APPENDIX 13
Memorandum by Councillor John Blacke (GP15)
1. I am the County Councillor for the Upper
Dales (since 1997), reputedly England's largest County Council
Division, covering an area of 275 square miles but only containing
a population of just 5,500 men, women and children. The Upper
Dales features some of the most remote, sparsely populated upland
moorland territory in England, part of the Yorkshire Dales National
Park, and consisting of the Dales of Upper Wensleydale, Swaledale
and Arkengarthdale.
2. I would welcome the opportunity of giving
oral evidence to the House of Commons Select Committee on Health.
I am sorry but lack of time has prevented me from submitting a
summary with my evidence. However towards the end of my evidence
you will find a list of lessons learnt and pointers to the future
that address the Terms of Reference of the House of Commons Health
Committees Inquiry into the GP Out of Hours services.
3. I would wish to say that none of the
comments I make here in any way call into doubt the commitment
or dedication to duty of all those healthcare professionals, and
particularly the on call Doctors, involved in delivering the Out
of Hours service in the Upper Dales. What is in doubt is the robustness
of the new Out of Hours service to meet the special needs of the
communities in the Upper Dales that I represent.
4. The Upper Dales feature the most acute
access to services (including healthcare services) difficulties.
In the 2000 Index of Multiple Deprivation the Aysgarth Ward was
13th worst ward out of all 8,414 in England in the Access to Services
domain. The 14th worst ward out of 8,414 was Grinton and Upper
Swaledale. Both these wards lie within the Upper Dales County
Council division.
5. As you may note from my letter heading
I am also the Richmondshire District Councillor for Hawes &
High Abbotside (since 1995), the Leader of Richmondshire District
Council (since 2000), and the Chairman of Hawes & High Abbotside
Parish Council (since 2000). I was appointed the Chairman of the
North Yorkshire County Council Scrutiny of Health Committee in
July 2003.
6. I am also a businessman, employing 10
local residents full time and 25 part time in various businesses
based in Hawes in Upper Wensleydale.
7. Unusually demography does not follow
the relief patterns in Upper Wensleydale. Whereas you may normally
expect that people living in remote rural areas to peter out the
further you go from the urban centres on the periphery and the
higher the land rises to (note that Hawes is England's second
highest Market town at 1,150 feet above sea level) this is not
the case in Upper Wensleydale where in the triangle formed by
the communities of Hawes, Askrigg and Bainbridge, right at the
far end of the Dale, there exists a block of population numbering
a little over 2,200.
8. This concentration of population furthest
from the key service centres containing the major service providers
and major provision has traditionally caused difficulties as can
be seen by the very lowly placements in the Index of Multiple
Deprivation as shown above.
9. The Upper Dales is characterised by a
low wage, low skill economy, heavily dependent on agriculture
(occupying some 25%-35% of the local working population) and tourism
(occupying some 25% of the local working population). Average
wages in the Upprer Dales are but 60% of the UK norm, but the
average price of a house is £210,000 due to the effect of
the second home and retirement home market. The unbridgeability
of this gap means it is becoming increasingly difficult to hold
on to the Dales youngsters and severe out-migration is taking
place.
10. This is resulting in an imbalance in
the local population and the Upper Dales features, at 27% twice
the National average of residents of pensionable age. This factor
is proving a heavy draw on the local healthcare facilities that
are available in the Upper Dales.
11. These facilities extend to three Health
centres to cover the local resident population, one based at Hawes
in Upper Wensleydale and one based in Aysgarth in Upper Wensleydale,
and one based in Reeth in Swaledale. Four Doctors working in partnership
cover the Hawes and Aysgarth Surgeries ("The Central Dales
Practice") and one sole practitioner works from Reeth.
12. The nearest Community Hospital is located
at Richmond, 27 miles away from Hawes. There are 12 beds available
at this Hospital, supervised by local GP's, but these beds serve
a population of around 40,000 people in all Richmondshire.
13. The nearest District General Hospital
is at Northallerton, The Friarage Hospital, 35 miles away from
Hawes. This Hospital has a 24 hour Accident and Emergency Department.
It takes just over 1 hour to drive from Hawes to this Hospital.
14. Tertiary acute care is provided at leading
Hospitals in Leeds, Newcastle and Middlesbrough. These are situated
55-75 miles away from Hawes.
15. Only in the last two years has the local
Ambulance Trust (Tenyas) upgraded the Bainbridge Ambulance Station,
which serves the Upper Dales, into a 24 hour Station. This has
led to a new Ambulance Station being built, again in Bainbridge,
and this new Station is likely become operational on 7 June 2004.
16. Despite this investment Ambulance response
times remain stubborningly difficult to increase to the Orcon
recommended level. The National Orcon Standard demands that 75%
of all emergency 999 calls are responded to in eight minutes.
For the Dales sector this response percentage languishes currently
at 59%.
