Examination of Witnesses (Questions 139-159)
8 JULY 2004
RT HON
JOHN HUTTON
MP, PROFESSOR DAVID
COLIN-THOME
AND MS
MARGARET EDWARDS
Q139 Chairman: Could I welcome you and
your colleagues. Could you briefly introduce yourself and your
team.
Mr Hutton: Certainly, Chairman.
On my left is Margaret Edwards, who is the Director of Access
in the Department of Health. On my right is Professor David Colin-Thome,
who is the National Director for Primary Care. David is a GP in
Cheshire and has been a GP for 30-odd years.
Q140 Chairman: And you are?
Mr Hutton: I am John Hutton. I
am the Minister of State for Health.
Q141 Chairman: Thank you very much. Could
I begin by asking a general question on the background to out-of-hours.
Over many years we have had a patchwork quilt of different arrangements
in different areas. Looking at your evidence, you have not gone
into the background in great detail. We are looking at the current
situation and the future situation primarily. I would be interested
in your comments in relation to this. Why has there never been
an attempt by successive governments to establish a common approach
to out-of-hours? We have a reasonably common approach to primary
care and yet the out-of-hours provision, which is a key provision
of the health service, has developed in very different ways in
different areas. Have you a view on that particular point?
Mr Hutton: Sometimes, Chairman,
it is difficult enough to explain what we are doing in government,
let alone to explain what other governments have done, so I do
not think I would like to offer a view about previous governments
in that regard. I would simply agree with that general observation,
that if you were to look critically at the development of out-of-hours
it is not an unreasonable conclusion to say that out-of-hours
services, although there have been tremendous amounts of change
in out-of-hours, has not had the same focus certainly in comparison
to other parts of the health service. I think it is a very, very
important issue now for us to get this right. I think the new
contracts in primary care certainly give us an opportunity to
take a different look, a more strategic look, I think, at the
development of out-of-hours services. I think that is a very,
very important thing that we do now. About nine million patients
a year make use of out-of-hours services. All of us in this room
have done it ourselves, maybe recently. It is an amazing comfort,
reassurance and security to know that there is someone we can
speak to. We are absolutely committed to making sure we take the
opportunity we now have to give the sort of focus to the long-term
strategic development of out-of-hours services that I think you
rightly said has not taken place in recent years.
Q142 Chairman: You were not here for
the previous group of witnesses. John Austin summed up at the
end by saying that they had given us a very positive picture,
and, despite predictions of doom and gloom, the picture we have
seems to be very positive. It has struck me in this short inquiry
that we have a range of different models in different areas impacting
in different ways. I come back to the point that we have never
developed a common approach. One of the concerns I have with the
evidence is that we are having examples of some very good work
that has been done, and people are grasping the opportunity of
this change to establish some very good working models—there
is no doubt we have evidence of that—but there appears to
be duplication of efforts in some respects. There appears to be
a lack of sharing of the good parts across the country. I would
be interested in your thoughts on that. A worry I have is that
we do not appear to have centrally any ability to draw together
the positive examples and are there people in areas who are struggling
a little bit on this issue.
Mr Hutton: I hope that is not
the case. We are putting a significant amount of effort into making
sure that we do precisely what you say we should be doing. We
have officials in strategic health authorities. I have a lot of
my people working in this area. For a number of years we have
been developing NHS Direct exemplar sites—20% of the country
now is covered by those sorts of arrangements. I think there is
a very substantial evidence base available to primary care trusts
and others who are involved in making these changes to draw on
to get it right. I do not want people to spend a lot of time reinventing
the wheel; I think we have other things we would all prefer to
do with our time. I hope that is not what happens here. Chairman,
we will take the observation very carefully to heart, but, you
are right, it makes absolute sense to provide as much strategic
support to the local NHS that we can. Maybe Margaret may want
to add a bit more detail to that.
