The use of overseas doctors in providing out-of-hours services - Health Committee Contents

Examination of Witnesses (Questions 1-54)


11 MARCH 2010

  Q1  Chairman: Good morning and welcome to this one-off evidence session in relation to the use of overseas doctors in providing out-of-hours services. I wonder if, for the record, I could ask you individually to introduce yourselves and the current position you hold.

Dr Wilson: My name is Fay Wilson; I am a GP in Birmingham. I am the Medical Director of BADGER which is a GP out-of-hours service based on a cooperative, mostly of doctors who have not opted-out of the responsibility.

  Mr Lejk: I am Antek Lejk; I am Director of Partnership Commissioning and Primary Care of Cornwall and Isles of Scilly Primary Care Trust.

  Mr Farrar: Mike Farrar, Chief Executive of NHS North West Strategic Health Authority.

  Mr Bates: Good morning. I am Paul Bates, Chief Executive of NHS Worcestershire.

  Q2  Chairman: Once again welcome and thank you for coming along. The first question I have is to all of you. The death of David Gray in 2008 has caused great public concern about the quality of out-of-hours GP care. How much confidence should the public have in these services? Is patient safety at risk? I do not know who would like to start. Antek?

  Mr Lejk: I can only speak on behalf of our area actually and I think it is probably dependent on the systems in place to assure and performance manage those services. From our point of view we had a new provider about three or four years ago and we had some initial teething problems with that so in response we set up a really quite tight performance management regime which includes GPs, LMC, public as well as our contract management type people on a monthly basis going through all the performance stuff. We were concerned about performance so we constantly challenge and check that, including the clinical aspects. I think because of what happened in terms of a new contract we took a fairly rigorous approach to that performance management role but that was a result of that initial set of problems and I suspect it is variable across the country to be honest.

  Mr Bates: Public confidence and GP confidence in out-of-hours is absolutely critical and without that public confidence the public behaves in a different way and accesses services in an inappropriate way which causes us problems. Do they have confidence? I think the patient surveys show probably across the country something like a 66% to 70% satisfaction rate with out-of-hours services which, given the nature of the services, is reasonably high. However, I suspect that is satisfaction about the access to the service rather more than it is about the quality of care that perhaps professionals have to judge. I think public confidence is absolutely critical and this may be something we return to during this morning.

  Dr Wilson: These services tend to have been commissioned on the basis of "never mind the quality, feel the width". That is not say that people are not interested in quality and safety, it is just that those were taken for granted or taken as read. The performance management has historically tended to be about access, how long it takes for something to be done rather than really anything to do with quality and there is a presumption there. The extent to which you can impose quality by performance management is something that would be interesting to debate. I think part of what we are looking at is about the culture within organisations. I am a believer—as you would expect me to be—in a doctor-led service because I think in general if you have doctors leading the service and being responsible for it they will take a responsibility for those quality aspects. However, where commissioning has been done—I do not say it still is because I think we are learning—on the basis of how fast is it and how low can we get the cost, then quality is something that gets squeezed. I am sure you know somebody-or-other's law that you can have any two out of three of cheap, quick and reliable and I suspect on out-of-hours, because of the way the market has worked, reliable has been taken for granted and there has been a focus on cheap and quick. I hope we are moving in the direction of reliable.

  Mr Farrar: My sense is that the public should have a generally high level of assurance about the quality of out-of-hours care but because you have multiple providers and because you have variability in some of the commissioning arrangements, it is inevitable that the quality of service will be variable across the country. There were tragic circumstances leading to the event that provoked this inquiry and I think the public should be very assured that is an unlikely occurrence; we would not expect that to be something that would be present in many of our systems. My sense is that they should have generally high assurances, as they should in the whole of the National Health Service. I think out-of-hours care is getting much better; I think it is improving. There are a lot of steps being proposed now as a consequence of this incident that should give people a lot more assurance, but I think it is inevitable there will be variability in the quality that is provided as there is in the health service across the whole in-hours service as well.

  Q3  Chairman: Since the out-of-hours services were reformed in 2004 how well do you think that Primary Care Trusts have done in terms of meeting their responsibilities? Mike, obviously you will have an overview but I put the question to all three of you really.