17. I hasten to add that the staff on the
Dales Ambulance are universally regarded as absolutely first class
but clearly there are some huge distances to cover, poor roads
to drive on, and wild winter weather with deep snow a problem
to contend with. It is recognised that given the nature of the
territory the Orcon standard is nigh impossible to meet in the
Dales except over short periods of time.
18. It will come as no surprise then that
the two Air Ambulances serving Yorkshire very often are called
to the Upper Dales to airlift patients to hospital in an emergency.
A helicopter can reach Hawes in 15 minutes from Leeds or Newcastle
Airport (often quicker than the Dales Ambulance particularly if
it is already taking another patient on its two hour return trip
to The Friarage Hospital) and then be in Northallerton 10 minutes
later.
19. The use of Air Ambulances has increased
in recent years with the advent of born again motor bikers for
whom the Dales roads and the TT like riding experience they offer
are a magnet. Sadly several are killed or seriously injured each
year and require emergency transfer by helicopter.
20. It is important to note that Air Ambulances
cannot operate in the Dales after dark.
21. As the Swaledale Doctor was a single
Practitioner, and given that Swaledale's population is concentrated
at the bottom end of the Dale just 15-20 minutes drive from the
town of Richmond, the Practice moved into the North Yorkshire
Emergency Doctors (NYED) co-operative arrangements five years
ago and whilst there were a few teething problems, not least with
Doctors new to the area finding remote farm tracks in the middle
of the night, the system settled down well.
22. However that population of Upper Swaledale
that live furthest up the Dale (from Gunnerside upwards) have
traditionally registered not with the practice in Reeth, but with
the Doctors based in Hawes in Upper Wensleydale. This was because
the Out of Hours Service was delivered by the Doctors in Hawes
(and subsequently Aysgarth) and this brought great peace of mind
to those small very remote communities furthest from healthcare
provision.
23. In Upper Wensleydale however the Out
of Hours Service has always been delivered by the Doctors working
in the Hawes and Aysgarth Practices. When these two practices
were merged together seven years ago to become the Central Dales
Practice, the key issue was that the four Doctors involved in
the new combined Practice would continue to deliver their own
Out of Hours provision. At a public meeting attended by 600 local
residents at the time of the merger, the huge attendance demonstrating
the local concerns about the apparent reduction in local healthcare
provision, the promise that the Out of Hours service would be
handled by the Doctors in the merged Practice brought a tremendous
round of applause and a lot of smiling faces to the public hall
in which the meeting was taking place.
24. It is therefore no coincidence that
the Central Dales Practice have been the last GP Practice in North
Yorkshire (England's largest County) to continue providing their
own Out of Hours Service. The healthcare requirements of the residents
and tourists in this very sparsely populated area, the huge area
covered by the GP Practice (in all 450 square miles), the distance
from the nearest hospital, the wild weather in winter, the poor
roads and above all else the need to provide peace of mind amongst
the local population demanded that there be a unique soloution
to a unique set of deeply rural circumstances.
25. With the impending implementation of
the new GP contract the Central Dales Practice announced late
in 2003, in conjunction with the Hambleton & Richmondshire
PCT (H+R PCT), that it would join the NYED Out of Hours co-operative
from 1 April 2004 and from that date give up providing its own
Out of Hours service.
26. The Central Dales Practice gave as its
reasons for this change that its Doctors wanted to be free from
the ties of providing their own Out of Hours cover, the difficulty
in retaining and recruiting Doctors in rural practices (although
there had been no problems in the Upper Dales where its five Doctors
have been resident for five years or more), the fact that 80%
of GPs nationally wanted to opt out of providing their own Out
of Hours cover, and finally that Central Government through the
new GP contract would impose an accreditation cost of £250,000
for practices wanting to continue their own Out of Hours Service.
27. Subsequently issues around the accreditation
cost were clarified by the H+R PCT when it made clear that whilst
the Central Dales Practice could have carried on providing their
own Out of Hours Service without incurring this accreditation
cost their Doctors no longer wanted to continue their own service.
28. Whilst local residents understood the
personal reasoning behind the decision of their Doctors to give
up providing their own Out of Hours service it is fair to say
that there was generally a high level of disappointment felt within
the community when news of the changes were announced. Many residents
felt they were to an extent being let down by their own Doctors,
especially as there were on average only between two and six calls
made each week by the Central Dales Practice Doctors at homes
out of hours.
29. The new Out of Hours Service required
residents to ring either the Hawes or Aysgarth Surgery and then
being given another number to ring (the NYED Call Centre in York).
Eventually this would lead to a call from the on call Doctor to
the patient. The Out of Hours Doctors would be based at Catterick
Garrison, 25 miles away from Hawes. There would be a satellite
Out of Hours Centre established at Aysgarth Surgery to be used
at the Doctor's discretion. It was made clear that the new Out
of Hours service would lead to more patients having to travel
to see the on call Doctor at the expense of them being seen in
their own homes. A free taxi service to carry those patients unable
to provide their own transport to the Out of Hours Centre would
be available.
