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20 Feb 2007 : Column 7WHcontinued
It seems that Serco has followed its usual practicesit has a track record in other areas. It bids for Government business, promising much and to do it for much less. When everything goes wrong, it toughs it
out and tries to make excuses. It then tries to make such improvements as are minimally necessary to maintain its profitability at the minimum quality of service that might just get it through its contracts. Frankly, that is totally unacceptable, particularly for an emergency service.
It is time to expose those practices. Surely the Government, who have worked with Serco for a long time, have recognised the trait that I have mentioned. As my hon. Friend said, Serco needs to live up to its promises and be exposed to real financial penalties if it fails to do so. If improvement is not forthcoming, it needs to be clear that it will lose the contract. Only through such a profitability motive might it begin to understand that it has to live up to its promises.
The Government profess to want value for money, when in this context all they are interested in is cutting costs. We had a good, reliable and robust service that had the confidence of doctors and patients. It was professional, caused no one to complain to us and was run on a no-profit basis. For us, that was value for money and seemed to deliver all that we wanted at a cost that did not produce a profit. We now have a service that still demands millions of pounds, but the money goes to a profit-motivated commercial organisation providing an appalling service. I fail to understand how that gives us value for money.
In their wisdom, the Government decided that they wanted a change, and they arranged the process of change. They helped to pick the winner of the contract. The disastrous result is their fault and it is up to them to fix it, and quickly. Unless they do, lives will be lost.
Julia Goldsworthy (Falmouth and Camborne) (LD): I, too, congratulate my hon. Friend the Member for Truro and St. Austell (Matthew Taylor) on securing this debate. Every single MP with a constituency in Cornwall has been inundated with correspondence on the issue since what my hon. Friend the Member for South-East Cornwall (Mr. Breed) described as the debacle at Christmas when so many people found it impossible to get through on the telephone and to access the services that they needed in an emergency.
I should like to expand on the background to the award of the contract. Let us not forget that it was awarded in the midst of the reconfiguration of primary care trusts in Cornwall. The concern is that a lot of attention was being focused on what the new PCT would look like and how it would manage the fact that some existing trusts were in deficit and others were in balance. In the context of that massive disruption and uncertainty about the future, the main motive was to find the cheapest possible service. That, not cost-effectiveness, was dictating what it was looking for.
We all accept that KernowDoc did not provide a cheap service. One general practitioner described it as a Rolls Royce out-of-hours service. The company recognised that Cornwall is geographically isolated, that it cannot pull in resources from other areas because it is a peninsula, and that, in the main, it is sparsely populated. It recognised that those aspects had to be reflected in where services were provided. We now have a contract that focuses services in a small number
of areas, which makes it difficult for many people to access out-of-hours services. Even if they were able to get in a car and travel to such services, they would still have to make a significant journey.
That draws us back to the point that all of us in Cornwall have been making for a long time about whether the county gets the funding that it needs to provide services. Unfortunately, it does not, and that was once again reflected in the decision on the Serco contract, which has resulted in a poorer service for everybody in Cornwall.
In the summer, we were told that the appalling response rates were due to teething problems under the new contract, and that they would be resolved in a few months. The problems were not isolated to out-of-hours care. They had massive knock-on effects on other emergency services. Ambulances queued for up to five hours outside accident and emergency at Royal Cornwall hospital in Treliske, which meant not only that that hospital was at full stretch but that the ambulances were not on the road trying to cover the massive geographical area. It also meant that the Cornwall air ambulance, which is charitably funded and which extends emergency cover across Cornwall, had to do things such as nursing home transfers because there was not a single ambulance available to do that. We cannot consider the problems in isolationthey have important knock-on effects on other services.
When the issue came up again at Christmas, the concern was that the difficulties were not due to teething problems but to a complete inability to deal with Cornwalls entirely predictable seasonal fluctuations. For instance, we know that Cornwalls population doubles in the summer, which has important implications for demands on the service. Moreover, the fact that the countys main arterial roads are often entirely blocked for large parts of the day affects peoples ability to access the service.
It is very difficult to get information from Serco. The repeat of the problems at Christmas prompted my hon. Friend the Member for North Cornwall (Mr. Rogerson) and me to undertake a survey of GPs and ask for details of their experiences, and I understand that some of the material that has been used today was accessible only after a freedom of information request from the PCT.
The survey has resulted in a mass of correspondence from constituents and GPs keen to relate their experiences. I shall start off with some peoples personal experiences, beginning with those of my sister, who developed an allergic reaction on Christmas day and started having breathing difficulties. We do not know the cause, but she has experienced similar allergic reactions in the past and, on this occasion, was struggling to breathe. Fortunately for her, we live near the most densely populated part of Cornwall, and someone in the household was able to drive a car. Although we had to wait on the telephone before we got hold of someone, we were eventually told that, if we could get her to a doctor, she could be seen. Because we had a car, we were able to get to a doctor and a pharmacy to access the services that we needed.
Unfortunately, that is not the case for many people. My hon. Friend is not here, but he has said on many occasions that people in Bude, on the northern-most tip of Cornwall, have been told that the only way that they could access services was by getting to Pool. For
people with a car, that is an hours drive on a good day. I would not even attempt to make that journey on public transport, because I am not sure that I would ever get there.