Ms Edwards: We have deliberately
allowed different models because there are different circumstances
and obviously what you need in Cornwall is different from what
you need in Birmingham. Having said that, we do have common quality
standards, so everybody must reach the same quality standards,
and we have been very clear about that. In the guidance we have
sent out, we have put a model in for good practice. So we have
a clear model that people can use to test their own models against
to see if they fulfil these criteria. We have 14 regional co-ordinators
who meet regularly and bring that local knowledge and share it
and we have a number of ways of making sure that we get the best
of both worlds, local areas for doing what is right for them,
but we certainly do make sure that we are sharing practice right
throughout the country.
Mr Hutton: Margaret has referred
to the national policy standards. I think this is a very important
part of the new landscape in out-of-hours. If you track back the
complaints—and there have been many complaints about out-of-hours
services over the years—a lot of those come down to basic
issues about the sort of level of service patients can expect
and are entitled to expect the NHS to provide. But the national
quality standards which now have to be built into the new contractual
arrangements for out-of-hours I think will help make sure that
across the country there are some benchmarked quality levels that
out-of-hours' providers have to meet. I think that will go a significant
way to address what lies behind the point you are making about
variability, but without forcing the NHS to fit into one straitjacket,
because I think that would not be a sensible thing to do.
Q143 Chairman: I was struck in the previous
session by a minor example of duplication. We have had one ambulance
trust commendably giving information out about how to make use
of out-of-hours services and the distinction between the different
services and NHS Direct commendably using the Thomson Directory
to help people. It struck me slightly as duplication, and that
a little more central coordination on this issue might have reduced
the amount of money that had to be spent on publicising to people
the appropriate use of services. Is that an area you have looked
at? Obviously with people going in different directions, I have
no problem, because each area is different, but where you have
a national, overarching scheme like NHS Direct, the relationship
locally seems lacking in that respect.
Mr Hutton: Practices are required
to provide the sort of information to patients on their list—there
is a requirement for a practice leaflet and so on. PCTs have a
responsibility to make sure that locally people understand what
the new arrangements are going to be, what the new number might
be to call, for example, and what sort of service they can expect.
But I think communication is a very, very important part of this.
Whenever you make a big change—and this is a big change—the
one thing we always have to guard against is the fear that some
people will have that that means the service is no longer going
to be available, so they will start going to A&E or they will
do something else. We have to avoid that. I think communication
is a very, very important part of explaining the new landscape
of out-of-hours services to people. I want to commend the NHS
locally for the efforts they are making on communication, but
we certainly do not want to do what you have just hinted at. Maybe
that is something that Margaret again might want to say something
about.
Ms Edwards: We have picked this
up as an issue. One of the things we are doing is working with
NHS Direction communication leads across the country to get some
common messages and work so that we do not get different bits
of NHS Direct. We have a group now working with the communication
leads to do that, but, again, it does need to be tailored.
Q144 Chairman: I entirely accept that.
Ms Edwards: It is just that balance,
but we are co-ordinating it, definitely.
Q145 Chairman: I mentioned the previous
session was very positive in relation to what has happening in
the areas we looked at. We have had, as you would expect, criticism
of the new approach. One of the areas of concern was the way in
which within PCTs the development of out-of-hours services with
the changes has been handled by junior and inexperienced members
of staff. The National Association of GP Co-operatives said, "There
have been people in the PCTs taking this job on with no experience
really, thinking it is all going to be fine and reporting up the
line that everything is fine: whereas on the other universe there
are people doing the hard-edge of the provision, knocking up against
financial constraints and misunderstandings and not confident
in many areas that everything is fine." Obviously nationally
you get feedback from the SHAs which may well be positive, but
at grass-roots level they are saying is that perhaps the picture
is not as rosy in some areas as maybe you are being told.
Mr Hutton: I am sure there will
be parts of the country that will find it more difficult to make
these changes and this transition than others; that is, after
all, the one thing we know about the National Health Service.
But I think there is a huge amount of effort going into this.
