UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 697 - i

House of COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE

HEALTH COMMITTEE

 

 

GP OUT-OF-HOURS SERVICES

 

 

Thursday 24 June 2004

DR JOHN CHISHOLM, DR RUTH LIVINGSTONE, PROFESSOR DAVID HASLAM,
DR MARK REYNOLDS, DR MIKE SADLER and MR MARTIN SHALLEY

Evidence heard in Public Questions 1 - 70

 

USE OF THE TRANSCRIPT

1.	This is an uncorrected transcript of evidence taken in public and reported to the House. The transcript has been placed on the internet on the authority of the Committee, and copies have been made available by the Vote Office for the use of Members and others.
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Oral Evidence

Taken before the Health Committee

on Thursday 24 June 2004

Members present

Mr David Hinchliffe, in the Chair

Mr David Amess

John Austin

Mr Keith Bradley

Jim Dowd

Mr Jon Owen Jones

Dr Doug Naysmith

Dr Richard Taylor

 

________________

Memoranda submitted by British Medical Association, NHS Alliance,
Royal College of General Practitioners, National Association of GP Co-operatives, Primecare and British Association for Emergency Medicine

 

Examination of Witnesses

 

Witnesses: Dr John Chisholm, Chairman, General Practitioners Committee, British Medical Association, Dr Ruth Livingstone, NHS Alliance, Professor David Haslam, Chairman of Council, Royal College of General Practitioners, Dr Mark Reynolds, Chairman, National Association of GP Co-operatives, Dr Mike Sadler, Medical Director, Primecare, Mr Martin Shalley, President, British Association for Emergency Medicine, examined.

Q1 Chairman: Colleagues, could I welcome you to this session of the Committee and welcome our witnesses and express the Committee's thanks for their willingness to join us today to give evidence. Before you introduce yourselves, could I say that we are hoping to conclude this session in time for us to get into the Chamber for the statement on the NHS White Paper. I anticipate we will conclude probably around 12.15. One of the consequences of that is that the session will be a bit briefer than normal. It would be helpful if witnesses did not feel they had to answer every specific question. Obviously there will be some you will want to answer and some not. I am sure you understand what we are hoping to do. Could I ask you each briefly to introduce yourself to the Committee.

Professor Haslam: I am Professor David Haslam. I am the Chairman of Council of the Royal College of General Practitioners.

Mr Shalley: I am Martin Shalley, President of the British Medical Association and Consultant in Emergency Medicine at Birmingham Heartlands and Solihull.

Dr Reynolds: I am Mark Reynolds. I am Chairman of the National Association of GP Co-operatives and Joint Medical Director of On Call Care, which is the first of the new mutual Community Benefit Society out-of-hours' providers to be registered.

Q2 Chairman: Are you still practising as a GP?

Dr Reynolds: I am a full-time GP, yes.

Dr Chisholm: I am John Chisholm. I am currently the Chairman of the BMA's General Practitioners' Committee which represents all NHS GPs.

Q3 Chairman: In your spare time, you do a bit of practising as well.

Dr Chisholm: A bit!

Dr Livingstone: I am Ruth Livingstone. I am representing the NHS Alliance. I am a GP and I am also Chairman of a PCT.

Dr Sadler: I am Dr Mike Sadler. I am the Medical Director of Primecare, which is the largest single provider of out-of-hours services in the UK.

Q4 Chairman: Is your background as a GP?

Dr Sadler: Yes, it is.

Q5 Chairman: Obviously this inquiry is looking specifically at the current situation and concerns about the future situation in relation to out-of-hours cover. It would be helpful from my point of view, probably from the point of view of one or two of the members, if one of the witnesses was able to paint a bit of a history as to how we have got to where we are now. Obviously, there has been an evolution and different forms of provision over the years since we have had a national health service. Does anyone feel able to give us a brief, colt-sized, potted history as to how we have got to where we are now?

Dr Chisholm: Shall I have a go? Traditionally, certainly if you look back to 20 years ago, general practitioners did their own out-of-hours work, either, if they were single-handed, literally doing it themselves, or, more commonly, if they were in a partnership, doing it in rotation with their partners or sometimes in an extended rota with perhaps another practice or two. However, from certainly the mid-sixties onwards, there were significant numbers of general practitioners who made use of a commercial deputising service which historically was the predecessor of Primecare. From the early eighties there has been a development of GP out-of-hours co-operatives, which were small in number until the early to mid-nineties, when, particularly as a result of developments in Kent - the original co-operatives had started off in the North-West of England - there was a great burgeoning of co-operatives, helped particularly by major negotiations that took place in the mid-nineties which ended up in the establishment of an out-of-hours development fund to help the local primary care organisations and GPs develop alternative models of provision. There was a major trend towards care delivered by organisations above the level of the individual practice and also towards more premised-based care, so that when somebody rang asking for help out of hours, they would either receive advice over the phone or be asked to come down to a primary care centre to be seen or be given a home visit if that was what they required or be referred directly to hospital by an emergency ambulance. From the mid-nineties onwards, the great majority of general practitioners have either been members of a GP out-of-hours co-operative or have used a commercial deputising service, and only a relatively small minority of doctors have, either by choice or because of geographical isolation, continued to provide a practice-based service. That really takes us up to 1 April this year, when the possibility of transferring out-of-hours' responsibility to the primary care organisation became an option, and sometime between 1 April and 31 December, except for a very small number of doctors in very isolated and remote communities, doctors will be able to transfer the practice's responsibility by agreement with the primary care organisation if that is their wish. The reason that change was made was because, in negotiating the new GP contract, all the negotiating parties, the NHS Confederation, ourselves and the health departments came to perhaps the rather sad realisation that one of the things that was putting young doctors off coming into general practice, becoming general practitioners, was the 24-hour responsibility. Therefore, if that could be addressed, we might be able to get more of the general practitioners we need.

Q6 Chairman: That is very helpful. Does anybody want to add to that at all?

Dr Sadler: As Dr Chisholm suggested, some doctors sought to contract out-of-hours care really 30 to 40 years ago and it is fair to say the majority of the cases in which that happened were in urban areas, often with quite high levels of deprivation and quite high health needs, and, as you will see from our written evidence, we continue to provide care most often in those urban areas where needs are highest.

Professor Haslam: I think it is important to stress the real workforce recruitment crisis that has faced general practitioners. As I hope and expect the Secretary of State will make clear today, primary care is absolutely central to the future development of the health service, and yet, for the last five years at least, the General Practitioners Committee of the Royal College have made repeatedly clear that there is around a 10,000 shortfall in the number of GPs required to offer the sort of standard of service that the nation's patients deserve and it is very clear that the responsibility of the out-of-hours care - not necessarily the doing of but the responsibility of - was a major turnoff for two main reasons. One is the demographic changes in the workforce, an increasing number of women doctors and male doctors who wish to work part time. That is my second point as well: that it is not just the women but it is the fact that the men want as good a life - in fact a life - that has changed recruitment fundamentally.

Q7 Dr Naysmith: The actual change is not as fundamental as it seems to most people outside of your profession, because, as you describe it, Dr Chisholm, in fact most GPs are already not directly fulfilling their role out of hours. Although they remain responsible for 24 hours, that responsibility has now been taken away, but it should not make all that much difference in all that may different places.

Dr Chisholm: For a patient using the service, they will not notice a great change. If anything, the greater change occurred particularly in the mid-nineties.

Q8 Dr Naysmith: That is what I am saying, it has already occurred. This is kind of marking by financial responsibility measures being introduced.

