Examination of Witnesses (Questions 160-179)
8 JULY 2004
RT HON
JOHN HUTTON
MP, PROFESSOR DAVID
COLIN-THOME
AND MS
MARGARET EDWARDS
Q160 Dr Naysmith: I have to pick you
up on community matrons. The power of the matron in the old days
was that she was unique—or he, occasionally—and really
respected. This is a complete sideline to this inquiry, but do
you not think you are making too many matrons?
Mr Hutton: I do not think you
can ever have too many matrons! I love matrons, that is all I
will say about that! It is a very serious question and I think
the role of these new advanced nurse practitioners in the
community is the thing that we should focus on; it is what they
do that is going to count. We know from the work that we have
done, which we are very happy to share with the Committee, that
we have maybe up to a quarter of a million chronically ill people
in the community, who make up a significant usage of, for example,
A & E and inpatient resources. We obviously do not want to
deny anyone access to a hospital when they need it, but neither
do we want a state of affairs where that is the only option. If
you ask people what they really want they will say they want to
be independent, they want to be looked after properly at home.
If we can get this right it is not just attendances at A &
E or pressure at hospitals that we make a contribution towards,
it is making a contribution here too in terms of primary care
and out-of-hours services because these people make very heavy
use, as you can imagine, of out-of-hours services and primary
care too.
Q161 Dr Taylor: Just briefly going back
to NHS Direct, living in a semi-rural area with a first class
GP co-operative, my impression is that NHS Direct is less needed
in rural areas with good co-operatives than in urban areas. I
put that to Mr Lester of NHS Direct previously and he felt there
was no evidence that it was used less in semi-rural areas. Is
that your understanding?
Mr Hutton: I think that is our
opinion.
Q162 Dr Naysmith: Carrying on with the
NHS Direct tack, you have already heard that many of our witnesses
have expressed a profound lack of confidence in the ability of
the NHS Direct to handle out-of-hours calls. We have heard some
fairly stringent things said and the NAGPC told us that they did
not believe that "without radical change in culture and organisation
NHS Direct will ever be able to safely front all primary care
out-of-hours calls". Is that a reasonable question? One GP
co-op said that it would not use the NHS Direct in its current
form, as it feared this would lead to worse outcomes for patients.
The concerns seemed to centre around capacity, response times
and referral levels. It is quite clear that the NHS has to improve,
so how are you going to make sure that it does?
Mr Hutton: Let me say one or two
things in relation to that and maybe Margaret will deal with it
in more detail. We have 34 sites across the country which cover
20% of the population, where the first point of access in primary
care and out-of-hours services is through NHS Direct. Then obviously
the call goes down to the local GP co-op provider and then they
will make the visit. I think generally those arrangements are
working well. There will be times when something goes wrong in
the system, unfortunately—that is likely to happen—but
I do not think that there is anything inherently wrong with the
model. I agree that if we are going to extend the service, clearly
by definition NHS Direct will need more capacity, and we are building
that in so that by 2006 it will have the facility, the technology
and the people to run a fully clinically integrated out-of-hours
service, if that is what Primary Care Trusts locally want to use.
But we have never said to Primary Care Trusts that they will have
to have all of their out-of-hours services commissioned through
NHS Direct. It is there for them to use if that is what they want.
I think that is a sensible thing to do. I think Margaret will
have more information in relation to the specifics about NHS Direct
and its plans to expand.
Ms Edwards: NHS Direct is doing
a million out-of-hours calls at the moment, and it is doing those
very successfully and, again, the evaluations that we have had
done at Sheffield University, which we are happy to share, endorse
that, as does the NAO report. I have a lot of evidence that we
can provide on the 34 exemplar sites, and I have some quotes here.
For example, a GP saying, "I am always very impressed with
the professionalism of NHS Direct," and another one saying
that the involvement and integration in NHS Direct has been excellent
for them. So we have a large number of these exemplar sites saying
that it has really worked. In terms of statistics, 25% to 40%
of calls are what the exemplar sites are identifying that NHS
Direct saves the GP from getting involved in. So there is real
and solid evidence now that NHS Direct has reduced the pressure.
Q163 Dr Naysmith: That is an area where
the statistics are not very clear and different people say different
things. So if you have good university based evidence we need
to see that.
Ms Edwards: There are two lots
of statistics, looking at previous evidence, which we need to
be clear about. One is normal NHS Direct calls and what proportion
of those end up getting referred to a GP, through the normal work
of the NHS. And when people ring up the 0845 number and ring up
NHS Direct, as opposed to ringing up their out-of-hours GP service,
what happens is that about 6 to 10% of patients get referred to
A & E or to an ambulance, so those are groups of patients
who may not otherwise have had appropriate care. So one of the
things that NHS Direct certainly does is to pick up people who
might have had unmet needs. Sometimes they need an ambulance.