  Mr Farrar: One of the reasons why out-of-hours care has always come in for some attention when we have been looking at the reform of the system is that probably since the early 1990s when individual GPs stopped doing their own out-of-hours—which was the big real sea change in this—and were allowed to use third parties to deputise for them, we moved away from the kind of model that people had that their family doctor would always be available to them. It was the right thing to do because constantly in surveys people were saying, "We don't want to work in the profession because of the out-of-hours commitments". We did have a high level of complaints compared with in-hours services about out-of-hours and I think we have still seen that situation. In 2004 one of the key changes that we wanted to make was by moving to commissioners—PCTs commissioning GP out-of-hours who also commissioned A&E departments, walk-in-centres, NHS Direct, minor injuries, et cetera, et cetera—we were able to try to get a framework where PCTs could commission a coherent out-of-hours service. I still think we have a long way to go. My sense is that we still have a variety of entry points to the system and we have not quite navigated the public. If you say to me, "Has this been a sensible change?" I think it is a sensible change. We have yet to get the benefits of that sensible change, and Paul might want to talk about it from a PCT who have thought hard about commissioning that range of services and how they have gone about it. The technical aspects of whether they have contractually made sure that all the key quality elements are in place, I think when we have looked at our patch we have 15 Primary Care Trusts that we are very assured on, seven where we have some questions we are pursuing, and a couple that really need to do an awful lot better. That is the kind of scale of things, but we were trying to get that coordinated out-of-hours service and I think PCTs still have some way to go.

  Q4  Chairman: Paul, would you agree with that? Obviously you sit in one.

  Mr Bates: Absolutely. The journey in Worcestershire has been an interesting one. I came into Worcestershire in 2005 and was the Chief Executive from 2006 of the pan-Worcestershire PCT. Worcestershire was providing its own out-of-hours services through the PCT as a direct provider. I was uncomfortable with that; I did not think it was our core business, the daily operation of an urgent care service. We were getting a significant number of complaints and therefore as a good commissioner we decided we were not the right people to be providing that service and we embarked upon an incredibly extensive commissioning and procurement process. In preparing for today we have looked at this again and we think it is probably the best procurement we have ever done. We have put in more expertise, more time and more resource; we have brought independent experts in, including independent GPs and patient representatives to help us do it. The Care Quality Commission is looking at that currently so I think they will be the judges of what I have said but, having gone through all that process, we entered into a contract with Take Care Now and we therefore return to the issue I said beforehand that if pubic confidence in the service dips, because of something that is happening hundreds of miles away from your own patch, it can actually have an impact back on your home territory. Despite the fact that we think it was one of our best procurements, clearly there are still lessons to be learnt, there is still a sophistication to that which needs to be applied. I think one of the lessons that I would offer up to the Committee today is that if you think you can procure a service, sign a contract and say that we have everything pinned down in a contract and we can now turn our backs and work on some other problem, you are wrong. Experience shows that you need to put somebody quite senior—a senior clinician—to work alongside your out-of-hours provider for many, many months when they first take on that contract.

  Q5  Chairman: Antek, do you agree with that?

  Mr Lejk: In 2004 when we went through our tendering for a provider what we had before, which was the GP co-op, we did not really know what the quality of that service was like and we were having complaints and there were issues that were not at the high end of quality, so what we now have in place is something which is much more aware of what the issues are and gives us a chance to really drive into those. I agree very much with what Paul was saying, it is one thing to secure a new provider but actually you then have to work with that provider, as you would with any other provider, on a really, really regular, rigorous basis and in terms of our performance we are interested in quality, we do look at things like complaints, we look at what is happening with our health service and we look at patient information as well and play that back to try and make sure they are working on that. Appraisal and those kinds of things are all part of what we expect. One of the things we have done recently is to really try to embed that provider in our health system so they are an integral part of our pandemic flu planning, they are an integral part of our emergency care network and that kind of thing. What you cannot do is just see them as a bolt-on, a bit of a contract, you do a bit of performance management just to make sure the numbers are okay; actually they are an integral part of that health community. By being drawn into it I think they feel better; they feel more engaged and they can tell us the problems they have with the rest of the system and we can use that to re-align our commissioning elsewhere. It is not helpful if you just see them as a kind of separate contract and treat them in isolation.

  Q6  Chairman: Fay, what is your view on this?