Dr Chisholm: Yes, indeed. The chances of a patient seeing their own doctor out of hours - they still sometimes do by chance - are really now quite low and have been for a number of years.

Dr Reynolds: I think in fact there is an enormous change in the culture of responsibility that is occurring because of the new GP contract. I would wish it to be the case, as you put it, that in fact, in 70 per cent of the country - the more difficult to cover areas, the more rural areas, perhaps the more expensive areas, where GP co-operatives are working - the 24-hour responsibility has been the glue that has held those organisations together: one GP working on behalf of another. With the transfer of the responsibility to the PCTs, that glue has been removed and it essentially becomes voluntary whether GPs choose to take a turn in the out-of-hours' rota or not. This really is a paradigm change in the responsibility and in the culture of out-of-hours provision. In the areas where the GPS have bought services from a commercial provider, there may be less of a change in paradigm and in culture; in areas where it has essentially been voluntary for them to turn up on each other's behalf, there is a big change. The good news is that we learned from our membership that on the whole about 70 per cent of existing GP co-operative members have indicated a willingness to continue to work for their membership-based organisation because they get some potential satisfaction out of it, because of the benefit to their patients, and because they will be able to earn a decent amount of money for doing so as long as the funding streams are correct. But no one can really tell how this will pan out a year into the contract, when actually GPs may decide in fact, "I don't want to earn £150 for working tonight, I would rather do some more insurance supports or fine tune the practice to earn that money during the day." So the culture and the environment in which GPs will be working in the out-of-hours period in years to come is crucial. It has to be a fine balance between appropriate remuneration and good working conditions and a rewarding job, mixed with the rapid and urgent development of skill mix and developing local healthcare networks to provide an NHS-based solution to the evolution that must occur in primary care out of hours. Our vision as an association is to build on the success of co-ops - the local ownership, the local motivation, the grassroots' enthusiasm to run a patient-focused service - to provide something that we call a clinical service provider which would be an organisation not-for-profit, NHS aligned, capable of coordinating and pulling together ambulance, A&E, general practice (by which I mean primary care in the broader sense of other practitioners able to practice general practice apart from GPs: properly trained paramedics, nurses and others) in a unit that could have a variety of organisational structures, one of which is this new one called the Community Benefit Society, others could be companies expert in IT, others could be PCT-based but hopefully at a hand's-length budget to allow innovation. One of the great successes of co-ops has been that we have had enthusiastic people, able to draw budget from the members and able to take their income from the members. If they need another computer or another car, the membership base - they are co-owners - recognise the need to do it. Money is very rapidly in and out, not-for-profit, so the money into the organisation less operating expenses goes out to the members in payment. It is easily able to fine tune the service - rapid, fleet of foot and quite innovative. We think that culture is valuable, and really we are very keen it should be promoted on to a new level where that culture crosses the boundaries between primary and secondary care and pulls in ambulances, A&E and others as well.

Dr Naysmith: I think we are planning to explore co-operatives a little bit later on and we are probably jumping ahead. The Chairman was trying to work out how we had got from where we were to where we are now and where we are going. I think Dr Chisholm and Professor Haslam have said that one of the reasons for theses changes was that it was becoming difficult to get young graduates, medical graduates, to come in to the GP profession because of the 24-hour responsibility. What we are doing now might well make it very, very difficult to get people to fulfil the out-of-hours service and maybe we will explore that.

Q9 Chairman: What objective research has there been into the impact of the different approaches to out-of-hours cover over the years and the different approaches that will indeed be taken with the changes that are occurring now. All of us have anecdotal experiences of dealing with out-of-hours cover. My work before I came in here was in mental health social work, so I have had a lot of contact with different models of out-of-hours care in the area in which I worked and I gained certain impressions as a consequence of that experience. It is 20 years' out of date, but I certainly have several memories of having to get a black coffee out to some of the doctors I was dealing with and on one occasion of sectioning an alcoholic when the GP was in a worse state than the alcoholic patient to be honest with you. We have these anecdotal experiences. Over the years, has there been any objective analysis, independent of the organisations that you represent, of what has been a more effective approach?

Mr Shalley: I am not aware of any.

Dr Chisholm: I think there has been a little bit of research from the National Centre for Primary Care Research and Development in Manchester on out-of-hours provision, and also from Bristol University. I am hesitant to summarise, but in conclusion I think they have felt that the new models, particularly looking at the growth of co-operatives, have been positive and beneficial and well accepted by patients in delivering a high standard of care. But that research of which I am aware is itself a few years ago now.

Dr Sadler: Chairman, the same is also true of the research which I was going to talk about, which is looking at the use of nurses in out-of-hours services. There was a lot of research six or seven years ago showing high patient satisfaction in patient safety with the use of nurses in telephone triage.

Chairman: We are going to touch on that a bit later on.

Q10 Dr Taylor: Could I go first to Professor Haslam, and then I am sure Dr Livingstone, as a PEC chair, will want to come in. In your evidence you have suggested there was a lack of understanding among PCTs about the needs for out-of-hours care and also that there were some adversarial relationships between PCTs and GP co-ops. Could you expand on that?

Professor Haslam: I think there is a general underestimate of the complexity of what goes on in an out-of-hours consultation. There is a huge amount of safety and risk management done by general practitioners. Obviously to become a general practitioner requires an absolute minimum of nine years' training and usually more. I must stress that the Royal College strongly supports skill mix and developing the team with the use of nurses and paramedics but you cannot substitute a paramedic with an additional 12-week course for a general practitioner with a nine-years plus training plus many years of experience. If you do substitute with the less experienced/less trained people, you are inevitably going to have less ability to absorb risk, uncertainty, and a more rapid default to, "You had better go to hospital." One of the real concerns - and I am sure it will be shared by my colleague on my left - is the increase in referral through to A&E, either because someone feels uncomfortable handling the case or because the patients recognise, "Actually, if that's all I'm going to get, I might as well go to A&E and see a doctor." So there are real issues there. With regard to primary care organisations, I think they are extremely variable and I feel extremely sorry for them. I am sorry if that sounds patronising, but they have so much on their plate at the moment, with the new GMS contract and with the out-of-hours and everything else that is happening to them in a very rapidly changing and expanding and improving health service, that I am not entirely sure that this has been the highest item on their agenda and yet it is in credibly important to the safety and health of patients.

Q11 Dr Taylor: Could we have the PEC perspective?

Dr Livingstone: I endorse some of what David has said. I think for PCTs this has been a tremendous challenge and some have risen to the challenge faster than others, I think, organising out-of-hours properly. And I would actually contest whether it has ever been organised properly, because out of hours we should have a full range of multidisciplinary skills available just as we have in hours: at six o'clock patients' needs do not change. I welcome this opportunity to put right what has currently been going on in out-of-hours - not to imply there has been anything terrible going on in out-of-hours, but it is a real opportunity to work better and to work more cohesively and to have the proper professional skills in out-of-hours that we desperately need. PCTs have an immensely difficult job, because we have a very fast-changing agenda with lots of targets, with lots of focus on secondary care up until now, and I think those PCTs that have grasped the nettle and done a lot of work on this have realised how immensely difficult this is going to be, particularly in areas where there is a terrible shortage of GPs.