So there is a whole piece of work where NHS Direct is very successful.
The NAO report suggested that about 50% of the NHS' costs were
being offset by the savings it made to the rest of the Health
Service. Again, there is a lot of evidence that the 0845 number
is working really well and has for a long period. The out-of-hours
is obviously a newer service. The evidence we have there is the
exemplar sites. We are due to have a full report on the exemplar
sites at the end of July, but the early evidence is saying that
25% to 40% of the pressure is what they take off the GPs who are
using it. So, again, very solid. The next stage is to go from
one million calls to six million calls ultimately in 2006, and
that is the big step that the Minister was referring to that we
need to gear up the NHS Direct to do. So what it is doing now
it is doing well, and the next big challenge is to escalate that
up with a very significant increase in the number of calls and
attendances.
Mr Hutton: We will share with
the Committee the research into the exemplar sites.
Q164 Dr Naysmith: It is a bit of a chicken
and egg argument here because you want to expand NHS Direct and
improve various aspects of it, but at the same time, as we heard
this morning from Hull and East Anglia, there are alternative
solutions being laid out, and these people are not going to want
to transfer back to NHS Direct if you have these centres as well.
Mr Hutton: They will not have
to.
Q165 Dr Naysmith: At the same time you
are pouring resources into NHS Direct to make it better for everyone
and at some stage you have to get that balance right.
Mr Hutton: I do think we need
to get the balance right, but if people are happy with the call
centre and call managing service that the local Ambulance Trust
might be providing as part of a local out-of-hours service, then
they are perfectly free to stick with it. What we know from the
exemplary sites is that NHS Direct can provide a very, very good
service and we are trying to make sure that it can do that for
everyone who wants to use it.
Ms Edwards: Just to add to that,
the money that we are pouring in we are pouring in via the PCTs,
so PCTs are holding the budget to purchase NHS Direct. Obviously
if it decides it does not want to go down the NHS Direct solution
it can, via that money—
Q166 Dr Naysmith: They can use it on
something else?
Ms Edwards: The only criteria
are that the organisation they employ has to meet the national
quality standards and has to be within reasonable costs. That
would be our criteria for them. But if they chose to use their
money differently and it was more appropriate, subject to the
SHA and those criteria, they can do that.
Q167 Mr Amess: Just to sort of spoil
this rosy picture, the British Association of Emergency Medicine
has expressed concerns about GP out-of-hours services, and they
have said: "The impact on Emergency Departments could be
very serious and may well affect us achieving our 4-hour target
times unless the re-provision of out-of-hours services is handled
swiftly. The view from our members across the country is that
the provision of GP out-of-hours services is patchy and may be
inadequate to cope with the numbers of primary care attenders."
Then another witness has said that the increases in A & E
attendances are very hard to reverse—"As yet, there
has been no initiative, as has been shown, ever to decrease attendances
at emergency departments." There we have Victor Meldrew,
no doubt!
Mr Hutton: I thought we had partly
addressed the issue about the figures about A & E attendances.
I think we need to treat them very carefully. As I explained,
the reason for this is very largely attributable to the adding
into the figures of people who are attending Minor Injuries Units
and Walk In Centres. I think where I agree with the Association
is this, that of course if we do not get the provision there is
always going to be a risk that people, because they need the care
and treatment, will turn up somewhere else in the system. So we
have to manage that risk and make sure that we anticipate it and
deal with it. I agree with them too, as you would expect, and
as I made clear earlier, of course it is true to say that now,
leaving on one side the new arrangements, that we have all, as
Members of Parliament, have had concerns and complaints from our
constituents about the existing service. So it is not part of
my argument today to say that the existing service is as good
as it can be; that is absolutely not my argument. I think we can
make out-of-hours services significantly better if we take the
advantages that the new contract provides, the additional resources
and the strategic planning focus on developing new services and
involving skills and talents of other members of the healthcare
community—nurses and others as well—and providing
a more tailor-made and better service. We are trying to build
up services during the hours we would say are not out of hours,
and we have talked about community matrons. Yes, of course there
are risks, but I do not see any evidence at all—and I have
to say this bluntly—to suggest that that is what is happening
today, and I do not accept that. If you or anyone else has any
evidence to suggest to the contrary I would be very interested
to see it.
Q168 Mr Amess: Would you just say something
about how witnesses have been adamant that the best way to counteract
all this is through a concerted public education campaign? How
could this be done and do you think that is the right approach?