My contacts, not just the advice I get from my officials but what
I hear when I go round the country, is that chief executives at
PCT level are putting a huge amount of effort into this. The strategic
health authorities are very focused on this and we have made it
very clear to them the importance that we attach to making sure
that these new arrangements work smoothly and effectively. My
ideal through all of this is that the patient does not notice
the difference at all. That is what we should be aiming at. Yes,
there is going to be a different infrastructure, the contractual
relationships will be different, but why should that impact at
all? Why should that manifest itself in any different way, shape
or form to a patient who uses the service? There is no reason
for it to do that. I also read what Mark Reynolds was saying last
week. I take from Mark's evidence that the picture is not uniform—that
is what we would expect—but we are working very closely
in those areas that are having more difficulties than others to
try to get the new arrangements right. Certainly in those areas,
in the 40-odd PCTs where there have been these arrangements in
place since April, the general feedback I get from staff, not
just my officials but from GPs, is that the arrangements are working
pretty well actually.
Q146 John Austin: From the evidence we
have had, it is quite clear that the pre-existing situation was
far from ideal, patchy, fragmented and not really co-ordinated,
with a great deal of inappropriate use of the emergency services.
One of the key messages that came out in the evidence is that
in order to deliver this new service the key issue is going to
be the skill-mix of the people available. Have you made any estimate
of the number of the different healthcare professionals, whether
they are paramedics, care practitioners, practitioner nurses,
that will be needed to deliver an effective service? How many
are currently available and how many do you think it will take
to have the appropriate staff in place for the kind of service
that we all want to see?
Mr Hutton: I agree with what I
think lies behind the question you are asking me, but we do have
an opportunity to reposition some of these services. It does not
always make good sense for the service to be entirely staffed
and run by GPs when, as we know in every other part of the National
Health Service, there are tasks that can be done perfectly well
and perfectly efficiently and effectively by skilled nurses, for
example, and other therapists, and we need to have that same approach
in out-of-hours services. In relation to skill-mix, I am going
to ask David to say something about that, but I think generally
we will see a change over time in the skill-mix in provision of
out-of-hours services, and that will be a good thing. We have
to be clear how that relates to the quality standards level you
expect out-of-hours' providers to comply with. I think we can
do that, but I do not think that in the short-term there is going
to be this big-bang in terms of a need right now, today, for tens
of thousands of qualified emergency care practitioners, who are
nurses, to come in and fill the breach in out-of-hours services.
The evidence we are getting is that, although clearly GPs want
to exercise—and most of them will—their right to opt
out of out-of-hours services, large numbers of GPs will continue
to want to provide out-of-hours services themselves, either on
shifts or through their co-ops or whatever. I think that will
continue to be the case and we need to make sure that that is
the case because there has to be a GP input. I think the skill-mix
agenda is going to develop over years and not over weeks and months.
Certainly there is plenty of evidence coming through from the
NHS, from local sites and local work, about the steps that the
NHS is making locally to do that. I think that primarily the responsibility
for this will lie with the local NHS in terms of planning, working
out what sort of service they want to provide and making sure
that the workforce development confederations have in place, over
time, a programme to train up, if they want to, the additional
nurse practitioners that might slot into out-of-hours services.
David might want to add to that.
Professor Colin-Thome: I would
agree with that. The issue about how many numbers there should
be centrally is probably not the best way forward because different
PCTs will come up with different approaches. In some places they
may use the Ambulance Trust more and in others they might use
nurses, and so on and so forth. So it is a local issue, but there
are many national initiatives to give a range of workers, like
emergency care workers, through the Changing Workforce Programme,
through PCT development locally and co-ops for a long time have
been the mainstream for work and use skill-mix quite a lot. So
it is hard to give a national figure, that we need X number of
nurses, et cetera, because there will be different models. The
issue is, are they adequately trained locally and the evidence
seems to be, both from the old co-operative movement and what
is happening now, that the answer is yes. I happen to be in a
PCT as a GP, which actually went early, in April. Largely, the
model is similar to before, which is predominantly GP with some
nurses, and with a migration as more and more people get trained,
and I think that is the model you will see. It is certainly impossible
to give central figures to the variations. It accurately echoes
what is happening in-hours in general practice, with the new GP
contract, and you will see different approaches where there will
be more nurses and others working in there too.
