Westminster Hall
Tuesday 20 February 2007
[Ann Winterton in the Chair]
Health Care (Cornwall)
Motion made, and Question proposed, That the sitting be now adjourned.—[Mr. Watts.]
Ann Winterton (in the Chair): Before I call Mr. Taylor, I can let hon. Members know that as it is rather cold in here this morning we have asked to have the heating put up. No doubt that will take all day, but never mind. I hope that we will survive.
9.30 am
Matthew Taylor (Truro and St. Austell) (LD): We will try to warm things up during the course of the debate.
I am pleased to have had the opportunity to secure this debate. The issue has raised considerable concern among Cornwall’s MPs as a team; that can be judged by the turnout from Cornwall today. The out-of-hours service was run by a GP-led service, KernowDoc, for nine years. It was set up as a local, non-profit-making operation and it was successful. Since April 2006, however, it has been transformed into Kernow Urgent Care Services, a branch of the US-owned company, Serco, following a contracting process that the Government require to take place. The three-year contract is worth £16.5 million and the company won the bid on a promise to deliver a service as good as, if not better than, before, but for a much lower cost—a saving of several million pounds, we are told.
During the contracting process, all the MPs in Cornwall expressed doubt that as good a service could be delivered for that much less. I guess that our theme was, “If it ain’t broke, why fix it?” However, Serco and the primary care trust insisted that it could be done, and now we have the result. Serco has failed month after month since taking over the service. Formal complaints, which Serco referred to in its briefings, have risen from four per month to as many as 27 in a month, but those formal complaints are the tip of the iceberg. I do not recall receiving a complaint about KernowDoc for years, but now it is a major part of my casework. GPs say that they have lost confidence in it. The ambulance service complains that people are resorting to the already overstretched 999 blue-light service because they do not trust the service provided by Serco.
From the evidence of my own constituents, those of my colleagues, and indeed the PCT’s media statements, it is clear that KUCS as it has been operating is unfit for purpose, and as a result patients are potentially at risk. Last month, the PCT announced that it would carry out a review early in April and that it was seeking a response from Serco to its requests to put the service right. I have never in 20 years felt the need to resort to a parliamentary debate to tackle problems in such a local service. I have challenged the Government on
their policy, but I have never felt that the inadequacy of the responses received merited taking the matter to the level of a parliamentary debate. I have been enraged, frankly, by Serco’s poor service, which has been made worse by its unwillingness to respond to the complaints that I have made on behalf of my constituents.
The constituents’ concerns that I have raised have been met with as poor a response as the service itself provides. I have had to fight to get any reply at all. KUCS then hid behind the barrier of patient confidentiality, even when I wrote to raise concern that the phone system was not working, meaning that people could not get through. I am not sure how patient confidentiality could be the justification for not replying to me. Even when I sent a copy of the regulations showing that patient confidentiality did not apply to MPs’ queries of this sort, I could not get a response.
I have to say that it was not much use taking the matter up with the Minister either. The Minister wrote to me on 5 February, referring me back to the PCT. I would not have written to the Minister if I were happy with the response from the PCT. Only this debate has had any real effect. Indeed, it has already had a wondrous effect. Last week Serco and the PCT insisted on meeting me. Now the matter has hit Parliament, Serco genuinely appears to realise that it has a problem and that it has to act. I received a promise of proper responses to MPs’ concerns, a promise of big changes to improve the service and a promise that it accepts that it has to get it right, even if its original costings were wrong. Bluntly, we aim to hold it to those promises, but I cannot say that I have great confidence that it will deliver.
I believe that there is an element of ministerial responsibility involved, and I am calling on the Government to ensure that KUCS delivers on its promises should it retain the contract. They must also review the contracting process to redraw lines of accountability and ensure that private contractors charged with public service delivery, which the Government want to come into the NHS, cannot renege on their promises or underbid and then fail to provide an effective service. There must be an effective process of judging whether bids are deliverable for the price cited, and of holding those involved more quickly to account than has happened in this case. I shall return to those requests to the Minister after giving a rather more detailed outline of the abysmal record of the service so far.