Mr Hutton: I think it is very
important—and again I said this earlier—that whenever
there is a change in the way the service is organised, and particularly
against the background of some of the very unhelpful comments
that have been made in the Press about this, that we have to deal
with a concern that many people will have that, somehow, from
1 April or some time later this year, there will be no out-of-hours
services and they will not be able to get a GP. We have to deal
with that and we have to deal with that by telling people clearly
that the arrangements are continuing; that if they need to see
a GP out of hours they can see one. I think it is the responsibility
on behalf of the local NHS and everyone who works in it, to make
sure that patients use the most appropriate service. That is a
job that we have to discharge, that is one of our responsibilities
as an organisation, and I think that every effort that we put
into doing that and communicating that sense of what is the appropriate
service for patients to use, is a good thing for us to do. Yes,
there will be some expense around that, but if that helps us make
more efficient use of our services then it is money worth spending.
Q169 Mr Amess: Are there any plans for
TV advertising on this, or is it going to be done through leaflets,
word of mouth, speeches?
Mr Hutton: I do not think we are
planning a big TV advertising campaign because I know what you
guys would make of that—that it is all propaganda! There
are campaigns locally and nationally and we have a Use The
Right Services campaign, and we will continue to do that,
but we are not planning any big TV-based campaign advertising
what the new services are.
Professor Colin-Thome: We have
that campaign, but also it is quite rare for people to access
these services, so what they need is access to something when
they need it. Just learning all this stuff about the change in
the Health Service does not impact on people who need it. So the
issue is that things like NHS Direct are a good place to signpost
them when they may need the service.
Q170 Jim Dowd: Just briefly, on looking
at the impact on other parts of the Service, you mentioned in
the Memorandum, "An integrated system of out-of-hours provision,
covering all unscheduled care services would have the potential
to reduce patient demand for in-hours services." The other
side of that is that if it is not established, if they are not
effective services, then the reverse of that could also be true;
is that right? It would not just impact on A & E; it would
actually reverberate back to the GP service itself?
Mr Hutton: My personal view is
that there is a risk of that. Remember that the big picture has
various bits of it to make up the whole. Automatically, if one
part of that service is not working properly the negative impact
is going to show and can show across another range of services
in our Primary Care, Walk In Centres and A & E. Whereas our
argument is that if we get it right it can have a positive effect,
but, of course, if we do not get it right, if the service is not
sufficiently comprehensive, then it will show up in different
parts of the Service. When someone makes the call, they want treatment
and care, they need it from someone, they need it from somewhere
in the system, and our job is to make sure that they get it at
the right time from the right person. The demand is there, that
is the fundamental issue here, and it is a question of how you
deal with it.
Q171 Jim Dowd: But it is extremely unlikely
that it would just hit the balance where it had a benign effect,
where it did not impact positively on anything?
Mr Hutton: I think that is right.
Q172 Mr Jones: Minister, I am meant to
ask you some questions about community hospitals, but before I
do can you tell us what community hospitals are?
Mr Hutton: It is one of the odd
things about the Department, that we do not have a definition
of a hospital, and until recently I do not think we knew how many
hospitals we had. I think it was under the previous administration
that we stopped counting hospitals because they kept closing them!
A community hospital obviously is a local service that is not
providing a full range of trauma and surgical facilities. There
may well be some inpatient, outpatient facilities there, and a
combination of any minor surgery and medical beds, and there will
either be operating staffed by doctors from the hospital or a
mix of hospital doctors and GPs. I think it was Churchill who
said that none of us could define what a rhinoceros is but we
know one when we see one! I think that is the best I can do for
a definition of a community hospital.
Q173 Mr Jones: That is a shame really
because that does not help us define where the problem lies. If
I could try and narrow the range? Those hospitals that are working
almost entirely with the doctor support being from primary care,
that is the area that is of concern.
Mr Hutton: The contractual arrangements
there are not part of a doctor's primary care contract. So, if
a GP is providing medical cover in one of those sorts of units,
that is paid for through the Acute Trust, through the hospital;
the hospital doctors have contractual arrangements and they will
be paid separately, in other words outside of their own contract
as a GP, to do that. So there is nothing in the new contract,
either in substance or specifically to out-of-hours that has a
direct effect on the work that GPs do in community hospitals.
They get paid for that work over and above anything that they
are paid for in terms of their contract.
Q174 Mr Jones: The BMA tell us, absolutely
full of doom and gloom, on community hospitals that it is meltdown;
that you have to get a grip of it and if you do not then the whole
community hospital problem will get out of control. The new out-of-hours
arrangements mean that GPs will give up working within the community
hospitals and the community hospitals will close unless—and
I am paraphrasing, but I am not really exaggerating—the
Government comes to some negotiated settlement about how GPs will
be paid.