Dr Chisholm: I would agree with what Dr Livingstone has said about the opportunity here for the primary care organisation to think strategically about reforming emergency care. As Mark Reynolds was saying, it is important that, in doing that, all the contributors to out-of-hours care are brought together so that the response is a more integrated one than it has been in the past. That does mean bringing together the ambulance service, accident and emergency departments, community nursing, social care, NHS Direct or NHS 24, as well as GP out-of-hours' providers, rather than what the more timid primary care organisations are doing, which is really just commissioning what is already there. I think there is a real opportunity here actually to produce something that is potentially better.

Dr Reynolds: May I briefly add that there is a real opportunity but our fear has been that there has been, to an extent, a parallel universe. 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.

Q12 Dr Taylor: What should we be recommending in our report in regard to making PCTs more aware of the problems, that they have one particular specific lead who really knows what is going on.

Dr Reynolds: I think there is a key and it is the engagement of senior people at PCT level. We have always thought it ought to be at least chief executive or director of primary care involvement in this, rather than more junior managers. The other thing is really to trust the people who have been doing it on the ground and to build on the expertise that is out here in the network already, rather than feel that because there is not enough money in the PCT budget that it has to be re-configured to a lower price rather than a quality level, if you see what I mean.

Dr Sadler: If I may, I would make two points. One is to support my colleagues in their assessment that this is not an easy service to provide. We receive almost 60,000 calls a week and have made significant investment to achieve the service improvements we have outlined in our evidence. I think the second thing is that some of the decision-making processes that primary care organisations have put in place to decide out-of-hours services are not clear. I think the people involved are not clear why the decisions made were made in that way and feel that perhaps there is a lack of explicit criteria by which they might make those decisions. There was some guidance issued by the Department; it is not always clear to all of us involved that primary care organisations are following that guidance in making their decisions about out-of-hours services for patients.

Professor Haslam: Very briefly, I would say that the mindset that is required is not just how do we survive, but how do we thrive and develop. Far too often it is just about how we get through this crisis when actually there is the potential for really joined-up work. For my entire professional lifetime - I should have added that I am a general practitioner as well - we have complained about patients attending inappropriately here, there or everywhere. That mindset is inappropriate. We should be providing the services where the patients are likely to be and make sure they are the right services. For instance, there is very good evidence that general practitioners within A&E departments reduce admissions because, again, of what I referred to earlier, this skill at absorbing risk and uncertainty. Instead, we frequently have in A&E departments junior senior house officers or junior doctors who of course do not have that experience. So it is an opportunity for improvement.

Chairman: Mr Shalley, I noticed that you pulled a face at certain remarks. Do you want to expand on that face-pulling?

Q13 Dr Naysmith: Could I just ask a question of Professor Haslam. I wonder why you used the phrase "get through this crisis".

Professor Haslam: Because I think in too many PCTs it is seen as a crisis, that there is a deadline looming, they are not sure who is going to do the work. I think this comes back to what Mark was saying: in the past it has been the clear mutual responsibility and mutual support of practices for each other; that has now gone.

Q14 Dr Naysmith: It may be a difficult situation, but when there is a crisis things are falling apart.

Professor Haslam: No.

Q15 Dr Naysmith: You are not saying that.

Professor Haslam: No. I think for many people there is a feeling of potential crisis: "Who is going to do this work?" That really is an issue and therefore creates fear in every other branch of medicine as to where all the work will end up - because, sure as anything, it ain't going to go away!

Q16 Dr Naysmith: I have seen one or two crises in my time, but I would not call this a crisis.

Professor Haslam: No, a potential crisis.

Q17 Chairman: We are in a permanent crisis! Mr Shalley.

Mr Shalley: From emergency departments' perspective, I would like to corroborate what everyone has said here. A lot of our members around the country are very concerned about what is going to happen, and the word that keeps coming to me from members of the association is that it is "patchy". We are not sure what is going to happen throughout the country, it is going to be different. There are various models, but you will not get a model that will fit everyone or every area. In emergency medicine we have found that our attendances in the last 12 months have increased by 13 to 15 per cent: the hospital across the river is 15 per cent up; Kings College attendances are up by 25 per cent. For the past three to four years there has been only a very modest one to two per cent increase, so something has changed. It may be that our performances for our targets are so good now that patients are saying, "Let's go to emergency department because we know we get seen and turned around." It may be - and this I think is important - that, from a patient's perspective, many of them believe that primary care or emergency care in the primary care setting does not exist outside of nine to five. The other thing, just to get everyone straight, out-of-hours is two-thirds of the week. As George Alberti says, this is a huge timeframe, and our concern is the default position will be that patients will come to emergency departments. As yet, there has been no initiative, as has been shown, ever to decrease attendances at emergency departments.

Q18 John Austin: I agree. I was talking to the London ambulance service a few weeks ago, and I am not sure of the precise figure but their assessment was that something like 70 to 80 per cent of the emergency calls they attend are not emergencies at all. That would suggest that it is not the changes in the contract but there is something already happening in terms of people's perceptions about the way they get their out-of-hours service. But, far from all the doom and gloom that has been talked, talking up the use of the word "crisis" that Dr Naysmith picked up on, all we have heard about the new contract and out-of-hours has been doom and gloom, but the evidence which two or three people have given is that this presents some real opportunity for the first time to present a coordinated, seamless service for out-of-hours services. Is it not time to be talking more about the opportunities? If we are going to come on to the problems of lack of skill mix, lack of resources and all the rest of it, nobody is pretending that it is going to be simple, but would all witnesses agree that this presents a real opportunity to prevent a seamless service for out-of hours provision?

Dr Reynolds: I could not agree more, there is a great opportunity, but there is also a highly uncertain few months ahead where, essentially, voluntary bodies and voluntary management teams are struggling to produce a service specification that matches the PCT's financial constraints and to begin to think about inter-linkages with other services. Those essentially voluntary bodies, the medical directors of the co-operatives, if they are not given the green light and an open door in localities, have a choice to say, "It's not worth the hassle any more, we are going to pack up and go home." I am hopeful that in the last month or two the culture on the PCT side has changed somewhat and the understanding of the difficulties of providing an out-of-hours service has increased, but in many areas of the country it is still highly uncertain whether or not the co-operatives and management teams associated with them all wish to continue, so I think the word potential "crisis" is strong but there is certainly a very difficult period of uncertainty. But there are things that can be done about it. One of the things that can be done about it is to encourage PCTs to think out of the particular financial box of just GMS service re-engineering through the finance that is liberated from the new contract and to think about the wider unscheduled care budget. We have to realise that this may need some pump-priming. This work is so important that if it is not done properly the consequences on colleagues in A&E and ambulance services could, in parts of the country where it does not work well, be very significant.

Q19 Dr Taylor: You have picked up the point Dr Reynolds made a little earlier about the lack of incentives for some GPs to go on providing out-of-hours cover and you reassured us somewhat by saying 70 per cent of co-operatives are prepared to continue. That is right, is it?

Dr Reynolds: No. Forgive me. At the stage at which we took our soundings, which is April, about 70 per cent of GP co-operatives members, individual GP members, were prepared at that stage to continue to take a turn at the wheel for the early future. Our initial figures suggest that a large percentage of co-operatives, possibly 30 or 40 per cent, are thinking of becoming immersed in the NHS and becoming part of the PCT; about 30 per cent-ish are undecided - and these figures are not exact because it is very uncertain out there - and about 30 or 40 per cent - although that probably does not quite add up - are looking to remain as companies limited by guarantee or to evolve into the Community Benefit Society. Department figures, as one networked outside the door, suggest that in perhaps 50 per cent of the country the co-operatives, are thinking of continuing and evolving their organisations, and the latest rumour is that 30 to 40 per cent are thinking of going into the PCTs and becoming part of the PCT. We are fearful that there is an inbuilt conflict between PCTs being both provider and commissioner of services. We know there is a cost to providing out-of-hours. We have a fairly good idea of the range of costs rural to urban: generally speaking, it is cheaper to provide services in urban areas; generally speaking, it is a lot more expensive to provide services in rural areas. We are getting a picture. It is muddled. We hope there will be a thriving, independent NHS-aligned sector, and Primecare will of course be there. I am unsure what their situation is at present but Dr Sadler, I am sure, will elucidate on that. It is unclear how the PCT-based services will really work and whether that conflict can be resolved between them both having to fund it and provide it themselves.