Q147 John Austin: Can I go on and voice
one of the criticisms? We have heard some evidence—and I
hasten to say not the evidence we heard from our witnesses this
morning—and you have indicated that for a considerable time
there will continue to be more of a reliance on GPs as the new
system comes in. I think your Memorandum says that at least half
of the future out-of-hours provision will be delivered by existing
GP co-operatives. It has been put by a number of witnesses—and,
again, I stress not the witnesses we heard this morning—that
by removing the GPs' 24-hour responsibility for out-of-hours services
you have effectively removed the "safety net" that ensures
GPs' involvement. The question is, in the light of that evidence,
what will happen if providing out-of-hours cover ultimately proves
unattractive to the majority of GPs, and large numbers of GP co-operatives
fold? What would be the position?
Mr Hutton: We have to make sure
that working out-of-hours shifts or rotas remains commercially
attractive to GPs. That is why the investment that we are putting
in to out-of-hours services is rising by 150%. It is going to
cost us more to provide a service like this, and that is something
that we have taken on board and we want to try to make sure that
it reaches the front line. The issue about what happens if GPs
suddenly decide that they do not want to provide out-of-hours
services is a difficult question to deal with. What we have said
to PCTs is that in working their rotas and looking ahead they
need to make sure that they have three months' worth of GP cover
in place in any one period of time, so that if there is going
to be an exodus they can manage that sensibly. I really do not
believe that there is going to be an exodus of GPs working in
primary care. There is no evidence to suggest that from the 40
odd sites that are moving on to the new arrangements—GPs
are still willing to work out-of-hours shifts and, for the first
time, they are being properly rewarded for doing that. Those are
good things. I think the other reason why I am confident that
it is not going to be the case is that it is not altruism that
drives this, it is a dedicated view of their professional responsibilities
that drives it. All of the GPs, without exception, want to know
that their patients are going to be properly looked after out-of-hours;
all of them want to make sure that that is the case. If they are
going to work those shifts, if they are going to be part of the
solution then there is going to be a cost, and we recognise that.
I do not think any of us should underestimate the commitment that
GPs have in making sure that their patients, when they need it,
have access to proper out-of-hours services. I am absolutely confident
from all of the evidence, and from what GPs are saying to us,
that they want to be part of the new arrangements. This, in a
sense, gives me an opportunity to nail down one of the myths about
this whole argument, that in moving responsibility for organising
out-of-hours services from a practice to the Primary Care Trust
we are somehow ending out-of-hours services altogether. We are
not; we are simply moving the responsibility. We started this
questioning, Chairman, with you saying, where has been the strategic
direction? There has not been enough strategic direction. If we
want better strategic planning I think the best place to locate
it is with the Primary Care Trusts because they do have that across
the patch responsibility. If their work is being looked at by
the Strategic Health Authorities they can take a wider strategic
view as well. So we can get the synergies, we can get the joined-up
delivery between Accident & Emergency services, Ambulance
Trust, Walk In Centres, the GP co-ops and so on, but it is very
hard to do that when the responsibility is actually located at
the level of the practice. We need a different approach; we need
the responsibility to be located at a strategic place in planning
in the National Health Service and, by definition, that is above
the level of the practice. So it is not the end of out-of-hours
services. I think all it really is, is the completion of a process
in change in out-of-hours services that has been underway for
20 years, and the big change was actually, as John Chisholm said
when he gave evidence to you, maybe 15 years ago, when GPs were
given the option of delegating the responsibility to out-of-hours
providers, and most of them did that. It is a tiny fraction of
GPs who currently provide their own direct out-of-hours services.