First, I shall consider patient care, which is the primary issue. Frequently, Serco has not complied with, or only partially complied with the national quality requirements for out-of-hours service, or its own contractual obligations. Clearly, the most essential element of effective out-of-hours services is answering the call in the first place, but that has not been happening. For example, a Miss K from Redruth, who spoke very coherently in an interview on BBC Radio Cornwall earlier today, became sick a few days after returning home from an operation. She tried to call KUCS repeatedly, but could not get through. Eventually, an ambulance took her to Treliske with full-blown, life-threatening septicaemia. According to the doctors who treated her, 30 minutes later could have been too late.
Another patient who wrote to me called KUCS three times. None of the calls were answered in five minutes, so eventually they were transferred via NHS Direct. When the patient did get through, they waited over five hours for a doctor to see them. Those problems were meant to have been sorted after the awful track record of the service during the summer. In September, the PCT intervened, and in October, Serco promised that it would sort out the problem. However, over Christmas, almost one in five calls, according to Serco’s own figures, were abandoned. The accepted standard is no more than 5 per cent., and that rate of abandoned calls amounts to 2,500 calls in a month. KUCS has given high call volumes as its excuse, but the increase in demand over Christmas, when doctors’ surgeries are closed, is entirely predictable, and it is exactly the same excuse that Serco gave for poor performance during the summer.
The second essential element is correct triage when someone does get through. On the basis of the phone call, the right response should be given, whether that is reassurance that a problem can wait for a regular GP appointment, being seen by a doctor at an out-of-hours clinic or at home, or reference to the 999 service. According to the PCT, last summer, up to 40 per cent. of calls were not triaged by an appropriate professional. Some might be concerned about that, because people have found it difficult to understand by whom they are being triaged. The increasing use of emergency care practitioners is often confusing, and people are often under the impression that they are being triaged by a doctor. Serco has accepted that it has not made that clear, and that it needs to put it right. It has admitted that there is a problem, as the PCT has spelt out. I hope that it will be put right, and it is worth bearing in mind that firm oversight by qualified doctors should be part of the process. At least on those occasions, however, there was some response—the telephone was picked up.
The third essential element, once a patient is triaged, is that of response times when patients are assessed as needing urgent treatment At points last year, roughly half the total number of emergency callers were not seen at a clinic within an hour of contacting KUCS. The national quality requirements say that it should be 95 per cent. At points, more than 40 per cent. of emergency callers requiring home treatment were not receiving it within an hour of contacting KUCS. Again, national quality requirements say that the figure should be 95 per cent.
Indeed, the briefing that Serco has provided shows just how bad the situation was. For example, the standard for calls abandoned is no more than 5 per cent., but in December the figure was more than 18 per cent. The rate for urgent clinical assessments within 20 minutes should be 95 per cent., but Serco fell short, while for non-urgent clinical assessments within 60 minutes it fell short by almost 20 per cent. For emergency clinic visits completed within 60 minutes, Serco fell short by almost 30 per cent., and on urgent visits completed within 120 minutes it fell short of the Government’s target by 16.5 per cent. Those appalling records are repeated in many other months. For example, for emergencies completed within 60 minutes
on clinic visits, the rate was only 54 per cent. in September, 79 per cent. in October, 80 per cent. in November and 70 per cent. in December, as against the national target of 95 per cent.
A mother wrote to me, hugely angry about the treatment of her four-year-old son, who had shown signs of having a temperature. NHS Direct told his mother to ring the out-of-hours service if it hit 39° C. She did so and an appointment was made. However, the agency doctor she saw told her that it was not unusual for a child’s temperature to go as high as 41° C, and advised her to give him Calpol. According to the mother, the doctor did not notice while saying so that the child had slipped into febrile convulsions, slumped in a chair and was staring into mid-air. Apparently, even after she pointed that out, the doctor just sat there, as she lifted the boy up to prevent him from swallowing his tongue. The convulsions worsened and the mother screamed for an ambulance, while the doctor did nothing. Eventually an ambulance was called and the patient was treated, but not before a highly traumatic and potentially serious scene had unfolded.
Another constituent, Ms E, was rendered incoherent and immobile by a severe asthma attack. She was triaged and told to go to Falmouth for treatment, where she would immediately be put on a nebuliser. In fact, she was not given that treatment; she was given an unfamiliar treatment by a doctor who, she says, had little command of English. Ms E went home confused and still unwell, and so called back, only to discover that the treatment that she had been given would not take effect for six hours. Another appointment was made, this time with a different doctor, also handicapped by poor English. She was finally put on a nebuliser, but only because of the intervention of the receptionist, who happened to be a trained nurse, as the doctor did not know how to use it.