30. Generally there were misgivings when
the new GP Out of Hours service arrangements were announced. The
main issue was the journey from the top end of Upper Wensleydale
to Catterick Garrison (20-32 miles in distance), especially if
it was to be undertaken at night or in winter conditions, when
undoubtedly it could be perilous. Having driven down the Dale
which is difficult enough at times in snow or ice the route then
takes you over the high level "tank" road across the
Catterick Garrison Army training moors, very often enshrouded
in thick fog, desperately dark and particularly lonely.
31. Two other issues were the loss of the
Saturday morning urgent case only walk in Surgeries at Hawes and
Aysgarth which were abandoned as part of the new Out of Hours
arrangements and concerns about where the Dales Ambulance would
be stationed during the Out of Hours service times given that
the nearest Doctor in future would be 25 miles away rather than
based living within the Dales communities.
32. The Chief Executive of the H+R PCT had
attended local Parish Forum meetings which were well publicised
in the local Press. He was quoted as saying the answer to the
"wicked" issue of the new GP Out of Hours service was
the use of Aysgarth as a satellite centre. Whilst saying the final
decision as to when to use Aysgarth rested with the on call Doctor
the message to local residents was that its use would feature
in most of times when Upper Dales residents were asked to travel
to see the Doctor. Undoubtedly this message was very re-assuring
in the Dales communities.
33. The new Out of Hours service began on
1 April 2004. 14 days later concerns about the robustness of the
new Service exploded throughout the communities in the Upper Dales,
and these spilled over into the local Press. The contrast between
the Out of Hours service the Dales had enjoyed before, and the
new Service placing the Doctor on call 25 miles away was simply
too great once a few examples of how it would work in practice
became known amongst local people. There was a series of incidents,
each not particularly significant in themselves, but taken together
a considerable tour de force, where the new Service did not appear
to meet the needs of the residents and tourists it was there to
serve.
34. A local resident who cut his hand having
to drive to the Friarage Hospital in Northallerton whereas before
he would have been attended by his local Doctor, a death at home
where the on call Doctor told the bereaved wife to call the Police
where in the past again this would have been dealt with by the
local Doctor, a young mother having to drive all the way from
Hawes to Catterick Garrison at 3.00am with an severely asthmatic
child in a car that was very low on petrol: these and other examples
unnerved the local community and caused a crisis in confidence
in the new Out of Hours service.
35. In short the local resident's peace
of mind in their healthcare provision, so essential when you live
so far away from a hospital, had been taken away.
36. William Hague MP, our MP here in the
Upper Dales, spoke in Parliament specifically about the effect
of the new GP Out of Hours service on Upper Wensleydale during
the Debate held in April on the new GP contract.
37. A local Parish Forum was arranged to
take place on 5 May 2004 in Hawes in Upper Wensleydale. As Chairman
of the Forum I took the opportunity to arrange for all the key
individuals and organisations involved in the delivery of the
new Out of Hours service in be present. 120 members of the public
attended, giving an idea of the depth of concerns held in the
local community. The usual public attendance at a Parish Forum
is numbered on the fingers of one hand.
38. By now the National Media had become
interested in the issue and Mark Handscombe, of the Radio 4 You
and Yours team (from Manchester) was present at the Parish Forum
to record the proceedings. Extracts from the Parish Forum and
key interviews were later broadcast on Radio 4 on 12 May 2004.
39. All the community concerns that I have
tried to put across in my evidence here were put forward by speakers
from the floor in what was always going to be a meeting of utmost
importance. Whilst the healthcare professionals tried to put across
their new GP Out of Hours Service in the best possible light it
is fair to say that they failed and the audience went home unconvinced.
40. I re-emphasise the point that the contrast
between the old and the new Out of Hours system is too great to
make the new a saleable proposition when compared with the old.
41. Their case was not helped by the suggestion
from some of the healthcare professionals that the local media
had whipped up community dissent when plainly the concerns of
local residents were written in the faces of those attending the
meeting.
42. The Parish Forum heard that out of 26
cases where local residents had been called down to see the GP
Out of Hours Doctor, only three had been seen at Aysgarth and
the remaining 23 had been require to drive all the way to Catterick
Garrison. This was hugely disappointing news to the audience and
a contrasting message to that put out by the Chief Executive of
the H+R PCT in advance of the new Service starting.
43. However pressure of public concern had
resulted in an improvement in contacting the on call Doctor with
one step in the elaborate communications process being cut out
and this was announced at the Parish Forum.
