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20 Feb 2007 : Column 14WHcontinued
Serco Health has a very good track record in providing out of hours service in Cardiff and North Oxfordshire.
At that stage, however, it did not have much experience, as the contracts had only just commenced. [Interruption.] As my hon. Friends point out, those services were not carried out in such a rural area.
On 27 February, just before the contract was to be implemented, the out-of-hours project manager sent out a question and answer paper. Among many reassurances that we were given at that stage, we were told:
The company will have three clinicians on stand-by, whom they will call upon when needs be. The stand-by doctors may be called in periods of extreme pressure, but also be called upon to see a single patient only.
We have already heard about the effectiveness of their response to problems of extreme pressure.
The problems have been amply expressed by my hon. Friends. GPs have told me of their problems with the service, with more patients being admitted to hospitals, fewer patients visited and some doctors having less experience. However, we also have a major opportunity. Under practice-based commissioning, many GPs say that if it were not for a contract with SERCO they could negotiate a wrap-around service. The Government have the opportunity to intervene and to help local communities. It has always been my view that public service for private profit will not work, especially not with emergency care. Public service is not best run if it is compromised by having to produce shareholder dividends.
I finish with a question. Given that Serco is failing to meet its targets, what provision is there for the PCT either to renegotiate the contract or to withdraw from it to find better ways, through public service and with public servants, to provide the more than adequate out-of-hours service from GPs that I know our local communities are crying out for?
Dr. John Pugh (Southport) (LD): I congratulate my hon. Friend the Member for Truro and St. Austell (Matthew Taylor) on securing this debate. It will be agreed, I think, that Cornwall is well represented here.
I knew little about the problems of Cornwall until I started preparing for todays debate, but I already knew of Serco, because it runs the railway trains that pass my house. However, I know a great deal about the problems of out-of-hours cover, because in my neck of the woods it is provided by UC24, a private organisation. Over the Christmas holidays, doctors wrote with grave concern about its delivery of services, offering resignation as the only way to trigger action.
When comparing the two, the stories are oddly familiar. We have an out-of-hours service contracted to a private companyin Cornwall it is Serco, in Southport it is UC24. They both replaced a GP contract system. KernowDoc was described by my hon. Friend the Member for Falmouth and Camborne (Julia Goldsworthy) as a Rolls-Royce service. In my neck of the woods, the Southport out-of-hours service was described by the local primary care trust as a blue ribbon service. The switch to a private company was based primarily on cost.
The histories, too, are uncannily similar. There have been quite unacceptable waits in my area. In one case, a gentleman had to wait eight hours to be admitted for urgent bowel surgery. In another case, doctors had to come from afar to get to the patient. We also suffer the problems of poor handling of calls and of triage and local doctors are protesting. We sense that the service is absolutely on the edge, especially at times of peak demand, which are often predictablefor instance, Christmas and bank holidays. In fact, some legal cases are pending as a result of the poor delivery of service.
When it comes to the facts, we are up against similar phenomena, including issues of confidentiality and commercial secrecy. The Cornwall data was wheedled out only under the Freedom of Information Act 2000 and because of action taken by a local newspaper, the Western Morning News. In my neck of the woods, an IT specialist who worked for UC24 had resigned; wanting to say why, he found himself the victim of a gagging order and had to use the Freedom of Information Act to get information out of Liverpool PCTthings that he already knew but that he wanted to put into the public domain.
We then come up against a lack of adequate monitoring. Essentially, the monitoring is done by aggrieved patients reporting to their MPs who then raise the matter in Parliament. That is not the right way to do it. When UC24s contract was extended in my area, the PCT did not have a report on its previous performance. There is a general lack of transparency and clear accountability for the servicebut, hey, its cheap. That is why it is preferred. That reinforces the conclusion of the recent National Audit Office report on the clinical governance exercised by PCTs. In paragraph 11, it states:
Implementation of clinical governance is weaker where PCTs have to work with others to deliver services with PCTs needing to build quality, more explicitly, into commissioning decisions.
Clinical governance links between PCTs and independent contractors are undeveloped.
It would be nice to believe that we are talking about isolated incidents, that in principle there is nothing wrong with delivering an out-of-hours service via a private contractor, and that all that is required is that the commissioning should be smarter. I am not convinced. I have no a priori argument; however, I suggest that it is at least a high-risk strategy. Essentially, it involves subcontracting the NHS responsibility to deliver basic health entitlements to a private, profit-making firm, subcontracting almost the entire responsibility during the hours of darkness, when most are likely suddenly to fall ill. At the least, that must reduce accountability and
transparencyunless we get rid of commercial confidentiality. It also reduces the control of the responsible bodythe PCTbecause control by contract is not the same as hands-on control.
In addition, the system will be burdened with extra costs, which in a sense are the shareholder profits alluded to by hon. Members. Frankly, few blessings are brought to the table from the market because in real markets organisations respond to clients, clients demand better services, and organisations lose out if they do not provide improved services to sharper and better-equipped clients.