Mr Hutton: If a patient is in
a bed in a community hospital the funding of that has nothing
whatsoever to do with the out-of-hours funding; it has nothing
to do with the GP's contract. It is the hospital budget that arranges
for the care and provision of treatment for a patient in that
setting. So it is nothing to do with the new contract. I know
people have tried to link the two things but, historically, factually
and financially, the two things are totally separate. Clearly
the BMA may have some concerns about the rate at which GPs are
remunerated when they are providing medical services in the community
hospitals, and we have asked the NHS Confederation to take forward
its work in scoping the size of the problem and then coming to
a view about whether they want a new national pay, terms and conditions
package in relation to all of this. I think that work is going
to be completed in October and, if my memory is correct—obviously
I will correct this if it is not true—it was the view of
the Doctors and Dentists Pay Review Body who suggested to us that
that is precisely where these discussions should be leading.
Q175 Mr Jones: They tell us that if the
issue is negotiated, as you suggest, this could take up to three
years to resolve, by which time the community hospital problem
may have got out of control.
Mr Hutton: I have no idea where
they get that figure of three years from, no idea at all.
Q176 Mr Jones: They also told us that
what you should do is be proactive like the Welsh Assembly and
negotiate a deal with the doctors.
Mr Hutton: Let me reflect upon
that.
Q177 Mr Bradley: We have touched throughout
the session on finance and it is quite clear that the Government
has put extra money into improving the out-of-hours services through
a variety of routes. But we have had a great deal of evidence
to suggest that there is still a shortfall in the budgets for
PCTs in this particular area of work, with an estimate of £200,000
per PCT. How would you respond to that claim?
Mr Hutton: I am puzzled by it
because it is the first time that has been put to me. When that
evidence was submitted to the Committee it came as a surprise
to me because that is not what the evidence would seem to indicate
from the 40 areas where these new services have been put in place.
We have put in significant additional resources. I think there
will be problems. There may well be problems in some parts of
the country with this, almost as you would expect, and those problems
may well reflect historical issues and difficulties in recruitment,
for example. That is why some of the money that we have allocated,
we have focused on those parts of the country where we anticipate
that there will be additional costs in running the new service,
particularly in those areas where there is an issue about rurality,
remoteness, and so on, and we have targeted additional help to
those PCTs where we think they will face additional costs. I have
no evidence to suggest at all that that figure of everyone being
£200,000 short is anywhere near an accurate assessment of
the situation—no evidence at all.
Q178 Mr Bradley: You are confident that
they have got enough money?
Mr Hutton: I think they have a
significant amount of additional money, yes, to fund this. Not
only that, some of the money—and we do not include this
in the £316 million being made available to fund out-of-hours
services this year, because there is another element that £30
million worth of incentives that go with that too. If the Primary
Care Trusts can demonstrate some robust and sensible plans are
in place and progress in implementing them by the year end, each
of them will get another £100,000. So, with respect, I think
this is something that obviously we need to keep under careful
review, and it will be the job of the SHAs in the first instance
to deal with any financial pressure that arises. I think we need
to see this in context. Primary Care Trust has a budget of £100
million and there is maybe £200,000 pressure, that is 0.2.%
of the budget. I am not saying that that may not be a serious
problem for a PCT at a local level, but we need to keep a perspective
on this. If that is a risk that is being run financially I think
that is well within the tolerances of financial good management
within a Primary Care Trust to deal with. I think we have done
our bit; we have put 150% more cash in; we have incentives to
back good and sensible planning at a local level, and we are trying
to keep a close eye on it to deal with those issues that come
up. I have no way of confirming the accuracy of those figures
because they are new to us and they do not seem to be the pattern
and experience by the Primary Care Trusts who are now operating
these new arrangements. David might be able to speak about the
arrangements in Cheshire, where I think all the PCTs have opted
out.
Professor Colin-Thome: From the
evidence in Cheshire that has not been a particular issue. They
have managed to find money for the out-of-hours provision. They
have to model it over time to get more skill-mix, as I said, over
a gradual phase, and train more people, but even in the short-term
where there is more GP element in the service that has not been
the case. There is no doubt that some PCTs may have these, but
I do not think it is a systematic thing by any means.
Q179 Mr Bradley: I think it is only right
to share with you the fact that the Office of National Statistics
this morning admitted that they missed 26,000 people in Manchester—26,000
more people who need out-of-hours services than others, and presumably
money will flow to compensate for that!
Mr Hutton: Possibly! On that issue,
I think there is a very important question for us in terms of
Primary Care Trusts' allocations and how we deal with issues of
population growth. Because of the success of regeneration in Manchester
it is bringing more people into the centre of the city, and that
is true in many other areas. Historically we have always followed
behind that so our PCT allocations have never actually, in some
cases, kept up or anticipated population growth, and we need to
anticipate more if we are going to have three-year allocations
that are actually meaningful and helpful. That is work that is
underway in the Department, so we are trying to help PCTs with
some of that sort of cost, and if the population is growing in
Central Manchester, which it is, and because PCT funding is per
capita, clearly there will be a point where that catches up, but
sometimes it is too slow, and in the meantime there is clearly
pressure.
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