Q20 Dr Taylor: Presumably it only needs a few GPs to opt out for a particular co-operative to go out of business, does it?

Dr Reynolds: The average size of co-operative currently is 80 GPs. That is the normal size up to now. That is too small in the modern world. Most are pulling together in order to be able to afford skill mix and to network more effectively and to rationalise service provision. At present the rota is compulsory essentially in co-operatives: you have to turn out because if you do not the co-operative can turn to the practice and say, "Right, no one has volunteered for this shift, which doctor in your practice is going to go on duty this weekend." With the new contract, that is changing of course, but where there is a strong ownership and a mutual ethos amongst the co-operatives and there is a real club spirit - which is where co-operatives are at their best - our evidence is that 70 per cent of existing GPs who turn out at the moment all wish to continue to do so in the near future and we hope that can be built on.

Dr Sadler: If I may offer two bits of optimism or reassurance to the Committee. To some extent Primecare and its historical predecessors have been working in the new contract era for 30 to 40 years. People who contracted their services out to ours have not had to work for the service and so we have a fair understanding of trying to ensure we have sufficient clinicians in an era where they are doing it on a voluntary basis. Our findings have been that if the work is stimulating enough, if the environments are appropriate and remuneration is appropriate, clinicians will work in the out-of-hours service and find it intellectually satisfying and challenging. The other reassurance being provided - because we last year put £1 million into an investment into home-tele consultation, whereby we put all the technology and telephony and information support that you need into clinicians' homes, so that they could provide by telephone clinical assessment in the out-of-hours period from the comfort and convenience of their own home - is that I actually had 400 expressions of interest from doctors alone in becoming involved in providing out-of-hours services through that resource. So I think that further reinforced our view that if you make the environment appropriate and the work challenging and interesting you will still get doctors and other clinicians to work in the out-of-hours services.

Q21 Chairman: One of the witnesses made reference to the fact that some PCTs were struggling to respond to this. I wonder if you have any thoughts on that. In particular, where we have PCTs within a certain SHA area is there not some collective thinking going on organised by the SHA, or is it everybody kind of reinventing the wheel?

Dr Livingstone: I think there is some collective thinking. I think we could argue that collective thinking began a bit late in the day. However, I would like to reassure the Committee based on a survey that the NHS Alliance did in preparation for coming here to give evidence today, where we e-mailed around our PEC chairs - who by and large are GPs, fairly cynical people. I have their responses here - which are nearly 50 - and most of them reassuring. They are all approaching it in different ways and I would like to stress there is no one answer that suits every single PCT or every single locality. If the Committee would be interested, I am happy to submit this collection of documents.

Q22 Chairman: That would be very helpful. Is it geographically representative? Is it a fair cross-section of different parts of the country?

Dr Livingstone: It seems to be a fair cross-section. I would have to say that that when the PEC chairs submitted their e-mails they had no idea we would be submitting their comments direct to the Committee, so I think I would only be prepared to do this if you could promise to keep the identities of individual PEC chairs confidential.

Q23 Chairman: We have a good track record on that!

Dr Livingstone: On that reassurance, I think it would be helpful for the Committee to see a cross-section of responses. There are some PEC chairs who express concern but by and large most of them feel at this moment that there are good plans in place and that they should meet deadlines that they have set themselves at various stages through the autumn to have a service in place by 31 December, which is the ultimate deadline.

Chairman: That is very helpful. Thank you.

Q24 Dr Taylor: Turning to patient involvement, it was the Carson report that said services should be designed from the point of view of the patient. I think it was the NHS Alliance that produced a booklet about patient involvement, stressing the necessity not only to train the patients but to train the GPs as well. The Royal College I think stresses that there appears to have been little patient involvement. Do you have any ideas on how to improve this? With the Government threatening the Commission for Patient and Public Involvement in Health and therefore patient forums, what are your thoughts on improving patient involvement?

Professor Haslam: Our comments in our written evidence were based upon our impression that there seemed to have been little in the way of patient involvement and I think it comes back to planning being patient-centred rather than professional-centred.

Q25 Dr Taylor: How do you make that happen?

Professor Haslam: I think fundamentally it comes down to a mindset but you do have to have good patient involvement in the planning discussions. It comes back to what I was saying earlier, the old comment about inappropriate attenders here, there and everywhere is an inappropriate mindset. We have to look at the reality of what is going on and then try to address it. The comments that have been made - and I agree - that the use of the ambulance service is genuinely inappropriate, but that is telling us something about perceptions. So there has to be, either at a national or a local level, a very clear patient input into the process. That is not an incredibly specific answer, I agree, but to me these things come down to mindsets.

Q26 Dr Taylor: Do you think patient forums have the potential to put the patient's point of view across?

Professor Haslam: One day.

Mr Shalley: It has to be much more general than that. There has to be a media campaign to let patients know what is available, where it is available and what they are going to get.

Q27 Dr Taylor: You are talking about it the other way round. You are talking about doctors education the patient on what is available.

Mr Shalley: No.

Q28 Dr Taylor: I am trying to get at patients saying what they think ought to be available.

Mr Shalley: I think the fora are important for that, but it must just not stop there. It then has to be devolved to the public, so the public know what is available and where to get it.

Professor Haslam: I want to reinforce the point Martin Shalley is making, that there is uncertainty out there, and, in particular, I think there is uncertainty for members of the public. Of all the changes resulting from the new contract, one that has the potential for being reported in a way that could cause alarm is the change in out-of-hours provision. As we talked about earlier, in fact as far as the service available to the patient is concerned, there is not gong to be a huge change, except perhaps in the sense of a more multidisciplinary response over time, with a greater use of nurses and paramedics and pharmacists and social care staff as well as general practitioners, so that general practitioners give the care that GPs can give best, and they are always available to patients who need a GP, but that we make better use of the skills of other professionals. Now, I think there are two levels at which the messages about the out-of-hours changes need to be got out - and the importance of this is something we have certainly discussed with the NHS Confederation and the health departments. There is a national message which I hope is a reassuring message that this is not a change that is going to threaten the safety of patient care, far from it, but also very importantly there is a targeted local message at the time in the run-up to local change, so that through using local newspapers, local radio stations and so on, the public is well informed about the nature of the local changes, which, as has been commented earlier, are going to be different depending on the part of the country that you are in.

Q29 Mr Jones: I was going to ask some questions about the role of GP co-operatives, but in the evidence Dr Reynolds has given quite a few of those questions have already been covered, so I will be briefer than I would otherwise be. In the evidence to our inquiry the National Health Service Confederation expressed the view that renewing the contracts with existing GP co-operatives is "clinically unnecessary, maybe financially unviable and goes against the grain of systems' integration." What view do you have on that comment, Dr Reynolds and Dr Livingstone?