  Dr Wilson: I suppose I come from a different angle. Our co-op has been in existence since 1996 so when it came to 2004 we were completely unsuccessful in securing any contracts. It was just as well that the majority of our GPs had not opted-out because otherwise we would not have existed from then. The reason really was that we were too expensive and we had a set of quality standards which were too expensive to run for people to buy. That was at a time when there was not much sophistication around commissioning. By 2006 we had learned that we had to be competitive so we had to modify our standards and stop trying to sell people diamonds when they did not want to buy them. We also realise by now that you do have to have more or less an industry in bidding and doing all this sort of thing. One of the difficulties we have as a small GP co-op type provider is that we do not have the resources in order to keep up with the processes which PCTs use, which are increasingly the sort of processes they would use for contract managing, say, an acute trust or a large NHS provider. The paradox, I guess, is that we might want to see more local involvement of GPs and less what you might call industrial process, but if you are not a very, very large provider the difficulty is keeping up with the processes involved. We are continually trying to get ourselves large enough so that we do have a back office team which can cope with the sort of contract monitoring requirements for everything really from meetings to turning out reports and so on, while at the same time not losing our connection with our local frontline. I suppose part of the trick of this is it is primary medical services but it is being managed in the same sort of way as the hospital sector or the ambulance service but with a different sort of basis.

  Q7  Chairman: It seems from what you are saying that two years into the change you were a lot more comfortable with where you should have been and presumably with what the PCT were asking.

  Dr Wilson: No, we were not comfortable at all, it is just that we felt that we were not big enough to carry on and we had to make a decision that either we modify our offering so that it was cheap and cheerful, if you like, or we would go out of business. We had to make a decision whether to give it up and say that we were eccentric and enthusiastic but not a saleable product, or we had to say, "Let's find out what people want and sell it to them". I really am fundamentally anxious about the fact that this is a purely marketised privatised bit of the health service. I am personally uncomfortable with it but here we are and we have to make the best of it. I talk to GPs and people who have been in my position who say, "I will not work in the new system because I have had to drop my standards too much and I cannot reconcile myself with it".

  Q8  Chairman: The implication in my first question to all of you was this issue about patient safety. How can you reconcile that you have to drop standards and reconcile the events of the last couple of years? What standards did your co-op drop?

  Dr Wilson: For instance, if we look at how fast we visit people, the national policy requirement is that a routine home visit or routine face-to-face consultation will happen within six hours of the decision being made; our previous internally imposed standard was within three hours. That is a simple example. Obviously if you are going to do things faster you are going to have to have more doctors on duty and that is more expensive. If you are going to produce an offering which is competitive with the market it has to be less expensive. It is simple as that.

  Q9  Chairman: In terms of economics I accept that, but what I am trying to tease out here is what it means to patients in the end?

  Mr Bates: Chairman, can I just help complete the picture, as it were? Because otherwise there is a danger we believe that the PCTs' approach to commissioning here has been about cheap and cheerful. I do understand what Fay is saying about being in a competitive position tendering for these services it may well feel as though you are having to look back all the time at what you are going to be able to say in comparison with your competitors. In Worcestershire where we undertook our procurement we did not accept the lowest price tendered. Our conviction was that the best proposal being put to us was one which was actually not the lowest price and that was the contractor we should go with to get the service that we wanted. Amongst the lessons that we have learned in the last year or two is that sadly the national standards can be used in a way that says, for instance around the six hours that Fay has referred to, that is the norm. Clearly our expectation was much more in line with Fay's that actually visiting should be done within the hour or two hours as the norm, not "Oh, we are only required to do this within six hours". I am not criticising our contractor because I think that is a phrase that many of the contractors around the country might well use because of this interpretation of standards. So that is a lesson learned. It cannot be that those standards become the average and the norm; they have to be the exception.

