Examination of Witnesses (Questions 20-39)
SIR IAN
CARRUTHERS, OBE, PROFESSOR
DAVID COLIN-THOMÉ,
MR GARY
BELFIELD AND
MR CHRIS
SHAPCOTT
22 MAY 2006
Q20 Greg Clark: To be clear, the
Department does not have a view as to whether the out-of-hours
service is urgent or unscheduled provision?
Sir Ian Carruthers: At this stage
we have not defined whether it is "urgent". Generally,
people understand "urgent" to mean care and treatment
given there and then with an appointment maybe the next day.
Q21 Greg Clark: How could you negotiate
a contract with GPs when you were not even aware whether or not
this was a service dealing with urgent or unscheduled care, since
clearly one will be used far more than the other?
Sir Ian Carruthers: The contract
was based on a broader range of issues, which was to say that
when people needed out-of-hours care they could access it by a
range of different routes. The precise definitions of those two
areas were not undertaken.
Q22 Greg Clark: You are the Accounting
Officer of the Department and I know that you had predecessors,
but if the Department was about to negotiate a contract why did
it not decide that issue then rather than start to think about
it now?
Sir Ian Carruthers: What we are
saying is that we now recognise that it is an issue.
Q23 Greg Clark: But the specific
question is: why did the Department not decide this before negotiating
the contract?
Sir Ian Carruthers: I cannot answer
that. What we are saying is that we recognise this is an issue
to be addressed.
Q24 Greg Clark: Do you concede that
it was wrong and you should have settled it before?
Sir Ian Carruthers: I am not saying
it was wrong or right. The out-of-hours service was about replicating
what was there previously. We have now got into definitional issues
which we have indicated will be taken forward as part of the White
Paper.
Q25 Greg Clark: These are not semantic
issues, because the Report makes clear that commissioners and
providers would like the Department to decide which kind of service
they should provide. It is so basic it is scarcely believable
that we are discussing it.
Sir Ian Carruthers: From the point
of view of the public, they want the ability to obtain access
either to advice and information or the services they need.
Q26 Greg Clark: I think that is rather
obvious for a committee that is looking at value for money. Of
course we want to give the public what they want, but in order
to provide value for money it is essential to know what the contract
is about and what it provides?
Sir Ian Carruthers: Yes, but value
for money is about balancing two things, the actual sums involved
and the service, and the view was taken not to restrict the service.
Q27 Greg Clark: Does the contract
with GPs represent value for money?
Sir Ian Carruthers: Do you mean
the GMS contract or the out-of-hours contract?
Q28 Greg Clark: The element relating
to the buy-out of out-of-hours services. Is it good value for
money?
Sir Ian Carruthers: I think that
it was——
Q29 Greg Clark: In your view—yes
or no—is it good value for money?
Sir Ian Carruthers: The answer
is yes. The £6,000 deduction from income very much helped
to improve some of the issues which were the nub of the contract
and were about recruitment, retention, and different working practices
and improved service quality.
Q30 Greg Clark: But we know from
Sir John's Report that doctors accepted a £6,000 reduction
in income but the actual cost of providing the service was £13,000.
Sir Ian Carruthers: Yes.
Q31 Greg Clark: Yet this was good
value for money?
Sir Ian Carruthers: It was good
value for money in the context of negotiating the overall contract,
because it was designed to secure the better recruitment, retention
and working arrangements for doctors. Many doctors who have now
had the contract adjustment come back and contribute to the out
of hours service.
Q32 Greg Clark: So, this was a good
deal?
Sir Ian Carruthers: In the overall
context of the contract one can say that.
Q33 Greg Clark: The fact that 90%
of doctors signed up delighted to be able to swap £13,000
worth of activity for £6,000 worth of sacrifice is coincidence?
Sir Ian Carruthers: Yes. It is
important to see this in the wider context of the GMS contract.
The contract also put in place a number of other matters, albeit
incentivised, to improve the quality of care. It is difficult
to pick on one specific issue when it is part of a package of
changes which have been agreed.
Q34 Greg Clark: You said that this
contract was a good deal, but you expected that its cost would
be £9,500. The Report said that you funded the system to
the tune of that amount and yet it turned out to be £13,000.
Is it still good value for money even though it is £3,500
more than you expected?
Sir Ian Carruthers: We allocated
in addition to the £6,000 income further sums which covered
rurality. That covered the £3,500. The implementation of
this was undertaken at local level by primary care trusts which
agreed different salary rates.
Q35 Greg Clark: Whatever was spent
on this would be value for money?
Sir Ian Carruthers: No.
Q36 Greg Clark: At what level would
it stop being value for money?
Sir Ian Carruthers: I think that
is a judgment given the local context.
Q37 Greg Clark: I am interested in
your judgment, Sir Ian.
Sir Ian Carruthers: I would not
make a judgment because this was handled at local level. One matter
I want to raise is a point mentioned in the National Audit Office
Report, namely that if everyone worked to the ability of the best
a sum of money would be saved which would be less than the allocation,
and if 50% of the providers worked to that standard we would virtually
be back within budget.
Q38 Greg Clark: But 90% worked to
it?
Sir Ian Carruthers: No; it is
50% refers to the out-of-hours providers in contract with the
others, and the GP figure is the other one.
Q39 Greg Clark: Did the Department
take an active role in these negotiations which clearly are so
crucial to all our constituents and the finances of the NHS?
Sir Ian Carruthers: The Department
set the framework. The negotiations were undertaken by local primary
care trusts. As the Report says, that was done either through
competitive means or otherwise.
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