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"the current system does not adequately safeguard patient safety."
The Minister must ensure that he completes the immediate implementation of the Department of Health report "Tackling Concerns Locally", which has been collecting dust in the Department since March 2009. Will he address the concerns of the GMC and lobby for a change to EU law, to ensure proper skills and language testing for doctors who wish to practise in the UK? Will he consider including in the process of revalidation locums and doctors from the EEA who are working in the UK, and will he ensure that access to the performers list is tightened and that there is a much greater flow of information between PCTs and the GMC? As far as I understand from what the Minister said, there is still no mechanism in place to ensure that a doctor struck off in another EU country cannot practise in the UK.
To put it mildly, this is not the Government's finest hour. It has taken the tragic death of Mr. Gray for action to be taken, despite persistent and consistent previous warnings. This is a serious situation that will be resolved only when the Minister accepts that in some geographical areas the system of out-of-hours care has failed; when, as the Royal College of General Practitioners recommends, a comprehensive review of out-of-hours care takes place; and when the Government accept, for the sake of patient care and safety, that responsibility for commissioning out-of-hours services must be with GPs.
Mr. O'Brien: I certainly agree with the hon. Gentleman that we must ensure that we do all we possibly can so that this sort of incident never happens again. That is why we responded to a series of reports and ensured that after the Carson review on out-of-hours services, we changed things-it was clear that the system that existed before 2004 was unsafe; therefore, changes were put in place.
We do not want a situation in which we return responsibility to GPs for the management of out-of-hours care, as appears to have been suggested. Dr. Laurence Buckman of the British Medical Association has been very clear on that. He said:
"The old system meant many doctors were tired and therefore potentially dangerous to patients and it is for that reason that the BMA, and the GPs it represents, would resist a return to doctors taking back personal responsibility for delivering care out-of-hours."
"The current out-of-hours system desperately needs improving, but we can't go back to where we were before 2004 where doctors were on call 24 hours a day, meaning many were operating in a constantly sleep-deprived state."
We need to ensure that we deal with some of the issues that exist in the current system. I think we all, as parliamentarians, need to confront the issue of decentralisation of power. We have been pushing down responsibilities to PCTs. That is all very good, and there is a broad consensus in the House that that should happen-the closer to the patient, the better-except some PCTs are more capable than others of doing a good job. That presents us with the question how best to manage that. We have taken the view that we need to bring about two changes. First, we need much more central involvement by the Department of Health in ensuring that PCTs have minimum standards, through a model contract. All PCTs must ensure that providers comply with that contract. Secondly, we need to get local GPs more involved-that does not mean giving responsibility back-so that they can monitor the quality of the out-of-hours service that is being delivered.
The hon. Gentleman set out the concerns expressed in the report by Dr. Colin-Thomé and Professor Field. I remind him that that report was commissioned not after the coroner's report last week, but on 23 September last year. Indeed, discussions on it took place with those involved before that time, because we knew that we needed to ensure that we improved out-of-hours care. I want to have further discussions with the doctors' organisations on some of the coroner's recommendations, but in a broad sense, we accept them. We must go through some of the detail with the doctors' organisations on how that will be done.
When can we put those changes in place? I have said very clearly to officials that I want it done by the end of the year. I want to be sure that we have got the system right by then at least. I was asked how that would be monitored. For the next six months PCTs will be required to have on the agenda of every board meeting, at least once a month, the quality of out-of-hours care and its improvement. That will be monitored by the SHA. Thereafter, PCTs need to take a higher level of responsibility for it.
There are three checks on foreign doctors from the EEA. First, the GMC checks their medical qualifications. Secondly, since 2004 the PCT is responsible for checking that they speak English and that nothing is known about them that undermines their medical capability. Thirdly, the employers are responsible for ensuring that the GPs whom they employ not only speak English, but are clinically competent. In some cases it is clear that some PCTs have been a weak link. Some have not always complied with their responsibilities.
The GMC, as was pointed out, has indicated that it would like to do some tests on GPs who do out-of-hours work. It was clear from the Medical Act 1983 that the GMC could not carry out such tests, and it cannot do so under the directive which has been renewed but predates that. In 2004, therefore, the responsibility for ensuring that English was spoken was given to the PCTs. Most of them have delivered on that. Some have not, and that is what we need to change.