In the Serco model, the client, the PCT, and the quango are not the recipients of the service. The recipients are the patients, who communicate only indirectly with the PCT. No one is suggesting that we have an on-demand service, but once the contract is in place there is little real effective competition. This model is not like Sercos rail division, which is extremely successful and delivers an excellent service in the Mersey area. In relation to that model, as long as the contract is properly drafted, more customers equal more profit. People can make as many journeys as they wish and they have alternatives if they do not want to use the rail service.
It is not as if changes are being proposed because contracts bring substantial blessings from a private contractor or a market economy. Such contracts are not doled out because efficiencies need to be made and they do not deliver much private sector acumen because, frankly, many staff are simply transferred from other parts of the NHS. Changes are proposed because, to put it explicitly, contracted-out services are relatively cheap. As I said, services that are abandoned are described as blue ribbon and Rolls-Royce and new services are recommended simply because they are more cost-effective or cheaper.
At the end of the day, we do not need smart commissioning; we need smart marketing. It is difficult to persuade the public that when they get something new they do not also get something substantially second rate.
Tim Loughton (East Worthing and Shoreham) (Con): I congratulate the hon. Member for Truro and St. Austell (Matthew Taylor) on this debate, which has certainly warmed up, although I fear that Westminster Hall has not mirrored that. We will struggle through the last half an hour of the debate in this chilly Chamber.
The hon. Gentleman and his colleagues raised a catalogue of failures by this part of the health service in Cornwall. As he said, the service is unfit for purpose and he and his colleagues confirmed that it is putting the health and the lives of their constituents at risk. That is simply unacceptable. The hon. Gentleman also said that during his time in Parliament, which may soon be coming to an end, it is unprecedented that he has had to bring a local health matter to the attention of the Chamber. That underlines the seriousness of what is going wrong in Cornwall with this service. I hope that such problems are an isolated incident. I do not want to take against new configurations per se, but
the Department of Health has a key role and interest in learning from the lessons that are now painfully being learned in Cornwall.
We are again talking about health issues in this Chamber and about the failures within the health service. Such debates are becoming a regular gig for the Minister, myself and other Front-Bench spokespeople on health. This is another debate involving deficits, bungled reorganisations and, above all, complete discontent among patients, who are at the heart of the NHS, what it stands for and what it is there to do. Today, there are reports in the papers that civil servants in the Department of the Secretary of State for Health have lost all confidence in her and the Governments ability to run the health service. It is of little surprise that we are again here to debate shortcomings in the NHS after 10 years of this Government.
Clearly, hon. Members have raised several common themes relating to this problem. Professionals and patients have lost confidence in the service. The previous service, KernowDoc, was a Rolls-Royce service that worked rather well. It might not have been as cost-effective as other services, but it worked well and as the saying goes, If it aint bust, why fix it? A further problem is that poor information is provided by the new operators of this service and even Members of Parliament have to resort to freedom of information requests to find out exactly what is going on. That is surely unacceptable.
GP survey findings show that the service has become worse. It is not just a few whingeing patients raising concerns, it is the entire population of Cornwallpatients and health professionalswho are united with their local councillors and MPs in condemning the way the service is run. Despite the reassurances that hon. Members have had from Serco, things are still going wrong and this is resulting in enormous, acceptable and unsustainable pressures on the 999 emergency services. As the hon. Member for South-East Cornwall (Mr. Breed) said, these are false economies if they shift costs to other parts of the NHS, where they may be higher.
What has been achieved by the people who have raised concerns in Cornwall? There have been many complaints and the patient forum for Cornwall and the Isles of Scilly primary care trust has asked people to come forward with their experiences. The chair of that organisation, Mrs. Hewett-Silk, has said that she wants to hear from GPs. She is quoted as saying that since Serco took over, very few doctors in Cornwall have worked with the service and she wants to know why. The hon. Member for Falmouth and Camborne (Julia Goldsworthy) said that 95 per cent. of GPs used to work for the out-of-hours service and that that is now down to 15 per cent.. That shows that many GPs have voted with their feet. There was particularly heavy criticism of the service over last Christmas between 23 and 27 December, when the service took about 3,500 calls, which is 10 per cent. more than the out-of-hours service took during the same period in the previous year. Serco had nine months to prepare for that situation and knew that GPs surgeries would be closed over the Christmas period. When Serco took over the contract last April it restructured the administrative, finance and personnel teams. That resulted in many redundancies and perhaps we are now seeing the implications of that.
Problems with the service include slow response times and, in some cases, responses were non-existent. The ambulance service has complained about excessive use of the 999 service and ambulances. As hon. Members have mentioned, that also puts pressure on the air ambulance service and results in queues at the Royal Treliske hospital. Great pressure has been put on the accident and emergency department, as going to hospital has simply been the only way people can receive a service. There have been instances of serious misdiagnosis, and treatment by doctors who have an inadequate grasp of the English language and British medical procedure. Many doctors are drafted in from eastern Europe on a temporary basis. People have had to wait hours to be called back or given an appointment and, if they have use of a car, have had to drive considerable distances, particularly over the Christmas and new year period. There has been little sympathy and concern from Serco when patients call and are unable to get through at all. Those are all experiences that hon. Members have relayed from their constituents.