Dr Reynolds: I think it is unhelpful and probably misguided. I think it has to be accepted that the costs of out-of-hours provision are going to rise, and, indeed, the Department of Health and the Government have recognised that with some additional investment, although there probably is not quite enough in each area. GP co-operatives must change. They practically all realise that they must evolve. All GP co-operatives are not perfect - I would be the last person to say that. GP co-operatives have had to work up to now in isolation, run by GPs for GPS. Breaking down the barriers into the rest of the NHS has been very difficult. Gaining access to skill mix, gaining access to influencing other areas of the NHS has been difficult because it has been in part a choice of its own but also because it has been so separate and poorly understood elsewhere and it has been very difficult to achieve. There is a new opportunity of re-engineering, providing local experts and enthusiasts with the ability to build a wider network. I think that is exactly the right way to go and co-op successor organisations or the teams involved that have been running services successfully for the last five, maybe ten years in an area, largely unwatched by the rest of the NHS - simply getting on with it, with high levels of patient satisfaction - provide a very good starting point for producing this. I think the NHS Confederation evidence makes the assumption that other professionals working in the out-of-hours environment may be cheaper. I am not sure that is the case, because generally speaking other professionals work more slowly and you have to have more of them to replace the single general practitioner. General practitioners could be criticised for working too fast in the out-of-hours period. Quite where the truth lies there, I do not know, but I am not at all convinced that skill mix will necessarily be cheaper, certainly in the short to medium term.

Dr Livingstone: I think the emphasis has to be on the provision of a good service for patients, and, where we have well-established co-ops that have shown themselves to be limited and to rise to the challenge, I have no hesitation at all in saying that is certainly the right model for those areas. I would say there is no single model, so a lot of areas do have the advantage of having well-established co-ops or have co-ops who are not prepared to change and who have seen their membership gradually lose interest in out-of-hours as the realities of a new contract have begun to come home. In those circumstances, the primary care organisations will have to do that networking, produce those multidisciplinary teams and run the service. So I think it is a mistake to think that is the right way of doing it or that is the wrong way of doing it; I think we will just have to grasp what we have and turn it into something bigger and better.

Q30 Mr Jones: I am sure everybody would argue that we need a good service, but I also think people would probably argue that we need a cost-effective service as well.

Dr Livingstone: Certainly we do.

Q31 Mr Jones: What are your views - and I am not sure to whom this is best addressed - on the new mutual models that are being proposed? How do you see those working? Your role up to now seems to be defending the existing model and I was trying to extend it.

Dr Reynolds: I was medical director of the fourth co-op in the country many moons ago and it felt like a very exciting development, pulling together a community and producing a useful, cost-effective and patient-friendly service. After a period of gloom for the last year or two and trying to make sense of the changes, this new organisation feels equally exciting in terms of the opportunity that it creates to build something genuinely new and exciting, involving a wider NHS solution to this problem. I am deeply biased, I am personally in favour of it. I am a joint medical director of the first mutual society that is now up and running, incorporating four co-ops across the south-east, in Maidstone, Tunbridge Wells, Sussex and East Sussex, covering three quarters of a million population, one thousand square miles roughly. We are up and running now, busy pulling together the four co-operatives, and we are just beginning to pull together the Advisory Council on which we hope to represent the powers and members of the public. In theory, public involvement in these organisations is as open as it is in foundation trust hospitals, because the rules of the society are similar to that. The difficulty with involving the public is that they only use the service once every five or six years on average, so a campaign simply raises awareness that there is something out there. My own feeling is that as well as some information there has to be what we call patient triage, "phone before you go", with calls dealt with on the basis of assessed clinical need. We believe that is best served not by remote call centres but by people staffed and embedded in the local health economy. We hope that these new Community Benefit Societies will pull together and retain ownership, and a motivation not from just GP owners and members, but nurses and administrative staff, pulling together to provide a service, with the PCTs, A&E, ambulance and others having a seat on the council of these organisations and able to play a part in the strategic direction of the organisation. Open-book accounting - the NHS can see exactly where the money is going - hopefully providing a good working environment for all the professionals within it, to motivate them to continue to turn out. There is clearly a mutual benefit from working closely with A&E and the ambulance services. You can begin to see it now - the ambulance service is beginning to bring people to us. If someone has just had a fit, for instance, the waits in our primary care centres are 12 minutes, half an hour. A patient can be seen, turned round and sent back again very quickly, which is of course of enormous benefit to the ambulance service and is one less load on A&E. We would like to get into trading with A&E. Where we clearly on the phone have assessed somebody as needing direct admission to hospital or 99 per cent likely to do so, we would like to have the quid pro quo of saying to A&E, "Right, would you please deal with that. What can we do to help you?" If A&E are on the board of these organisations, which they will be, then we think this begins to break down the barriers that exist between the existing NHS organisations and produces a genuinely exciting possibility to facilitate truly integrated services.

Q32 Dr Naysmith: Dr Reynolds has just touched on what I was going to ask. I was going to ask: Is it not true that there are co-operatives developing now which started off doing the out-of-hours service but are now beginning to provide other services.

Dr Sadler: Yes.

Q33 Dr Naysmith: I know one in London which is doing all sorts of things, clinics and things. They started off as an out-of-hours service and are now spreading out to do other things, and doing what you said, providing community service.

Dr Reynolds: The structure is not that important. This type of network could be provided from a PCT-base, properly financed, with an independent hands-off budget, run by a team of enthusiasts. In some areas it would suit PCTs to do it that way and there are good reasons for it - companies limited by guarantee, the same company structure as a co-op, could in theory do some of this. The actual company structure must serve the function of the health needs in the locality rather than a preferred structure be imposed on the health network until the health network has decided the job that is to be done, but the job that is to be done requires a leap of faith and some imagination about pulling things together. We think the CBS is a very good model, but in a variety of areas, for example Medway, the out-of-hours' provider is also providing in-hour services, and the clinical service provider network we could see assisting practices in the day time with aspects of the contract that they wish not to do, with coordinating nursing and other services, and providing access to patients out of their area perhaps or, if a practice is overloaded, seeing people in a primary care centre. There is lots of exciting possibilities that with some imagination and vision could produce a really useful local health service and addition to the health service.

Q34 Mr Amess: This is the opportunity now for some creative tension between our witnesses - but if you could restrain from having a sort of Big Brother style punch-up between yourselves. Dr Sadler you are strategically placed and we have Professor Haslam at the other end. Some of your fellow witnesses are not particularly enamoured with your organisation. They seem to have it in for you. In fact they see you as a necessary evil. According to Dr Chisholm's organisation, Primecare's "continuing stability is a matter of concern" and the chief executive of Nestor resigned recently over falling profits with the failure of Primecare to secure the proposed 30 to 40 per cent growth in out-of-hours business that it was hoping for. Of course tragically, a fortnight ago, Robert Wells, a police surgeon, was found guilty of rape and sexual assault. If I turn to Professor Haslam, you said that there are uncertainties around the role and performance of Primecare. Could you explain to the Committee what exactly you meant by that?

Professor Haslam: We put out to a number of our members basically the questions that you asked us and this was one of the responses that came back. I personally have no specific additional evidence to add to that. I certainly would not wish to single out Primecare for any particular concerns. Looking at the whole spectrum of care that is going to be available for patients, what is needed is the thing that everybody in this room has been trying to stress: reassurance for patients - that it is going to be all right, that it is going to be safe, that not only are we going to be all right but we are going to build. That does require all the organisations involved to be long-term viable. I think that is really all that came out of our consultation.