GPs made a decision years ago that they wanted to delegate and
now we are completing that process of change with this new contract.
So it is not the end of out-of-hours; I think this is the beginning
of a new period when we can take that strategic approach and focus
through the quality standards and the extra investment that we
are putting in on improving the services for patients and not
compromising them.
Q148 Chairman: The message I got, implicitly
from the previous session, where we saw two positive examples
of local arrangements for out-of-hours services, and some might
say that the strategic level is higher than the PCT. Obviously
the SHA plays a role, but what struck me is that in the areas
that we looked you have an Ambulance Trust that initiated the
solution, and the Ambulance Trust obviously covered a larger area
than the individual PCT.
Mr Hutton: I think there is something
in that, but, as Margaret said earlier on, I think we should avoid
the temptation of assuming that there is necessarily a one-size
fits all solution to this; there will not be. My Primary Care
Trust covers a population of 350,000 people, the PCT up the road
covers 75,000; so I think it will inevitably be above the PCT
level, that is absolutely clear, in some parts of the country,
but I think that is a good thing if we want an efficient and effective
professionally delivered service that operates to clear standards.
Professor Colin-Thome: We need
to cover the out-of-hours area but really we need to have a bigger
package for what is known as "unscheduled care", which
will integrate much more with the hospitals and that sort of thing,
and for some areas that will mean above the PCT or in strategic
health to make sure that one PCT takes the lead from others, which
is a model in lots of ways of working. What our vision will be
is how does this link with other aspects of community care rather
than having a separate silo?
Q149 Dr Taylor: Turning to NHS Direct,
it is certainly proving popular with patients and we have heard
evidence of the amount it is being used. But we have had worries
expressed from A & E Departments and from GPs that rather
than reducing the load it could be increasing the load on them.
Are there any figures? Is there any comment on this?
Mr Hutton: There are and they
suggest exactly the opposite. We can certainly share with the
Committee the evidence that Sheffield University has given on
the impact of NHS Direct on Accident & Emergency Departments
and, in a nutshell, it showed that there was no adverse effect
on numbers.
Q150 Dr Taylor: So the fears that have
been expressed are unfounded?
Mr Hutton: I think they are unfounded.
I think the other issue—I know it came up when you took
evidence last time, on 24 June—was this concern (and it
is a real concern) that when one looks at the attendances at A
& E they have risen very significantly in the last year. I
would say to the Committee that we need to look at that very,
very carefully. What we do now, in measuring those figures, is
include, for example, the people who are attending Walk In Centres.
We did not previously do that. So what we try to do is to have
a better capture of the data about who is turning up for unscheduled
care and we are bringing into the data measurement things like
the Walk In Centres and Minor Injuries Unit. I think that will
largely explain that significant hike. What I do not think is
the case is that there is any evidence emerging at all yet—for
example in the five SHAs where we have the larges number of practices
who have exercised the right to opt out—that that has had
any adverse effect at all on A & E attendances.
Q151 Chairman: So the global figure that
has been bandied about on A & E is misleading?
Mr Hutton: No.
Q152 Chairman: You are implying it includes
Walk In Centres?
Mr Hutton: Yes.
Q153 Chairman: Is it possible to break
it down because that would be very helpful?
Mr Hutton: Yes, we can do that.
Q154 Chairman: We need to look at that
before we come to a conclusion because that is an issue that is
raised, as you are well aware.
Mr Hutton: We will certainly do
that; we are awash with data.
Q155 Jim Dowd: Those figures there are
not just A & E attendances, they are all non-primary presentations
as well?
Mr Hutton: Yes.
Q156 Jim Dowd: Is there any indication
that these are in addition to primary presentations or is the
number of presentations going up?
Mr Hutton: A & E attendances
have been rising; in traditional A & E Departments they have
been rising about 3 or 4%.