  Mr Farrar: I have been in front of this Committee before looking at the costs of the overall contracts and if I remember rightly one of the significant additional costs post-contract was the amount of money spent on out-of-hours services, which I think went up by something like £300 million across the country after the contract. Part of the reason that happened was because the unit costs of the labour went up so when GPs were not obliged to provide care, and therefore it was on a contracted basis, the actual individual costs of GP input went up. When we were doing the contracts we assumed that you would be able to offset some of that and in fact the maths suggested that. Another constant concern with out-of-hours which the profession put forward is being called out for things that do not require a doctor's input and therefore call triaging was an important element of this. The view was that call triaging would offset some increase in the price of GP input. That is why the business about the standards is quite tricky to compare because some of the call times, if we had very good call triaging in place, would actually take away the need for the face-to-face contact therefore you could get those standards up, at least maintain the standards as they were before and potentially improved in terms of the time it would take. I think the comparison of saying, "We used to do it in one to two hours before and now there's a minimum standard which is six hours", it is actually a more complex picture than that because what you would hope is that you got people there as fast as possible for those people who need a response as fast as possible and, for those people who did not, they might not even get a response in the way they previously had because they had been dealt with properly on the phone. I just think we need to bear that in mind, but particularly the fact that post-contract there has been a lot more money spent on out-of-hours than there was previously.

  Q10  Chairman: It is a bit of a confusing picture. Mike, as you hinted there you were involved in the actual negotiations. I think you held a position with the NHS Confed in the 2003 negotiations. The simple question I would like to ask is do you now regret allowing GPs to give up providing this service for something like £6,000 a year which is not a very high sum in terms of cost, is it?

  Mr Farrar: No. The work we did at the time benchmarked the cost of out-of-hours care across the country and it ranged from about £4,000 per GP to about £13,000 per GP. The mandate that I had leading the negotiation was that there was a £3,000 element of new resource to put into PCTs baseline to buy out-of-hours care and the negotiation landed on a figure of £6,000 from the GP's pocket and £3,000 new, coming to £9,000 which sat pretty much in the middle of the range of out-of-hours care. Effectively it was more than £6,000 that went into PCTs; they had £9,000 per GP to buy that service. Our view—and I still come back to it—was that PCTs commissioning rather than GPs commissioning, effectively providing their own services, should have given you a much, much better opportunity to get a coherent urgent care response. £9,000 alongside the way that PCTs were working with their A&E departments, their walk-ins and NHS Direct as part of an overall offer in my view should have led to standards improving not deteriorating. I would still defend that decision but I think we have to fully exploit this business about coherence of the service offered. I think we still have to get some of that benefit back.

  Q11  Chairman: You suggested yourself that of the PCTs you currently oversee in this position some of them are not as good as others and so we are still years down the line and do not have that coherence you thought we should have had.

  Mr Farrar: There has been a rise in demand for urgent care and there are a lot of very, very clever people trying to explain why that rise in demand has arisen, but what I know now—particularly over the last year and maybe with necessity being the mother of invention, as the money starts to look tough for the NHS we start to address this—is that you have a much more coherent front-end of A&E with GP input, the out-of-hours service is better linked in and in my view, if you were asking me about where is the most danger around out-of-hours care, it is where it has always been: it is the handover between out-of-hours services and in-hours services. The systematic approach to transfer of information that we have now, in my view, is much better than it was in previous out-of-hours arrangements.

  Q12  Dr Stoate: If you had £9,000 per GP and you thought that was about right, why did it cost £300 million a year more to run the service?

  Mr Farrar: I think it was because in the first year a lot of Primary Care Trusts rolled over previous contracts and the previous contract price went up. When we were looking at the range that we had in place to base the £9,000 on—it was £4,000 to £13,000—what we had was a number of Primary Care Trusts who simply contracted with their existing supplier, but the price had gone up and they did not really have an alternative offer at that time. Over time my sense is that that price has probably been absorbed up as PCTs have been more rigorous about their cost for out-of-hours care. The initial problem was that we simply paid more for what we had before because of the price of labour going up.

  Q13  Dr Stoate: If I have done my sums right that £300 million is something like £100,000 per GP. There are approximately 30,000 GPs; £300 million. I am just trying to do the sums. That is an awful lot of money per GP. It makes your £9,000 so far out of left field that it does not make any sense.

  Mr Farrar: I am not certain I am right but I was trying to remember what the National Audit Office said in their Report into the contracts that tried to attribute where some of the over-spend on the contract came. I am sorry I cannot vouch for that figure.