The EU law will be reviewed in 2012, so the directive will be reviewed in any event. We must ensure that we examine the detail of that. However, we cannot wait until then. We must put in place safety checks to ensure that this year the lessons of that tragic death are learned and that Mr. Gray did not die in vain.
Norman Lamb (North Norfolk) (LD): I, too, thank the Minister for early sight of the statement, and I join in the expressions of sympathy and condolences to the Gray family. The two sons of David Gray, Rory and Stuart, want something positive to come out of their personal tragedy and I hope very much that that is the case. The system ultimately failed their father in allowing Dr. Ubani to practise in this country. Also, it failed the family by failing to ensure that he appeared before a court in the United Kingdom following a police investigation into what happened.
I welcome the report and the recommendations, but why the delay? A report on the performers list was published on the Department's website last March. That is 11 months ago. Why has it taken this long for the Government to respond to those recommendations?
Will anyone be held to account for the failure of Cornwall PCT? The Minister says that there are legal duties, but they are of no value if nothing happens when they are breached. The House was informed in February 2007 of doctors working in Cornwall with inadequate language skills. That was before Dr. Ubani was registered by Cornwall. What action was taken and who will be held to account for that? Will the Minister consider introducing a criminal offence of PCTs failing to protect patient safety, in order to give some teeth to the regulations?
The greatest safeguard of all would be to prevent a foreign doctor who has inadequate language skills or competence from registering with the GMC. The EU directive allows a regulator to satisfy itself on language, but the Medical Act, as the Minister said, needs amending. Will he consider amending it so that, under existing directives, the GMC could test language skills? Will he agree to lobby for EU reform to protect patients, as the GMC accepts is necessary-first, to allow a test of competence; secondly, to require immediate notification of suspension across Europe; and thirdly, for suspension anywhere to apply everywhere that that doctor is allowed to practise under the freedom of movement of labour?
Does the Minister share the GMC's view that patients should have a right to safe and good-quality health care across the EU and to safe doctors? If so, these reforms are necessary. Does he agree that training in UK prescribing practice and medicines use-along with an induction and assessment-is essential before a doctor from overseas starts to practise in out-of-hours care? Will those requirements be part of the minimum standards? Does he agree that providing for a minimum number of local GPs on duty, particularly in widely dispersed rural counties, must be part of those minimum standards?
A European arrest warrant was issued in the Dr. Ubani case, but it failed to be effective because of action taken by Germany's authorities to prosecute him on a minor charge in that country. Co-operation failed in that case, so is the Minister prepared to make representations to the Home Secretary to press for proper co-operation, because the European arrest warrant is of no value if it does not deliver justice in cases such as this?
Mr. O'Brien: Certainly I want to ensure that we learn all the lessons from this, but may I deal with the legal issue last? On the performers list, a report was published last March and officials have been consulting on how all that will be put in place. Where regulations need to be put in place, that will be done shortly, but the hon. Gentleman will appreciate that consultation with the relevant organisations needed to occur and that we wish to move forward with this as quickly as we reasonably can.
The hon. Gentleman mentioned holding to account those who have failed in the system, particularly Cornwall primary care trust. The main thing is that we get the system right; that we ensure that those who have failed will no longer be in a situation where failures can take place again; that we are able to examine how the system operates; and that the checks that will protect patients are the ones that occur.
I am not convinced about imposing a criminal offence on a PCT. I am not sure who in the PCT the hon. Gentleman wants this to be imposed on-is it the PCT's chairman or its chief executives? I am also unsure as to what the penalty would be. We are talking about a criminal conviction, so does he want these people to be sent to prison? Does he want to fine them? Why would he convict them? These people have been employed to do a job, and appropriate disciplinary procedures are in place to deal with them if they do not carry out their job adequately. Boards can be dismissed, and chairmen and chief executives can be removed, so I am still to be convinced about his suggestion that a criminal penalty for these people is the best way of changing behaviour. I am also a bit cautious because we do not want to get into a situation with criminal law, which tends to be absolute in its implications, where people are reluctant to come forward and say that there is a problem in their system that needs addressing because they fear that they might get prosecuted if they were to do so. I am concerned about such implications.