Q35 Mr Amess: I have failed miserably to get sparks flying. You are going to get your chance, Dr Sadler, after some questions. Could I ask generally what our panel's views are on commercial deputising services.

Dr Chisholm: I think one of the good features is that henceforward all provider organisations are going to be assessed against nationally defined standards. Now Mike Sadler and Mark Reynolds may want to comment on those standards, but, I think, particularly after yesterday's announcements by two of the political parties about plurality of provision, it hardly behoves us to say that we do not welcome that. I think what is important, as Dr Livingstone said, is the standard of care that is received by the patient and we welcome any organisation that is delivering very high quality service to patients whatever the particular contractual status of that organisation. As Mark has said, the co-op movement is, in a sense, going in a multiplicity of different directions as far as structure is concerned. We are much more concerned about function and outcome.

Q36 Mr Amess: Before Dr Sadler has his say, does anyone else wish to add anything?

Professor Haslam: The document The Quality Standards in the Delivery of GP Out-of-Hours Services, which was produced by the Department of Health a couple of years ago and which is really the measure, was commissioned from the Royal College of GPs, so it was very much our work that went into that, and I would very much echo what John Chisholm has said, that it is the quality. It is not the who, it is the how and the what that matters.

Q37 Mr Amess: Does anyone else have any comments on commercial deputising services? I have failed miserably here. Let's turn over to Primecare to sing the praises of the company and particularly talk about what you feel you can offer over and above the service offered by an existing GP co-operative.

Dr Sadler: I would start with what I would have given in response to the previous question, which is that I do not think it is the structure that matters, it is the quality of care that you provide. We are still the single largest provider of out-of-hours services in this country. We take 60,000 calls a week, and that is substantially more than any other out-of-hours service. Because of our position in the way that we provide services, we have been able to invest over £13 million in changing the way that services are provided, both to meet the challenges of the Carson report, but also reforming emergency care and then the new GP contract as it came along. That has enabled us to invest in centralising telephony, because I think there are some economies of scale that you can achieve - and we do need to provide high quality care within limited resources always. So we have been able to achieve major improvements in service quality that are in the appendix that accompanied or written evidence. I think that size also enables you to be innovative. I have already talked about having tele-consultation. We also have extensive experience now in using nurses, emergency care practitioners, pharmacists to provide services to patients in the out-of-hours area. So I think there are several advantages to being a commercial provider and being the size that we are and I believe that we have the resilience and the structure to continue to provide those services in the best way possible for patients in the coming years. There are national quality standards now set out by the Carson report, there is a national accreditation process. We believe we are closer to achieving those national quality standards than probably many other providers and would welcome the publication of comparable data from all providers so that we can actually benchmark our own performance, but the graphs that we have shown to the Committee demonstrate how much we have achieved over the last 18 months. In every place where our branches have been assessed, which is now throughout the UK, we have passed the assessment process and have become accredited providers, so from my point of view there is more than enough work in the out-of-hours field for all providers. The important thing is that we do meet national standards, that we do provide high quality service to patients, and that the 250,000 calls a week that are generated in the out-of-hours primary care service now are answered in the best way possible and in the most cost-effective way possible and we believe we are extremely well placed to continue to do that for years to come.

Q38 John Austin: You have referred to the fact that you are a national organisation, running lots of services and therefore you can only invest centrally, in your Central Triage Pool, in your home-tele consultation. The question is really to some of the others: Would it be possible, given the localised nature of the out-of-hours service that is provided either through co-operatives or through other ways, that it is unlikely that the level of investment could be made that could enable some of these modern technological developments to occur? Is there, therefore, a responsibility on the Department to ensure that there is funding available to ensure those collegiate responses?

Dr Reynolds: I wonder if I could light a slow-burning fuse rather than a spark? In reply to that I would wish to point out that there are two cultures really in out-of-hours provision, and three-quarters of the UK's GPs have been unable to gain access to Primecare or have decided that that type of service is not for them. Mike said they are the single largest provider, but the co-op type provision is by far and away the majority provision of out-of-hours services in the country, through reasons of choice of local GPs that they wish to do it that way. Traditionally, that has been in areas where GPs previously have provided their own services or have become dissatisfied with the services provided by commercial providers historically and have chosen to set up a co-op rather than to purchase services from a commercial provider. There are differences in culture, there are differences in emphasis and there are differences in style. We believe there are not huge economies of scale to be made from massive service provision. Sometimes the economy of scale that can be talked about by call centre technology does not translate easily into the provision of health. We are firm believers in the local or semi-local provision of triage services: "phone before you go" advice to local populations to pick up the phone to decide, and to speak to the highly experienced, relatively locally based commission on whether or not a trip to A&E would be appropriate or an ambulance call is appropriate. We are very keen to assist ambulance services in off-loading some of their lower level calls to us to provide a locally-based service. And a locally-based service definitely need not be more expensive than a very large service, particularly given the fact that most of the larger not-for-profit sectors have now become quite large - and when you get too large the trouble is that you lose contact with your edges and it is actually quite difficult to get a balance. I am not saying there is one size that fits all by any means, but on our side of the fence we genuinely believe that locally owned, locally run, not-for-profit services provide the best compromise solution in this really quite challenging area of health care provision. We really believe that we can provide a high quality, sustainable, organisationally integrated service, or facilitate that service at semi-local level. I will not use the word "local" any more. Co-ops used to be very local, based on a market town, based on perhaps around a DGH hospital. I think there is a realisation now that they need to be bigger, and many co-ops are now joining forces to provide an economy of scale, the ability to employ skill mix, the ability to cross-boundary cover with neighbouring providers effectively so that patients do not fall between two nets. I think one of the problems we have had with PCTs is that up to now in some areas individual PCTs have felt that they wanted to provide their own service at their own cost and have their own costing process and have not in some areas worked as teams and have mitigated a little bit against joined-up thinking in localities in some areas.

Q39 Chairman: Dr Chisholm, do you want to respond?

Dr Chisholm: Yes, I just want to come in on the issue of what Mr Austin referred to in terms of additional central resources for the out-of-hours service. I think one reason that primary care organisations have found the agenda quite challenging, and that there is still some uncertainty in some areas about what the shape of the service is going to look like, is because of the cost of providing the service. They have the sums that practices are giving up in order to transfer their responsibility, but those costs are very much less than the total cost of providing the service. They have the out-of-hours development fund. In addition in England there has been some targeted additional funding, particularly for urban and rural areas, but still they are worried that they do not have sufficient resources to provide the high quality service that they identify patients require. So I think the case for the necessary resources being available is a tough one for the primary care organisation often, and there may be a place for some additional central initiative.

Q40 Mr Amess: One final question. Other than this chief executive who walked the walk, why would you say, Dr Sadler, that people like working for your organisation, because you do not seem to have too much difficulty in recruiting and retaining people?

Dr Sadler: May I, Chairman, respond briefly to Mark, and then come briefly to that question.

Q41 Mr Amess: Get your bit in against him.