  Mr Lejk: Just to reinforce that point about working in different ways after the change in contract, Cornwall is a very rural and dispersed county so we have particular issues about access and we tend to need more capacity in place than you would normally have in a city, for instance. We also have a network of minor injury units across 14 community hospitals as well. Before we contracted we had the situation of out-of-hours services sitting alongside minor injuries services not talking to each other and not working together. Through the contracting arrangements we have been able to force a more integrated and shared approach to the delivery of care. We have further to go so there is more we need to do around mental health services and so on to make sure we do have an integrated service out-of-hours. I think, as commissioners of all of that, we do take it more seriously and we can see the opportunities to make the system more effective.

  Dr Wilson: Part of the difficulty was that the costing of out-of-hours prior to the contract changing did not really take account of paying the doctors to do the work. In areas where people had to pay someone else to do the work or continue to pay the doctors to do the work, my perception is that certainly around my part of the country there were some quite big changes. For instance, there was an enthusiasm for NHS Direct to be the front end so the costs were different and I think that changing of systems partly cost more money. I think PCTs will legitimately say, "Let's see if we can do it a different way and see if the ambulance service can provide or if NHS Direct can provide" and in my view there had not been a full costing in the contract of the value as opposed to the price of the work that GPs were doing. I think we have not realised the potential benefits in terms of coherence and integration. I do not think that can all be laid at the feet of PCTs not commissioning imaginatively; it is partly the way the contracts are set up, partly the types of contracts they are in that they do not easily integrate, and partly the NHS in itself in its contracting mechanisms does not easily move across sectors and integrate them, and partly because in out-of-hours the contracts are fairly short term (generally speaking they are three-year contracts, three years plus one, plus one) and it is actually quite difficult if you are a provider to think about an investment in a long term either in relationships or services and, having put something new together, by the time you get it working it is time for the next tender. I think there is something here about length of contracts and some of the actual practicalities from the PCT's point of view of development as opposed to monitoring existing contracts. The PCT cannot just write down and say, "We want you to do this, this and this" and it happens the next day and keeps happening.

  Chairman: Thank you for opening this up. We are going to put ourselves under a bit of pressure in terms of time, but we now have a series of specific questions about this aimed at individuals. If you could all be quite brief in responses and questions as well we should be able to stick somewhere near the timetable.

  Q14  Dr Naysmith: You will all be familiar with the report by Dr Colin-Thomé and Professor Field about the out-of-hours service following Mr Gray's death. I just want to ask you, do you think PCTs are doing enough to improve monitoring of the out-of-hours services they commission in the light of this report? Are they moving in the right direction?

  Mr Bates: I think the report sets a standard higher than most PCTs have been working to of late. Because of the attention my PCT has put into out-of-hours over the last year I had expected that when I read that report I would feel very, very comfortable that we were doing everything it suggested. I think it sets out for us that there is still more we need to do. However, I think it also raises some questions about how far do commissioners go and how much ought we to be relying on the providers themselves to take this responsibility. It gives me an opportunity to say that however we move forward in the coming months and years, whatever we do we must not take away the primary responsibility for the quality from the provider itself.

  Q15  Dr Naysmith: You have just said something very interesting, at least I think it is interesting. In this Committee we looked at dental services not that long ago and one of the things we found was that if the PCTs really took commissioning good general dental services properly then there were good services in the area and there was not this hysteria about not being able to find a dentist. You have said you thought that your commissioning of this particular out-of-hours service was the best you had ever done. Does this not suggest that it is not possible for PCTs to do everything the best they have ever done, that there is too big a job to commission all the different complicated things that PCTs have to commission? How do you feel about that?

  Mr Bates: I think we are capable of commissioning and ensuring that we have good out-of-hours services. I think any PCT that is not open-minded and constantly looks to see how it can improve that commissioning is going to have a problem. Having said I thought we have done it well, you can always do it better. I think there is an issue that PCTs cannot be undertaking lots of major commissioning exercises at one time or in one year. You have to be very selective.

  Q16  Dr Naysmith: Are some of the PCTs too small to do the job properly?

  Mr Bates: Some PCTs would have struggled to undertake the number of commissioning tasks that we have undertaken over the last 12 months and therefore working together and collaboratively across PCTs is something that PCTs are increasingly doing now. We have arrangements at regional level and we have local collaborative commissioning arrangements so there is a lot of that joint work going on. I think the essential point that I would want to make is that the idea that in our case in a portfolio of services beginning to approach a billion pounds you can be constantly embarking on a dozen or 20 major commissioning exercises in a year; you cannot. You need to be selective, you need to get it right and you need to have long term contracts as Fay has referred to. The range and complexity of services we provide is just far too great for any PCT to be doing a massive turnover in that commissioning every year.