There are concerns among patients, doctors, professional counsellors and MPs. Indeed, my colleague, Sarah Newton, who is a prospective parliamentary candidate for Truro and Falmouth, reports similar findings about the service from her own survey of patient care. She has been working with Sue Hindle, the chairman of the association of friends of Cornwall hospitals, who will be monitoring the situation with Ann James, the new chief executive of the PCT.
There are serious questions to be answered. In particular, the Minister might wish to comment on why Serco was considered better than others to take over the contract. The South Western Ambulance Service NHS Trust made a bid to take on the contract. It has considerable local experience and already runs out-of-hours services in Dorset and Somerset. Given the Governments drive to centralise the health service and bring parts of it together in bigger and, we are told, betteralthough that is highly questionableservices, why did they not take the decision to co-locate such services with the ambulance service call centre and NHS Direct? It would have made a lot of sense to bring local knowledge together in one organisation. Instead, the service has been fragmented and that flies in the face of what the Government are trying to do elsewhere in the health service.
We welcome the fact that, very belatedly, Serco has woken up to the fact that it has messed up and must do something about the problems and take them seriously. A Serco spokesman has said:
We are looking to make progress in introducing best practice into the out-of-hours service, which includes a nurse triage system. We are committed to delivering an excellent service to the people of Cornwall. We are open and transparent about our performance and where improvements are needed we hold our hands up and take action.
That represents a rather significant disconnect from reality, given the testaments that we have heard from hon. Members, based on the experiences of their constituents.
I therefore have a series of questions for the Minister, many of which echo questions that we have already heard in the contributions from local Members of Parliament. How was Serco selected, particularly against other, local bidders who had a good deal of experience
and local knowledge? How are the systems being monitored by the Department of Health? It will not wash for Ministers in that Department simply to say that data are not collected centrally. The developments in the health service in Cornwall are strategically important with regard to other similar developments that may be happening elsewhere in the health service. Surely the Department of Health is monitoring the situation closely to assess whether the experience is a good one, whether the application and bidding process needs to be changed and whether better monitoring needs to take place. What monitoring is done by the Department or by the Ministers colleagues?
Who oversees the complaints procedure? Given the demise of community health councils and the various things that have followed them, exactly where do patients go to complain? We have heard from the hon. Member for St. Ives (Andrew George) that much of the monitoring of the service seems to be done by Serco itself, so where is the independent monitoring of whether what is being delivered is cost-effective, is of sufficiently high quality, complies with the contract that Serco was given and is doing what patients and professionals need it to do? Who is responsible ultimately for monitoring the quality and the independence of that monitoring?
What effect has the situation had on A and E admissions? Have the Government done an assessment of whether there has simply been a shifting of the problem and of the financial liability, which may end up being a bigger financial liability? What have the extra costs been on NHS Direct? What have the extra costs been on the hospital at Treliske?
Serco gave an extraordinary excuse for the problems experienced last Christmas. It had to do with staff sickness. I wonder where those staff went for their treatment if they had to call for an out-of-hours doctor, given that they would not have been able to get through on their own telephone service if they had the experience of other patients with whom it was supposedly dealing.
What locum cover arrangements are such firms expected to provide? We have heard that many agency staff have been employed, despite questionable qualifications and an inability to do the job. If, as I think was mentioned, the PCT is reviewing the contract extraordinarilynot as part of a routine reviewwhich is to be welcomed, what break clauses are expected to be placed in such a contract? What penalties may fall to the company or, more worryingly, to the PCT for early termination of the contract?
Clearly, what may have happened is that the national health service in Cornwall is paying more for less; for a service of lower quality. Is that happening elsewhere? We need assurances from the Minister that the Department of Health is on to this. A BBC investigation for File on 4 in 2005 found that the NHS was not meeting targets to see patients who needed emergency GP care outside normal office hours. Data from 21 PCTs obtained showed that one in four was not meeting the target of 90 per cent. of patients being seen within an hour. In some cases, the target was met in only 13 per cent. of cases.
On 28 November 2006, the Secretary of State said:
The result of the new contract is that GPs are providing better services for patients according to the quality and outcomes framework, and doing much more work on prevention and long-term care.[Official Report, 28 November 2006; Vol. 453, c. 956-7.]
How does that gel with what has been happening in Cornwall? I gather that the new snitching website that the Secretary of State has set up, for reporting on the quality of GP services, does not include the out-of-hours service, which is perhaps unfortunate.
Patients should be able to expect from the new service high-quality clinical treatment, good responsiveness, good access times, good communications and good accountability. I fear that in the case of the service in Cornwall, none of those has been achieved. The Minister needs to look seriously into why that has happened.
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