Ms Edwards: There are a number
of factors going on, but there are two big ones. Yes, we have
encouraged all organisations to report all their A & E attendances,
because the sort of thing that used to happen is if you had a
separate eye hospital you might not report with the figures, so
you might have a load of patients turning up with emergency eye
attendances. So we have made sure that everybody is counting on
a like for like basis, so we have a step change due to that. There
has, however, in the first quarter of this been a rise in A &
E attendances, but it has actually gone back down again, and we
are now lower—last week we had less A & E attendances
than we did at the same time last year. So these figures fluctuate
quite a bit. The key points we have been looking at what is happening
to admissions and what is happening to A & E attendances in
those places where, as the Minister has said, they have already
had large numbers opting out, and there is no pattern there so
there is no evidence. Again, CHI have looked at it, the NAO have
looked at it and Sheffield have looked at it and found that the
fears were unfounded in the terms that this would result in larger
numbers going through.
Q157 Jim Dowd: There is no indication
that these are people going to A & E or other outlets, other
than their GP—instead of?
Ms Edwards: No. We are certainly
seeing, and over time we will see, changes in trends and one of
the things that we have done very deliberately is to stop talking
about inappropriate A & E attendances, and it is about making
sure that we have appropriate responses for people. So what we
have done, for example in places like Lewisham, we have put Primary
Care Facility on the front of their A & E to recognise that
people turn up there, that is where want support, and they will
actually gear the facilities to suit them. There are a number
of factors all going on together, and it is about making sure
that we have the appropriate response in the right place. The
other thing I would say is that NHS Direct has acted as an excellent
signpost; we have had loads of research that shows that NHS Direct
has helped people to go to the right place so that—again,
using the old jargon of appropriate or inappropriate—it
has increased the proportion that were appropriate by making sure
that people go to the right place.
Q158 Chairman: On the A & E issue,
slightly off our subject today, do you have any comparative figures
proportionate to the size of the population of the use of A &
E? I am told that my own area makes a much higher use of A &
E than other areas, and I am interested as to whether you have
any thoughts on the reasons why some areas use A & E more
than others because that does have a bearing on your out-of-hours
provision and how you model the out-of-hours provision?
Ms Edwards: I do not have them
on me, but, yes, there are significant variations up and down
the country, proportionate per head of population how many attendances.
Q159 Chairman: Do you know the reasons
for that?
Ms Edwards: There are a number
of factors. Again, it depends on the primary care; it depends
on access—geographical access—to services; it depends
on whether there is a Walk In Centre or a Minor Injuries Unit.
There are so many different factors on what is available. Again,
in some of the big cities where a more significant proportion
of the population are not registered with the GPs, then we do
see more people turning up at A & E than in the more stable
parts of the country, rural parts of the country. There is also
the social class issue because in more deprived parts of the country
we tend to see higher proportions turning up at A & E. So,
again, it is demography, geography and history in a local area,
as well as the service.
Mr Hutton: One thing I would say,
Chairman, is that we are obviously very alert to the risk that
if we do not make a smooth transition to the new arrangements
it will have a potentially negative impact on A & E attendances,
and we want to avoid that at a very high cost because that is
not the sort of service that we want to provide for our patients.
Professor Colin-Thome: There is
evidence that better daytime availability will impact on out-of-hours,
and historically general practice in socially deprived areas has
been under resourced and the new contract begins to address that.
So what we are hoping—and we expect—is that better
provision of in-hours care, and in particular better in-hours
care for chronic illness, we know will have an impact on visits
generally, hospital admissions generally. So it is part of a bigger
package of in-hours development, which is where the policy is
very much taking us.
Mr Hutton: I think the new community
matrons, once their role is properly established and working across
the NHS, are likely to have a very significant impact on some
of the pressure points in the system currently around unscheduled
care, both in out-of-hours and in Accident & Emergency. So
we are trying to join up this whole picture. I know the purpose
of your Committee is on out-of-hours services, but I do want the
members of the Committee to know that we are not treating this
in isolation to other things.
Chairman: Neither are we, obviously.
There are wider issues, we appreciate that.
|