  Q17  Dr Naysmith: Antek, can we go back to the monitoring arising from the report that I mentioned?

  Mr Lejk: I think we probably put more effort into our performance management of out-of-hours in the last 24 months than we would have done if everything was hunky-dory. What we tend to do in terms of highlighting areas where we need to put more effort is to look at the data, look at the experience that patients are receiving and if there is a problem we go in and spend more time on it. That has led to benefits. I think the one thing that comes out for me from this having recently got involved in it is that we do tend to rely on assurances and I think we now have to double-check some of those assurance. There are things that we think are all right because a process has been adopted. I am sure there will be a question about performers lists later on but in terms of that I think what we relied on too heavily was that just because the right form had been filled in and a doctor is passed by the GMC, does not mean you do not have to assure yourself of their competence.

  Q18  Dr Naysmith: Are you saying your monitoring was just asking whether they were doing what they said they were doing?

  Mr Lejk: To some extent what we were doing was just thinking that the quality element was covered off by somebody having got into a system and not probing deeply enough to actually gain assurance for ourselves that that is the case and, going back to Paul's point, also then requiring providers to do the same. The danger is that each part of the process thinks that somebody else has covered off that assurance and therefore not enough checking is done to make sure that when you employ somebody to do a piece of work they are competent, fit for purpose and able to communicate. I think for me that is what has come out of this, that we are applying a much more rigorous review of that and re-reviewing it on a regular basis to make sure it is not just about getting into the system but staying in the system because you cannot just rely on the things that we were relying on.

  Q19  Dr Naysmith: Fay, both Antek and Paul are throwing it back to you and saying that it is partly your responsibility as well.

  Dr Wilson: Yes. Perhaps I am more optimistic, which surprises me slightly. You asked about the response to these recommendations and my perception is that it has put things up a gear, that PCTs are interested. My aim as a provider is to help them deliver this and to make it easier for them. We deal with six PCTs and I have a great interest in not having six separate local suites of KPIs, for instance, so that there is some logic across them but also I realise that the people who do the commissioning, for the reasons that you heard, have loads of things to do so I can help by saying here is an easy way to deal with the West Midlands Regional Check List, for instance, here is all the information we have and sharing it between them. I think they have geared up and I see movement here which I would say from the PCTs I have been dealing with, I would be positive about the fact they are taking this on.

  Q20  Dr Naysmith: This is probably not an appropriate question for you really, but do you encourage out-of-hours doctors to report on the performance of other out-of-hours doctors? I have become quite familiar with two or three different out-of-hours services and some of them rigorously check doctors who come in and some of them do not. Is there any system whereby if somebody new appears who has never been on the job before and somebody who is part of the system notices that, is there a way of indicating that to the people who are organising the services? I know we are going to have questions about this later on, but just in terms of your responsibilities.

  Dr Wilson: Yes, not just doctors but all staff and we do it by enabling them not to be named as the person who made the report and also to have a no-blame approach to it which I know is always said but not very often done. In terms of the number of reports coming in, it is a very intensive way of dealing with them but it works for us because of the way we deal with it. It means that a level of responsibility has to be taken within the organisation. If we had to report that information elsewhere I think the participation rate would be lower. Of course this is an issue for other organisations like the GMC and so on who have similar sorts of questions.

  Q21  Dr Naysmith: It is a question of picking things up early, is it?

  Dr Wilson: Yes.

  Q22  Dr Naysmith: Mike, what is the role of Strategic Health Authorities in this? Are they beginning to monitor what is going on?

  Mr Farrar: Clearly we would be looking at PCTs commissioning overall and ensuring they were getting good quality services. That would be picked up generally. We had a great focus on urgent care in terms of access and you have to see some of those key national targets as whole system ones which include the GP out-of-hours service so I think there has been scrutiny. In terms of the detail, looking at whether or not they will assess, we have done periodic reviews and questions, and obviously the last incident has provoked quite a flurry of activity as these things do, and when we have gone to another layer of detail about the assurance, as I said, when we looked at our PCTs we had 15 that we thought were well on top of this, seven that we thought had some questions to ask and a couple that we have gone back to and said, "You probably need a bit more help and you need to understand how important this is". That would be quite a normal distribution. If you looked at all kinds of areas, that kind of thing is not unusual in the health service performance management process really.

