Select Committee on Health Minutes of Evidence


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.





 
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