Another constituenta terminally ill patientrang the out-of-hours service over Christmas for pain relief. He was dying, and he wanted to die at home. Despite his wish, he was told that he would have to dial 999 because that was the only way he would get an injectionan injection that could be provided at home. The out-of-hours service did not have the capacity to help that person die with the dignity that he wanted.
Another constituent, Mrs. H, wrote on behalf of her mother-in-law who is 85 and who was unwell on new years eve. When she phoned at 11 oclock in the morning, she was put on hold. Her daughter-in-law got through to the operator at 2 oclock that afternoon. She explained the difficulty and was told that it would be about three hours before a GP arrivedthat is, six hours after the first call at 11 oclock. At 5 oclock, they received a call from a doctor asking what the problem was. The daughter-in-law said, I thought that you would be calling, but he said, No, I am just triaging the call.
At that point, the daughter-in-law got in a bit of a strop. She was told that the call would be put through as urgent, which meant another wait of three hours, or that they could contact the paramedics. That is what was happening: people were experiencing that kind of wait, then massive additional pressure was put on the paramedic service.
When the daughter-in-law rang again to find out why the call had not been dealt with at the time, she was again kept on hold. There were only five cars on call in Cornwall that day. It is clear that the out-of-hours service was totally unable to deal with demand that it should have been able to predict.
The surveys have gone out in the constituencies of Falmouth and Camborne, and North Cornwall, and they are still coming back. The forms went out in the past two weeks, but already we have had a response rate of more than 50 per cent. Ninety per cent. of GPs believe that the quality of the out-of-hours service has become worse since Serco took over in April last year, and 80 per cent. said that they have received more complaints since that date.
One of the most worrying statistics is that 95 per cent. of GPs worked for the out-of-hours service when it was run by KernowDoc, but only 15 per cent. of those surveyed continue to do so. We are trying to meet the demand for services from elsewhere, and there are all kinds of horror stories. I heard one anecdote of a doctor from somewhere else in EuropeGermany, I believewho paid for a holiday in the south-west for himself and his family by providing cover for one day. What impact does that have on continuity of care? Other examples involve doctors prescribing antibiotics that are not usually prescribed in the UK, resulting in a massive run on the particular brand to the point that the pharmacies ran out completely and were then at a loss as to what they were supposed to be providing.
I appreciate that self-interest will be reflected in GPs comments, but they show that GPs and their patients are worryingly lacking in confidence. One doctor said
that patients now receive a less personal service, and that morale among staff working for the urgent care services has plummeted.
As my hon. Friend the Member for Truro and St. Austell said, in the past a huge amount was done on the basis of good will. Then, the huge fluctuations in demand were dealt with out of good will, but now it appears that they are not dealt with at all.
Doctors also cite the increased use of the nurse triage system as a cause for concern. I understand that that is national best practice, so perhaps the Minister will comment on whether similar reports are coming back from other urgent care providers about the adequacy of nurse triaging. As has been said, fewer cars and clinics are available at any one time. People are having to travel further, and in Cornwall the logistics of that make things very difficult.
It is clear and undeniable that there are problems with the out-of-hours service. They cannot be considered in isolation, as they have knock-on effects on the ambulance service, emergency care practitioners and accident and emergency provision. As I said before, the issue brings us back to the fundamental question, which has not been adequately answered, of whether the county gets the resources that it needs to deliver essential services. We can undertake a strategic review in the county but, ultimately, the service was taken on because it came at a lower price. We are getting a lower level of service as a result, and that is very much a concern.
I want assurances from the Ministerreiterating those asked for by my hon. Friendthat the tendering process will be improved, so that there will be real understanding about whether the bottom line of the tendering process will mean that services will be delivered to meet the need in the area. Will Ministers reconsider the funding levels?
We do not want the removal of Serco: what we want is a level of service that meets peoples needs. Ultimately, and unfortunately, we have reached a point where we need ministerial assurances to ensure that that is delivered. Serco has no democratic accountability, and neither does the PCT. We want assurances from a source with genuine accountability, and that means that the matter rests on the Ministers desk.
Andrew George (St. Ives) (LD): I join others in congratulating my hon. Friend the Member for Truro and St. Austell (Matthew Taylor) on securing this important debate. I concur with his remarks and those of my hon. Friends the Members for South-East Cornwall (Mr. Breed) and for Falmouth and Camborne (Julia Goldsworthy).
Since the service commenced in April last year, it has notably failed in comparison with its predecessor. It must be acknowledged that KernowDoc and those involved with itthe service that preceded the Kernow urgent care out-of-hours serviceswere more expensive, and perhaps more expensive than necessary. Efficiencies needed to be secured, and many of the GPs involved accepted that during the re-tendering process. The debate
does not reflect the sour grapes of GPs who were engaged in organising the out-of-hours service at that stage and who feel badly about the service that is now in place. The complaints are coming from patients, not from GPs, and that is an important point.