44. Subsequent to the Parish Forum I wrote
to the Chief Executive of the H+R PCT and outlined 10 Points on
which receipt of his positive replies might begin the task of
restoring the confidence of the local communities in the new Out
of Hours service.
45. Most of the 10 Points have been answered
positively and for example it would appear that the use of Aysgarth
Surgery will feature more in the future than so far to date, there
is a guarantee that the Dales Ambulance will be stationed in the
Dales during Out of Hours service times, a waiting room will be
provided at Catterick Garrison for people who have travelled down
from the Dales to see the on call Doctor in the event of the Doctor
not being present when they arrive at the Centre (previously they
were having to wait in their car behind the wire in an Army Garrison,
hardly a welcoming or re-assuring place to wait particularly with
an unwell companion) and the free taxi service to Catterick Garrison
will be provided by a Dales taxi company thereby cutting down
the delay to patients in seeing a Doctor down to a minimum.
46. Most importantly statistics about the
new Out of Hours service and particularly the use of Aysgarth
surgery will be provided to me on a monthly basis which I will
pass on to the local community.
47. I have welcomed in the Press and local
Radio what seems to be steps in the right direction in providing
a GP Out of Hours service that meets the needs of the local communities
in the Dales (and its tourists). The key issue will be careful
monitoring of the statistics and anecdotal community information
over the next few months to ensure the promises made on paper
by the H+R PCT turn into reality.
48. If the promises do materialise local
communities will undoubtedly be re-assured and their confidence
will return.
49. What will not return in full will be
their peace of mind because the new Out of Hours service can never
be as good as the old service it has replaced. How can placing
a Doctor 25 miles away during Out of Hours ever be as good as
having your own Doctor delivering the service from just down the
road?
50. The new Service cannot overcome the
dimensions of distance and delay so intrinsic in an area like
the Upper Dales.
LESSONS LEARNT
AND KEY
POINTERS FOR
THE FUTURE
(a) The problem has been a "one size
fits all" approach and culture to the provision of the GP
Out of Hours service. This will not provide a service that meets
the needs of sparsely populated, deeply rural communities which
will require a bespoke solution to a unique set of circumstances.
(b) PCT's working closely with their healthcare
professionals and representatives in the local communities need
to plan very carefully in advance the Out of Hours services for
those communities. Imposing a Service from above or from away
will not secure the confidence of the residents in those local
communities. The new Service should be seen to work perfectly
from Day One rather than have to need tinkering as it is put into
practice. Maps to the Out of Hours Service Centres, proper waiting
facilities, simpkle connections to the Doctor on call and the
like should all be anticipated and ready and available as the
Service is introduced.
(c) PCT's need to win the confidence of the
Doctors who are to operate the new Out of Hours services. It is
plainly the case that although PCT's are to be in charge of the
GP Out of Hours services from 2005, the drivers for making the
system work lie with the on call Doctors themselves. This may
lead to conflicts between what the PCT's are saying in public
about the new Out of Hours Services and what is actually happening
on the ground.
(d) GP co-operatives running Out of Hours
services need to be more accountable to the public than they currently
are. Only then can the communities directly input into the shape
the services they are to receive. Despite commissioning their
services so far it appears PCT's will be toothless tigers when
it comes to regulating GP co-operatives.
(e) Clearly in rural areas the loss of the
Out of Hours service from the local GP practices and its replacement
with a Out of Hours Centre some or many miles away is going to
put an additional strain on particularly the Emergency Ambulance
service and the A&E Services provided at the nearest Hospital.
Ambulances take much longer to complete a rural transfer of a
patient than an urban transfer. This may well lead to increased
pressure for Air Ambulances to be financed by the NHS.
(f) The public perception of the quality
and robustness of the new arrangements for GP Out of Hours services
will diminish the further you travel away from the location of
the Out of Hours centre. Rapidity of response and provision of
backup become real issues of public concern when you are 25 miles
away from the Out of Hours Centre and 35 miles away from the nearest
hospital. It is important to consider satellite arrangements so
that an Out of Hours centre can be nearer the population it serves,
even if it is only used on a part time basis as and when required.
It is also important that when a Chief Executive say a satellite
centre is to be used he or she secures the co-operation of the
on call Doctors in the GP co-operatives to ensure it is used!!
Credibility in the eyes of the public in NHS Trusts and PCTs is
all important, it takes years to build up and can be lost overnight.
(g) Arrangements for monitoring Out of Hours
services are all important and need to be very robust, and the
statistics produced by the monitoring made available in the public
domain. This should flow as an advantage from the PCT's commissioning
the GP Out of Hours services from 2005 onwards.
(h) The implications for a rural and deeply
rural area is that inevitably the new GP Out of Hours service
will be seen as a degradation in the NHS unless special arrangements
are made to overcome the dimensions of distance and delay and
the feeling that, as with all other provision in these rural areas,
services are yet again retreating to the distant and far distant
towns.
June 2004
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