Dr Sadler: I will not accelerate the fuse. There are several areas where the co-ops and Primecare actually work together, where they provide services for parts of the day and we provide services for other parts of the day. I think the best models are a mix and match of where you are getting some economies of scale in terms of telephony and triage in the way that we have demonstrated in our evidence, but then you do have local services and the need for local integration in relationships. So if we in one of our appendices put the details of the Cleveland PCT model, we are providing services locally there that do have the resilience and back-up with the centralised pool and telephony so that if there are local problems in demand, local surges in demand, we are able to back that up. It is one thing I hope the Committee will come on to, which is up to now there is a built-in safety net in the existing GP contract that will actually be lost when the new contract comes in - and perhaps when I am not interrupted by that bell I may return to that. In terms of your specific question about why people work for us, I think I covered some of it earlier. The first thing is that out-of-hours work is actually quite challenging; we do see a different case mix. I think a lot of people find it often a more exciting end of medicine to be in, so we have always found doctors who work preferentially in out-of-hours services. The second thing is the environment. If they feel they are part of a service that is supportive, that is achieving good care, that does not put too much pressure on them, and that they can work in their own environment, perhaps in the home, as we have talked about earlier, they will also continue to want to provide services out of hours. The third issue, obviously, is remuneration, and you have to ensure that you are giving people the appropriate remuneration for them to wish to carry on working. So it is a range of factors really, and I think we hope and expect to continue to provide clinicians where they are needed. The other thing we have done recently is started to use some resource planning software to look at how many doctors, nurses and others you really, truly need. I think often in the out-of-hours services there has been a tendency to have five doctors on on a Saturday because that is what we have always done. By looking at the actual volume of calls coming in, and when those calls come in, you actually find that you probably needed six, three hours earlier, but only two later on. So we actually find you can use your clinical resource more effectively by looking very carefully at the volume of calls coming in, and when that is at a peak.

Q42 Dr Naysmith: Do you have any record of how many of the doctors that you employ are retired doctors?

Dr Sadler: No, I do not. What I would say is that all the doctors who work for us are either GP principals or eligible to be GP principals, so they are on the supplementary list of a PCT. What I do not have is a set of records to see how many are still providing services as a principal. The last time I looked at that, out of the 1600 doctors who provide work for us on occasions or more regularly, 1500 of them were still principals in practice.

Q43 Mr Bradley: Another player in this business is NHS Direct, and that from the Department of Health point of view has been well invested in. However, in one of the memoranda one of the GP co-operatives said they would not use NHS Direct because they feared the outcome of the patients. Do you share those concerns or do you have some general views about how NHS Direct should be used in the integration of the service for out-of-hours services?

Professor Haslam: I have little doubt that NHS Direct has been a popular and well-used service. The main question relates to both capacity and impact on the rest of the service. From a capacity point of view, as far as I know NHS Direct currently deals with six million calls a year, which is very impressive. British general practice deals with one million calls a day. So it is very difficult - and I have been trying before this meeting - and maybe some of my colleagues may be able to say what the total national throughput of out-of-hours telephone calls to all our organisations would be. I do not know what those figures are, but I would find it very difficult to imagine that NHS Direct would be able to cope with that. Secondly, as far as I can see from the research evidence, there is very little evidence that NHS Direct has either changed consultation patterns in general practice or in A&E; that it is an additional service and a very welcome one for people who are worried, but it does not seem to be reducing anything. That is not to denigrate it; it is just that if that is what it was intended to do, it is not doing it. The third one is just to come back to the question of local against national. I really think there is a tremendous logic in maybe patients having a single very simple number for emergency healthcare and less emergency healthcare. I think there is a logic in that, but somehow we have to build local knowledge into that, because what you do in Rutland and what you do in East Grinstead and what you do in Peckham are fundamentally different. If you have a call centre in Edinburgh, because people like the voices in Edinburgh, they are not going to know what those needs are. So savings on one level in terms of delivery will be lost in inappropriate healthcare provision.

Dr Reynolds: This is a difficult question to give a good answer to, in a sense, but as an association the jewel in the crown of NHS Direct is nurses' advice to worried patients with illnesses that can be safely managed at home and that should be very successful. However, what has not been made public, as far as I am aware, is the evaluation of the exemplar sites, which is where NHS Direct were the first point of contact for urgent primary out-of-hours calls, and we are upset that we have not seen that. Our understanding - and I am not entirely sure about the exact figures - is that through NHS Direct about 30 per cent of out-of-hours primary care calls are finished off - a rather unfortunate phrase - by NHS Direct; the episode is completed. But in nurses employed by co-ops working side by side with GPs, a team approach to this, with a different culture, experienced nurses, sometimes working with decision support software, sometimes working on the basis of careful training with access to paper-based protocols, can successfully complete 60 per cent of the calls that present to a primary care service out of hours, when they have immediate recourse to a GP working in the room next to them or at the end of a phone. We do believe that the filter that NHS Direct puts in front of patients ringing for urgent calls out of hours only removes 30 per cent, and delays perhaps 70 per cent, and we would like to suggest that the filter be re-thought, and that calls could be directed to NHS Direct after initial assessment, perhaps not necessarily by somebody clinically trained and bounced back to a clinician, if needs be. Having said that, the NHS Direct review has the potential to address many of the concerns that we have made right from the point of the out-of-hours review, where we said in the out-of-hours review model there is NHS Direct at the centre of all triage going to it, and calls dispersed to all other services. We had a ferocious argument with the out-of-hours team that that central box should read 'primary care/NHS D' (?) or 'GP/NHS D' so that there was a combined call filtering system at the centre, not one service doing it. We still believe that that would be the right way to go ahead. We do believe that the review gives PCTs the chance to wield some financial influence on the structure of NHS Direct to perhaps get them more locally responsive and to perhaps have a system whereby local call sorting systems could send calls to NHS Direct for very adequate response to the more, frankly, without being denigrating - because their software is so risk averse, NHS CAS - that it needs to be fairly self-limiting, almost mostly reassurance issues that go to NHS Direct. The other calls could go through to the services on the ground for clinicians to sort out at that area. Having said that, there are some areas where NHS Direct has worked well, and in the areas where it has worked well it has been because there have been motivated local clinicians of various colours working as a team behind it, and in some areas the figures are better than that which I have said previously. We at the moment would see NHS Direct - I share Dr Haslam's comments - as a popular and well-liked service that the patients appreciate, to call it, but in terms of clinical effectiveness and money well spent I think the jury is well and truly out, and we would like to see the pool of NHS Direct nurses given more freedom, perhaps more senior nurses, and the NHS CAS software radically changed to allow it to take more risks, with the suitable safety-netting that occurs, to get the resolution rate significantly raised and to have the nurses with access to GPs so they can work as a team in solution to dealing with what is essentially primary care work. That would be our suggestion.

Chairman: We have about half-an-hour left, and a number of areas to cover in some detail. Could I appeal for sharp questions and sharp answers as well.

Mr Bradley: I will not carry on.

Chairman: It is not pointed at you.

Q44 Dr Naysmith: We are beginning now to touch on things that have already been touched on before, so it should be easier to get sharp answers. This a question for Mr Shalley. In the evidence of your organisation you said that you feared that these changes would have an impact on Accident & Emergency departments, and have already touched on the fact that whether we have had these changes or not, things are getting very pressured for Accident & Emergency departments, with huge increases. Do you really have evidence that this is likely to make that worse?

Mr Shalley: The attendance levels, yes, just a huge jump in 12 months, which we have not seen for the past four to five years.

Q45 Dr Naysmith: And the changes have not really taken place yet.

Mr Shalley: It is public perception, I think, that is the main driver. What is available, that is what is driving attendance at emergency departments.

Q46 Chairman: In your figures that you are using, is there any analysis of the nature of the presenting problem at A&E, that you are dealing with.