Mr. and Mrs. T were gobsmacked when their daughter was seen by another overseas agency doctor who not only found it difficult to understand her—this has been an issue with the overseas doctors employed—but relied on an electronic word converter to communicate with the patient. He was also unable to communicate with other doctors. When the patient was eventually referred to Wheal Agar ward, it was discovered that the doctor had not provided her with the letter that she needed to present to nursing staff for any treatment to proceed.
I know that one or two regularly used agency doctors are good. However, I am talking about some of the temporary agency doctors who are called at short notice and for short periods, who do not know the best routes when out on multiple visits and as a result waste time and resources. Finally, patients have been let down at the final stages of care. More than 10 per cent. of patients do not have their details passed on to the GP by the start of the next working day, as is the standard. Patients have also been advised on numerous occasions that prescriptions have been faxed to their local pharmacy, only to find that the information has not been forwarded as promised.
The high complaint volumes are unsurprising, but they are only the tip of the iceberg. To add insult to injury, when constituents come to me or other MPs with complaints, we do not receive a response; or, if we receive any response at all, we are told that the issue is a matter of patient confidentiality. The patient might
be replied to directly, but we have no way of judging whether that reply is adequate. As I have said, I have raised issues that bear no relation to patient confidentiality, such as why it was not possible to receive an answer on the phone, but I was still told that patient confidentiality applied. Serco has assured me that that will no longer happen, as there are new routes of contact and new staff, but it should never have happened in the first place. That raises the question whether it is effective to use private contractors if they do not believe in proper lines of accountability through the elected representatives of the patients whom they are treating so badly.
When Serco saw me last week, it finally admitted all those errors. Serco sees them as part of a learning curve, but the question for the Minister is whether it is remotely defensible that the Government’s drive to use the private sector in the NHS should subject patients to, and put them at risk from, such an appalling learning curve. Serco also acknowledges morale problems among its staff and local GPs, and that it needs to sort that out. It certainly does, judging by the level of concern that has been expressed to me. Since this debate was called, my office has been inundated with calls from GPs and patients keen to add their problems to the list. GPs are particularly concerned that Serco has only recently dispensed with doctor standby altogether, so that if the service comes under pressure, there are no doctors ready to supplement the service. Doctors say that phones go unanswered. Clinics stay closed—sometimes those that are meant to be open—resulting in long journeys for some patients. That is another problem that Serco has acknowledged, but which we are yet to see put right.
Staff have also complained of being deprived of proper breaks and coming under a lot of pressure. That is true. Many of the staff who transferred to KUCS were from KernowDoc and were loyal to it. Surely one of the first priorities for any company taking it over should be to build the morale of staff, not to leave them jaded and disfranchised. The heavy reliance on agency doctors is partly the result of GPs refusing to work for KUCS. I understand that the situation is improving, but I should like to know how and what is being done.
KernowDoc thrived on good will and flexibility, as an organisation that the doctors had set up themselves. By definition, that was not likely to happen in the same way with Serco, but those considerations appear to have been ignored in the contracting process. GPs used to stay late. They wanted to provide a high level of service, because the service itself was theirs. They communicated for the sake of patients, sharing information and giving advice. They had trust in each other’s professionalism and support. That flexibility, communication and support has gone. Many of the GPs who have contacted me describe Serco as bullish in its managerial style, which has discouraged co-operation.
By definition, the agency GPs do a job and clock out, which is what I understand the management have encouraged. That is fine in an office environment, but not appropriate in health care. Many GPs have described the framework as difficult or even dangerous. Indeed, one GP complained prominently in the press that her prioritisation of patient need had been overturned by non-medically qualified administrative
staff working for Serco, who simply wanted GPs to get on to the next patient in order to meet the patient call-out times, rather than deal with what the GPs regarded as a dangerous position for the patient.