Many of us have been reflecting on the failure of the telephone system and of the service to respond to patient need during the Christmas period. In particular, there was a failure to respond to the needs of patients who were in difficulty, pain and distress over a period when GPs surgeries were not running, and who did not want to take themselves off to clog up the local accident and emergency service in Treliske or the casualty service at West Cornwall hospital. It was interesting that just before the Christmas period, on 21 December, because we had gone through the many concerns about the adequacy of the service, the primary care trust put out a press release anticipating the problem. Having discussed past failures of the Serco-run service, the trust stated:
The service has learned from
experience and changed the contingency plans to make sure they respond quickly to changing or unexpected circumstances in future.
The ink on that press release was hardly dry when the telephone service failed. Patients in desperate need were unable to get through, GPs supporting those patients were unable to get through and, when patients turned up unnecessarily at the casualty service in West Cornwall hospital in Penzance in my constituency and formed queues, the casualty service telephoned the out-of-hours service and it could not get through either. In the end, they all had to phone the ambulance service. That was the nature of the seriousness of the failure, immediately after a public reassurance that contingency plans were in place to cope with the Christmas pressures.
I am concerned not only about the way in which the service is managed and its failure to meet its targets, as my hon. Friend the Member for Truro and St. Austell ably pointed outKernow Urgent Care Services are hitting or near to hitting few of the targets set out in the original contractbut about inside information that suggests that the PCT is not undertaking independent verification, and that the targets are monitored, and heavily massaged, by Serco. We have doubts that the service is performing even at the poor level reported in the targets, and we could get copies of those targets only by making freedom of information requests. The whole thing does not read well at all, as I am sure the Minister appreciates.
We must consider the matter in the context of the ambulance service in Cornwall. We do not expect the quickest ambulance service because Cornwall is a long peninsula and difficult to cover for category A calls. Although we want a better service than we currently have, the out-of-hours GP service comes on top of a service that we already know to be overstretched. The South Western Ambulance Service NHS Trust has difficulty in providing both category A and B responses in a rural and remote area such as ours. The further west one goes, the poorer the response. Although the ambulance service is often slower than the target time for category A calls, at least people support the service and understand the pressures that it is under. If
ambulances are being called out unnecessarily because the out-of-hours GP service is failing, and they travel all the way from the far west of my constituency up to Truroa 40 mile journeyand queue up outside the accident and emergency service at Treliske, that will take up a lot of ambulance time. The problem is not only the failure of the out-of-hours GP services, but the knock-on effect on the health service, the urgent care service and the accident and emergency services.
Mr. Breed: Does my hon. Friend agree, therefore, that any savings that might have been made in the contractual arrangements with Serco have been totally dissipated by the additional costs to the ambulance and hospital services?
Andrew George: I agree entirely. The additional costs are lost in the service and add pressure on the Royal Cornwall Hospitals NHS Trust, which is already under budget pressure because it failed last year to turn around the deficit from the previous year. The additional pressures do not help the trust to achieve a recurring balance, which is what it is attempting to do.
We warned that there would be unnecessary journeys to accident and emergency and, possibly, unnecessary admissions. We argued, too, that we expected the use of less experienced doctors who did not know the patients or the area so well, which would mean more unnecessary emergency out-of-hours hospital admissions and put pressure on the trust.
In January 2006, I received a letter from Brian Steggles, chairman of the faculty of pre-hospital care at the Royal College of Surgeons of Edinburgh. On the subject of pre-hospital care and urgent GP care, he wrote:
We have therefore developed considerable expertise in the setting of standards and training in this most important area of medicine and with this background have grave concerns about the quality of out-of-hours emergency care that may be provided by a commercial organisation both in Cornwall and indeed elsewhere throughout the United Kingdom. With recent involvement with one of the providers of offshore medicine and the use of eastern European doctors I would equally share concern if Serco should seek to use this type of cheap labour.
The warning was made before fulfilment of the contract was entered into.
We all have anecdotes. I have one from a GP, who referred to a patient and the treatment of that patient just before the Christmas period. He summarised the situation by saying:
It seems that the patient and family were lied to, that the patient was given an inappropriate prescription, that the patient suffered unnecessarily, and that an additional visit was required. All in all not a very professional service, particularly in view of the high standard of the initial triage.
I have a letter from another constituent, whose name I will not give, who lives in the west of my constituency. He wrote to complain about the length of time that Kernow Urgent Care Services had taken to respond to a call. He said:
I phoned at 20.30 on 2nd August 2006, explained my wifes condition (she has liver cancer) to the operator and that she was in extreme pain. The operator said my wife would be the first visit when the doctor came on at 22.00. However, the doctor did not arrive at our house until 23.40.
Later, my constituent wrote to complain about the service, saying that he had other experiences of having
to wait for more than three hours for Kernow Urgent Care Services to visit the patient. On 30 September, he wrote:
On the evening of 26th August I called Serco at 18.25 to advise my wife had passed away. The doctor did not arrive until more than 3 hours later.
The situation is unacceptable. Prior to the commencement of the contract, we were given reassurances through press statements by primary care trusts. For example, the chief executive of the West Cornwall primary care trust, who largely led the negotiations, is quoted in a press release of 16 December 2005 as saying:
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