Mr Shalley: The evidence is that admissions are pretty much the same, so what we are seeing is a bigger percentage increase in what we would like to call our urgent care cases - walking wounded, or walking ill patients. That seems to be our biggest increase at the moment. There will not be a simple 'yes' - we do not believe in categorising people as inappropriate attenders, as David said; that is not our role. What we would like to see in urban areas is to have primary care actually located as part of the emergency department, with a single triage point to make sure that patients get sent to the right specialist - and I am calling primary care people specialists, because they are. I think we need to have it as part of the department, because we should not be turning people away. We need to actually keep them and get them seen.

Q47 Mr Bradley: Just relating back to NHS Direct, do you keep any statistics about who has advised people to go to A&E? Is it that because of contacts with organisations like NHS Direct, who may encourage them because of their own uncertainty, to go to A&E?

Mr Shalley: We do not think that NHS Direct has had a great effect on increasing attendance; it certainly has not dropped attendances; but the default position must be 'seek medical care', and we are very happy with that as an organisation.

Q48 Dr Naysmith: It may be the position that you do no not say there is such a thing as inappropriate referral, but I speak frequently with friends of mine who happen to be medically qualified, and when they are not talking in public they will tell you that lots of people turn up either at their surgeries or their Accident & Emergency departments who really should not be seen and should not be there at all.

Mr Shalley: I think patients need to access medical care, and the patient will go where they think they can get it.

Q49 Dr Naysmith: I think what they need is appropriate advice, good advice, on where they should go. Is that not fair?

Mr Shalley: I think that is entirely reasonable, but I do not think we should be turning people away from healthcare at all.

Q50 Dr Naysmith: Your question about your fears of what the effect of this will be on Accident & Emergency departments is positing the idea that somehow or other we are not going to get through this crisis and we are not going to solve it, and things are going to get worse. But if, as has been suggested today, things do get better, we do provide a better service, then I do not see that that in itself should have any effect on Accident & Emergency departments, other than other changes that might be happening in society, even such simple things as the use of mobile phones, which is getting police and ambulance services lots and lots of calls that they never used to have.

Mr Shalley: Like other people have said, I think there is a tremendous potential to make things better, but I do not think we should forget the risks that may happen if we are not all up to speed here. The other thing, just to say that our other major concern is that because of the new GP contract many of our staff grade and associate specialist doctors who provide a substantial proportion of our service are now leaving emergency medicine to join primary care, and this is having a major effect on recruitment nationally. That is another major concern that we have.

Dr Naysmith: It is interesting. We hear about GPs having difficulty recruiting, now it is emergency care specialists who are leaving that branch of medicine to go and work for GPs.

Q51 John Austin: It is just this perception of reality again. You referred, I think, to a 15 per cent increase, et cetera. When? We are talking about a new contract which came in on 1 April. Surely your figures for that increase pre-date those changes? So they are not as a result of changes on the ground; they may be as a result of a different perception that certain things are not available.

Mr Shalley: Yes.

Q52 Chairman: Can I just press you, Mr Shalley. You have made the point about not turning people away. I referred in the debate we are having in the Chamber this week to my experience of spending a night with my daughter about six months ago in a Casualty A&E unit. It was a Saturday night/Sunday morning, which indicates the nature of the business that was under way there, and some of you will know the kind of thing I am talking about. It did strike me very strongly that there were some genuine people there who needed help, and their ability to gain help was affected by the presence of people who, frankly, could have been dealt with elsewhere. Any city centre A&E on a Saturday night/Sunday morning has a certain kind of people who are drunk, vomiting, have been fighting. I would have thought that there was a more appropriate response outside A&E to that type of situation. I wonder whether you and your colleagues think that perhaps as part of this process of change we ought to be looking at alternatives to some of the responses that we give to people who have drink-related problems, that do not really need to be queuing up at an A&E department.

Mr Shalley: I think that is very difficult. More and more emergency departments are being seen as a place of safety by many organisations, including the police, because these people are difficult; they do present challenges both medically and socially. I think you are quite right in that we do not have the right place to see and deal with these people. Maybe something will come out of the reorganisation of out-of-hours service and that is something that we should all look at for the future. But, yes, I think they are a great challenge, and I do not think we have the answer to that question.

Professor Haslam: One specific and one general point. The specific one is that the difficulty is that you only know that you did not need to see and treat someone after you have seen them, so it is quite easy in retrospect but quite difficult in prospect. There is an issue there, and I personally believe that the answer is much more co-location of general practice skills and A&E skills together so that very early on the right person has dealt with it. I think an area that none of us have talked about - and it is probably far too big to even get into - is societal changes, in which society has become much more risk averse: 'If in doubt, let's see a professional'. A lot of that is driven by very understandable fears around things like meningitis, and where the first signs of a cold and the first signs of meningitis are indistinguishable, and you are a worried parent with no family support, and extended family support, then your reaction is going to be fundamentally different. I think that is probably one of the drivers of what is happening with all of us.

Q53 Dr Naysmith: Can I ask a question of Professor Haslam, and it has probably been touched on a little bit. Are your members concerned that the changes in out-of-hours provision are going to have a knock-on impact on regular GP during-the-day services, and in particular do you think this could affect the 48-hour access target?

Professor Haslam: That is a huge question. I think, as a number of people have said, actually not much is going to change, because most of the big changes have already happened. When I was first a general practitioner I did all my own out-of-hours; I was seeing my own patients at every hour of the day and night, I was completely exhausted. Over the last five or ten years I have been in a co-op, and that has handled things in a completely different way to the way I would have done it for my own patients, and far more has been - "You're OK, you'll get through the night. See your doctor tomorrow", which is actually fine. I do not think an awful lot of what is going to happen in the next year or two is that much different from where we are now. To me the biggest change is where the responsibility lies, not where the delivery lies; and that goes back to where we came in.

Q54 Dr Naysmith: One very simple way that it might change is often it used to be a doctor from your own practice who would be saying it, and that may not be the case in the future. A doctor would say, if he or she saw you in the middle of the night, "Come and see me in the morning and we'll sort this out".

Professor Haslam: The thing is, not only would that be the case in the future, it is the case now. The chances are, now.

Q55 Dr Naysmith: That is right, yes.

Professor Haslam: So if you are asking me what the concerns are, those concerns have already happened. Yes, Monday mornings are very busy.

Q56 Dr Taylor: Mr Shalley, you have already told us the workload has gone up tremendously. Has that affected your ability to meet the four-hour waiting time target?

Mr Shalley: That is very interesting. There are graphs that actually show that performance is dropping off with increase in workload. There are four departments in the country whose workload is decreasing. I think it would be good to go and see them and find out how they are doing it. But, generally speaking, with increasing attendance, four-hour turn-round times are dropping.

Q57 Dr Taylor: Would you be able to tell us which those four units are?

Mr Shalley: I wish I could. I have the graph, but it is anonymised. I shall try and find out.

Q58 Dr Taylor: This is probably rather academic, because in about half-an-hour we are going to be told what the government's new targets are; but would you have any suggestions about generic targets to help the whole out-of-hours service?

Mr Shalley: I think that is very difficult, for me to pontificate on primary care.

Q59 Dr Taylor: Not only you, the others.

Mr Shalley: I am very happy - I think the four-hour target for emergency medicine has been a godsend. I think it has actually focused everybody's thoughts on the emergency patient. As you can imagine, from my speciality, that has been a great change, and a great change for the good of patients primarily; and because of that, for staff, departments and trusts. I think it has done only good.

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 to be in negotiation. We would have 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 per cent of practices in the UK will have chosen to transfer responsibility to out-of-hours providers, and nearly 100 per cent will have been offered the opportunity 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. 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 care 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 per cent 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 per cent 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 of 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.