The ordinary staff working for Serco—the people answering the calls, the nursing staff and others—have similarly complained. Unison, the patient watchdog and the paramedics’ union, have all complained about Serco’s treatment of staff. They have complained about the number of staff who were made redundant immediately after transfer, which was 35 out of 122, that staff were forced to lodge employment tribunal claims to get the correct redundancy payments, that Serco failed to award an expected pay rise in April 2006 and that when it was granted in September, it was lower than the NHS rise and not backdated. Staff describe themselves as demoralised by petty cutbacks, such as no free tea and coffee, no Christmas party and other such elements. Again, Serco has admitted to me that it has a lot of work to do with its staff. Too right it has, judging from the responses that I have received.
Corners have been cut in an area where geography and scattered rural populations mean that out-of-hours health care is necessarily more expensive. My MP colleagues and I were sceptical when KUCS won the contract; it seemed unlikely that the service could be offered so cheaply. We were right to be worried. The fact that changes have been made—the recruitment of a lead nurse, an operational manager and a medical director—highlights how badly thought through the bid was in the first place. The Minister has to reflect on how it was possible for a contract to be accepted on those terms, given that the basic situation in respect of the lead nurse, operational manager and medical director was not right in the first place.
What now? The primary need is for patients to have a robust, reliable and quality out-of-hours service, whoever supplies it. They had that before, but do not have it now. The PCTs were told that they had to go through the process of tendering because KernowDoc was too expensive. They switched to a cut-price service, but—as they were warned—it has proved to be cut-rate. The PCT says that it is reviewing the contract. However, I am not going to call for an immediate change because the disruption of yet another contracting process, in which under Government rules there is no guarantee that yet another private company will not trial a service that it clearly does not know how to offer, will not necessarily result in the best outcome.
My first demand is that Serco should be made to put in place the quality of service that it is contractually obliged to, and that that should happen fast. It is clear that Serco is now embarrassed and that it knows that it needs to put the situation right, but it needs to be held to that. When its representatives spoke to me, they talked about needing three to six months to put the situation right; frankly, patients calling the service do not want to wait three or six months. That would involve Serco having run the service inadequately for a year of its three-year contract. It must be held to that now. The Minister needs to reflect on the accountability of such private services. Patient and GP complaints and a parliamentary debate should not be required to persuade Serco to offer an adequate service. The Government have a role as guarantor of adequate
health care in the NHS, and they must have a role in holding KUCS to its commitments.
The debacle is also an indication that the Government need to review the contracting process throughout the NHS for such private services, in respect of how they are originally offered, of the risks of cut-price bids that do not deliver the quality needed and, when things go wrong, of the speed of reaction in putting them right.
The Minister has a role to play for Cornwall in sorting the problem out now and for the nation in making sure that the use of private services does not make such problems occur in other places at other times; it is the one service offered by the country that is most important to every individual. When a person’s health or life are threatened, or when their child’s health is threatened, they need to rely on the NHS to give an adequate, professional and rapid response. I hope that the Minister will reflect that, when I raised the lack of response to the situation, it was not the right course of action to write me a letter referring me back to the local level.
9.53 am
Mr. Colin Breed (South-East Cornwall) (LD): I congratulate my hon. Friend the Member for Truro and St. Austell (Matthew Taylor) on securing this important debate. It is welcomed not only by his colleagues but by doctors and all the residents of Cornwall who have been exasperated at what has been happening in the past few months to a most important service. It should be remembered that we are talking about emergency services. When people access them, it is necessarily at a time of stress and strain and in an emergency, and they expect a response that recognises that emergency. However, we have a failure of a system that should work and was working extremely well.
We have all had complaints from patients, community groups, the ambulance service, doctors, doctors’ receptionists and even the staff of Serco themselves. Very few groups in Cornwall have not complained to us at some stage in the past year or so. Confidence in an important system has now been lost. People are beginning to wonder whether, if they call out of hours, they will get any service at all.
It is fair for us to recognise that when a system is changed, a period of changeover and preparation for that change will be needed, particularly for an emergency service. Nevertheless, there will always be some sort of learning curve. We accepted that, but the period needed to be short and clear so that the service could maintain its momentum and quality. Far from that being the case, we have seen a decline during the changeover period, and things have got worse and worse during the Serco contract. Last Christmas, that culminated in an absolute debacle: Serco said that it could not answer the phones because of a staff shortage due to illness. People ringing up for emergency services were not likely to accept that excuse.
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