit the standards of care that are being provided throughout
the UK.
Q70 Chairman: Can I just conclude—for
some reason the monitors have gone off, and I do not know why,
but we have five minutes left. One of the issues that I think
we touched on, particularly in terms of the use of A&E, is
the public understanding of our health system. I worry about the
way in which members of the public without a great deal of knowledge
of the health service—even people who have some knowledge
of the health service—work out which service they really
want to access: the GP out-of-hours, A&E, in my area we have
NHS walk-in, we have NHS Direct. What do you feel needs to be
done perhaps by government or at a local level by PCTs or collectively
somehow to educate the public in understanding the appropriate
access points for specific problems that they may have? It is
a fairly wide-ranging question. We have talked a bit about patients,
but not the patients' perception, and I think the patients' perception
of service is a very important area.
Professor Haslam: It seems to
me to expand way outside out-of-hours care, now that we have for
instance direct access in many areas to physiotherapy under the
NHS, and so on—absolute clarity that not everything, for
instance, needs to go to a GP first, is important. I think this
needs to be part of a joined-up publicity campaign, very simply
explaining what the options are and what is the right way of doing
it. It is a big task.
Dr Chisholm: Absolutely. I think
NHS Direct and the other services that NHS Direct provide, like
NHS Direct on-line, the home healthcare guide, which my understanding
is may shortly be delivered to houses with Thompson's directories—that
is I think a positive move forward, because I think the more people
are empowered to have the information at their fingertips the
better. I think there is a real issue about patients whose first
language is not English, and how they can be helped to make appropriate
use of the healthcare services. There is a really big agenda to
do with education and demand management; there is £10 million
allocated as part of the new contract implementation over two
years, to a range of demand management initiatives, and I think
things like the expert patients programme, empowering people to
be more confident in using self-care, using the pharmacists more
than they do—there is a whole range of things that we can
work on, but it is very complex, and much wider than out of hours.
Chairman: I am anxious to conclude, to
give us time to get across to the statement. I do apologise that
we have had to rush somewhat. Can I thank our witnesses for a
very interesting and useful session; we are most grateful for
your co-operation. I hope what we come up with will be helpful.
As I understand it, John Chisholm is retiring from his current
role. Can I wish you well, John. You have been here on a number
of occasions. We have not always agreed, but we have usually had
a dialogue. Now you will have time to do out-of-hours cover, presumably.
Thank you very much.
|