As for the GMC carrying out checks, we were aware in 2004 that there was a problem as a result of the Medical Act 1983. That is why we put in place the requirement on PCTs to ensure that English was spoken-that is something that PCTs must do. There may be ways in which PCTs can work with the GMC to ensure that it can be satisfied that people are not only able to speak English, but competent. However, that needs further discussion between the GMC and the PCTs. In other words, the GMC could act as an agent of the PCTs, but I wish to examine that. My main concern is to ensure that the checks are done-I am less concerned about who does them. I just want them done, because patients deserve safety.
As for ensuring that we have good and competent quality of care across Europe, we can discuss with other countries the need for them to improve the quality of what they do. We obviously have a limited amount of control over that, but what we can do is ensure that we have systems in place that enable people to become aware of information about doctors being disciplined or struck off elsewhere.
As far as minimum training and induction are concerned, I agree that, as part of minimum standards, we need to ensure that they are included in a national contract. There is a legal requirement now, through the national quality regulations, that those standards be applied, but
in this particular case, they were not always applied. That is why I want the model contract, so that there is no doubt on that point.
Finally, the hon. Gentleman asked me about extradition and the European arrest warrant. It is indeed the case that an arrest warrant was issued. Unfortunately, it appears that the arrest warrant was issued on 12 March 2009 but the German authorities refused it on 24 March 2009 on the basis that they were already prosecuting the case. I cannot quite work out why they were doing that. It has been suggested that Dr. Ubani asked the German authorities to prosecute him first, so he could avoid extradition on grounds of double jeopardy. The CPS was concerned about that, because it wanted to prosecute him, and contacted Eurojust to query that on 26 March. On 21 April, Dr. Ubani was convicted, received a four-month suspended sentence and made a payment, although it is disputed whether it was a cost or a fine. I hope that that deals with some of the hon. Gentleman's concerns, but we are concerned to engage further with the German authorities on this issue.
Mr. Speaker: Order. The exchanges between the Front Benches have been wide-ranging and doubtless illuminating, but they have absorbed 32 minutes, which is almost unprecedented. The House will be conscious that after this there is a 10-minute Bill and much important business, including the final day in Committee for the Constitutional Reform and Governance Bill. Sixteen right hon. and hon. Members are seeking to catch my eye. I want to accommodate everyone, but if we are to make progress timeously, we need short questions and short answers.
Jacqui Smith (Redditch) (Lab): I welcome my right hon. and learned Friend's emphasis on national minimum standards to ensure high-quality out-of-hours care for all patients, and the fact that local GPs will be involved in the design of the system. No GP has argued to me that they want to take back full responsibility, but they should be involved in the design. Does my right hon. and learned Friend think that, if new contracts are being let or contracts are being renewed, local GPs should also have a say in who receives those contracts?
Mr. O'Brien: I certainly hope that we will be able to engage our local GPs, through the various mechanisms that I mentioned, in looking not only at the rules and the best way in which services can be delivered locally, but at who gets those contracts.
Sir Patrick Cormack (South Staffordshire) (Con): Will the Minister reflect on the very wise words of the first family doctor I had when I was elected, who said that no true general practitioner can know his patient if he does not know him at home as well as in the surgery?
Mr. O'Brien: That is a good point to reflect on, but whether it is always possible to deliver in practice is another matter. GPs who are exhausted from working all day and then all night could end up being unsafe GPs.
Charlotte Atkins (Staffordshire, Moorlands) (Lab):
Can my right hon. and learned Friend tell me how he expects PCTs to ensure that they are co-ordinating the
out-of-hours service with other parts of the primary care system, including minor injury units and the ambulance service? The latter is especially vital in rural areas, where needy patients can be many miles from the out-of-hours provider.
Mr. O'Brien: My hon. Friend is entirely right. We need to ensure effective co-ordination between the ambulance service and out-of-hours provision to ensure that patients are well served.
Angela Browning (Tiverton and Honiton) (Con): In the guidelines and minimum standards recommendations, what is the ratio of doctor to population, and does it take account of geographical areas with a sparse population? Should that not be looked at, because there are parts of the country where people wait a long time? If the Minister is looking to improve standards, surely ensuring adequate coverage in the first place is one of the first things to consider.
