Examination of Witnesses (Questions 71-79)
8 JULY 2004
DR GRAHAM
RICH, MS
LYN REYNOLDS
AND MR
ED LESTER
Q71 Chairman: Good morning. May I particularly
welcome our witnesses. We are grateful for your presence here
today and for your cooperation with our short inquiry. Could you
each briefly introduce yourself to the Committee.
Dr Rich: My name is Dr Graham
Rich. I am Chief Executive of West Hull Primary Care Trust.
Ms Reynolds: I am Lyn Reynolds.
I am Primary Care Development Manager from East Anglian Ambulance
Trust.
Mr Lester: I am Ed Lester, Chief
Executive of NHS Direct.
Q72 Chairman: Dr Rich, as the only person
who might be familiar with Hull, which parts of Hull do you cover?
How far west do you go?
Dr Rich: We cover all of the population
within the city boundaries, so everything to the west of the River
Hull. There are two PCTs in Hull and we are one of the two.
Q73 Chairman: Thank you. Could I ask
you for your general thoughts on the past provision and practice
in the delivery of out of hours? Obviously there is a kind of
patchwork quilt that appears to have developed over many years.
What are your views on how good the quality of the services has
been and its variability and what are your general thoughts on
how it has evolved in the way it has evolved?
Mr Lester: Back in 2001 we entered
into 34 exemplars with a number of different doctors' co-operatives
around the country. It was quite a diverse mix and the idea was
to see just how this would actually operate. We have had mixed
success. Some have been extremely successful and some have been
less than successful. Those that have been really successful are
those where a partnership has been created, where there has been
transparency between the partners who are involved in the venture
and there is an objective that is understood by all of those who
are participating. Where that happens, it is very successful.
It does not matter necessarily whether co-operatives are co-located,
for example, with ourselves or whether they are remote. The important
thing is that the partnership is rigorous and well understood.
Ms Reynolds: In Norfolk we have
six GP co-ops, Prime Care and a number of practices and individuals
providing their own on-call. We even had one practice with every
single possible scenario. Each organisation operated independently
from each other and there were varying levels of robustness and
quality. We have now brought all those together under the leadership
of the ambulance trust. So far it has worked extremely well. We
are able now to offer much more of a team approach. It does not
matter that the patient belongs to that practice; we can now offer
the choice of which primary care centre they would like to visit,
depending on their location and access.
Q74 Chairman: Why is it that certain
solutions appear to have developed in certain areas? You have
gone for an ambulance trust solution. Why do you think that has
happened in your area and not in others? It has happened in Hull
as well. Why has it not happened elsewhere? What specific reasons
are there for this happening in your two areas and perhaps not
elsewhere?
Ms Reynolds: Certainly in Norfolk
the co-ops saw the opportunity to dissolve but work with the ambulance
trust to transition into the new service. The proposal we put
forward was in collaboration with the GP co-ops. The level of
quality that operated between some of the co-ops and some of the
Prime Care areas varied, so it was an opportunity to standardise
a lot of the systems, processes and quality.
Q75 Chairman: Is it the fact that you
are predominantly a rural area?
Ms Reynolds: Yes. We have both:
we have Norwich City, Great Yarmouth, King's Lynn and extremely
rural areas. It is a very difficult area to cover.
Dr Rich: We have a slightly different
situation. We have a highly dense population in an inner city
urban area. We did not have GP co-ops operating locally, we only
had one private provider locally. Practices asked the PCT to work
on developing another option and we started to think about how
we could construct an out-of-hours service which could offer an
alternative to this. We thought that we needed call-handling,
logistics, staffing, rotas, good response, and that really points
to an ambulance trust solution for us as one of the options. That
is what took us down that line.
Q76 Chairman: You two have gone in that
direction; other areas possibly have not. I can see the logic.
What would be your ideas as to why other areas have not followed
your logic?
Ms Reynolds: We were integrated
with the co-ops right from the onset. We provided the infrastructure
in terms of call-handling, cars, communications and staff.
Q77 Chairman: So there is history there
that you built on.
Ms Reynolds: Yes.
Dr Rich: We also had good working
relationships with the ambulance trust, who had already tried
GPs in cars, and started to work on their demand management to
try to help with the ambulance call demand.
Mr Lester: It sounds a bit simplistic
but it is all about the chemistry and relationship between the
individuals when they set out. If they really have a single purpose,
then it will work. If there is not that communication and there
is not that relationship, it tends not to be as successful, as
we said.
Chairman: In respect of ambulance trusts,
geographically they cover a larger area. One wonders whether we
are looking here at a lack of some sort of strategic joining that
has helped the two trusts from whom we have heard to forge ahead
with what seems to be an interesting model.
Q78 Mr Jones: My question is particularly
to Ms Reynolds and Dr Rich. What experience have you had and what
has been the result of that experience of commissioning out-of-hours
services from commercial providers?
Dr Rich: Prior to commissioning
our new arrangements, we had none at all. We clearly had commissioning
of ambulance services and commissioning of A&E services in
hospitals, but the responsibility for choosing and working with
out-of-hours providers and the legal responsibilities always stayed
with practices prior to the introduction of the new GP contract,
so although we have had a watching brief in terms of quality,
because PCTs have had the right to say that a provider is not
meeting minimum standards, we have not actually commissioned the
service ourselves before this recent role.
Q79 Mr Jones: So you have had recent
experience but no past experience.
Dr Rich: Our service now has been
operational for about 18 months. All the skills around commissioning
are very similar: business planning, value for money, service
specifications. It is similar to what we do in other parts of
the health service.
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