Mr. O'Brien: Adequate coverage is indeed essential. As far as I am aware, there is not a ratio as such. However, we need to ensure that people do not have to wait a long time and that someone is available to come out within a reasonable time to ensure that the patient gets the necessary care. I have seen some of the statistics, as I am sure the hon. Lady has, on the numbers of patients and out-of-hours doctors. They vary considerably, and I want to engage with doctors' organisations to ensure that we do not need such a minimum standard.
Mr. David Drew (Stroud) (Lab/Co-op): Does my right hon. and learned Friend accept that the last thing that we need is another group of professionals being forced out of the NHS, as would happen if the Conservative party's proposals were taken seriously? Will he look at how we handle people with mental health problems and how they engage with the out-of-hours service, because there seems to be some variation across the country? In particular, what responsibilities do the different trusts that engage with such people have in the out-of-hours period?
Mr. O'Brien: My hon. Friend is right that there is a difference between the Conservative party and us. As I understand it, the former wants to transfer responsibility to GPs. We take the view, however, that we should not force that responsibility on to GPs, but that they should be more involved in how those services are commissioned.
It certainly is the case that, in some areas, out-of-hours mental health provision needs to be looked at with great care, because its quality is crucial, particularly when those with mental health problems have an episode that needs urgent attention.
Dr. Richard Taylor (Wyre Forest) (Ind): As I understand it, the basic fault with Dr. Ubani was that he did not even know the dose of diamorphine, which is why I am so pleased with the emphasis on the greater involvement of local GPs in the commissioning, design and, in some cases, provision of the service. Will the Minister therefore support me in supporting the bid for out-of-hours services in Worcestershire that has the approval of local GPs?
Mr. O'Brien: The discussion on the out-of-hours service needs to be with the local primary care trust, but the hon. Gentleman needs to ensure that local GPs and doctors are involved in some of those discussions.
Mr. Peter Bone (Wellingborough) (Con): Will the Minister let the GMC test the competency and language abilities of EU doctors before they are registered? Will he put the lives of British patients before EU law?
Mr. O'Brien: It is not about EU law; it is about testing and ensuring that the tests are done by the people who are legally responsible for ensuring that GPs speak English before they provide out-of-hours care. That responsibility is currently with the PCTs. My concern is that those requirements be met-they are legal requirements, they ought to be being met now, and PCTs have been told that they must meet them.
Dan Rogerson (North Cornwall) (LD): Does not the Minister agree that, in the issuing of some contracts during the previous round, PCTs seemed to decide that they wanted to drive down costs above all other considerations for out-of-hours contracts? Some of those deals looked too good to be true, and have turned out to be too good to be true.
Mr. O'Brien: Funding for out-of-hours contracts has risen significantly in recent years. The spend by PCTs has risen from £209 million in 2004 to £378 million in 2008-09, so considerable funding has been put into it. However, the hon. Gentleman is right that PCTs have a responsibility above all to safeguard the patient. That is their primary responsibility. A secondary one is to ensure that they do it with value for money.
Chloe Smith (Norwich, North) (Con): I regret to report to the House that my constituent Mrs. Marjorie Alderson had a difficult experience with out-of-hours care. I am particularly sad to say that she has since passed away, but her daughters have been active in highlighting the difficulties faced in Norfolk. I would particularly appreciate the Minister's reassurance that he will look seriously at what it takes to attract doctors to work in the out-of-hours service. I have heard various comments from medical professionals to suggest that that is a particular difficulty.
Mr. O'Brien: May I extend my condolences to the family of Marjorie Alderson? As for attracting doctors, the hon. Lady is right: some parts of the country seem to be experiencing difficulties, whereas others are not. That is one of the points to come out of the report by Dr. Colin-Thomé and Professor Field, as well as my discussions with those in some out-of-hours services. I am not entirely clear, in that the issue does not seem to be funding or how much the GPs are paid. Rather, there seems to be a reluctance among GPs in some areas to get involved in out-of-hours services, whereas in other areas they are anxious to get involved. It is important to get to the bottom of that and identify exactly why the problem that the hon. Lady has identified is occurring.
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