  Q23  Dr Naysmith: We have had quite a lot of evidence indicating that clinical governance has not really been very high on the agenda. Is that the case in your PCT?

  Mr Bates: Not at all. I think we have shovelled loads of clinical governance into the system.

  Q24  Dr Naysmith: There are lots of good clinical governance policies agreed with the providers and yourselves.

  Mr Bates: Absolutely. In preparing for today I have been looking through the clinical governance arrangements of previous providers, current providers and potential providers and it is clear it is all there in policies and it is all there in processes. However, linking it back to the previous question, no amount of process and no amount of assurance systems replaces the value you get from people exercising their own professional responsibilities and saying, "This is not good enough; I have to speak out about this". The most likely source of immediate alert to the fact you have a problem doctor, problem nurse or problem call handler will come from the staff working alongside them. That is more important than any of the processes that we can put in place.

  Q25  Dr Naysmith: Fay, what is your view on clinical governance?

  Dr Wilson: My experience of this is that it is more the provider offering up rather than a creative, iterative sharing process, but that does not surprise me in a sense because if we look at the big picture for a PCT the amount of time and resource they could devote to this is not huge. I think it is greater following this report because there is more in the spotlight, so to speak, so I am optimistic about that being more of a creative process.

  Q26  Dr Taylor: Paul, you will not be surprised if I want to focus on Worcestershire just for a little while.

  Mr Bates: Not surprised at all.

  Q27  Dr Taylor: Talking about monitoring, the Care Quality Commission's interim report and I am quoting from Cynthia Bower: "Our visits to the five trusts that commission Take Care Now's services showed they are only scratching the surface in terms of how they are routinely monitoring the quality of out-of-hours services". I always remember coming to you with a string of complaints, comments from GPs and some crucial things from whistleblowers. You have made the point of it being the professionals' own responsibilities; these were whistleblowers who were frightened to come other than through me to protect their anonymity. I was amazed that the Overview and Scrutiny Committee had no clue that the service was not absolutely perfect and again criticisms had not actually come through to you until I brought these. I am absolutely with the Care Quality Commission because they actually detail the sorts of complaints that I was getting—the efficiency and quality of call handling and triage, the number of unfilled shifts, the quality of decisions made by clinical staff. I do not really want to go back into the past, I want to go into the future. We know that you have a new contractor coming in because Take Care Now are opting out and selling their contract before the Care Quality Commission reports on them. What steps are you taking to make sure that you can monitor the service that the new huge provider really gives us? I do not see how you can embed it, as I think Antek said, in the health community.

  Mr Bates: I will not go back over the past as you have asked me not to, except to say of course that the CQC report is about the five PCTs operating in their area. As Dr Taylor knows, once we had had his information and that from our local medical committee we commenced our own independent investigation of the quality of our service long before CQC were asked to become involved. In terms of what we will do, that will be essentially different from what we do now if TCN is taken over by a different company, we are actually in discussions which relate back to the most recent guidance that says you must get greater GP involvement in influencing the quality of the service. I think we have to be careful what we mean about GP involvement because some GPs are just GPs, but some GPs are shareholders in private companies that want to be the alternative provider of a service. I just want to flag up that there are issues of interest here. However, we have made it clear we would not allow our contract to pass to any company that was not able to demonstrate to us how GPs are going to have a bigger influence on the quality of the service. The current conversation we are having is about the establishment of a GP advisory body on which there will be nominees of the local medical committee and the PCT and practice based commissioners. Within its first month of life it will agree with any new contractor the ways in which you would, first of all, measure the GP influence and GP involvement. One of those measures might be the percentage of local GPs that actually work for the service. That GP management body will have direct access to the PCT as a corporate body and to me, and it will review in its own way the quality of the service that has been provided which of course will largely be based on the intelligence their own patients are giving them when they see them in surgery during in-hours. I think we have tried to work up a proposal that puts in something completely new than we have had hitherto. It should mean the sorts of issues you brought to my attention are brought to my attention earlier. I do need to flag up that having a conversation with your local GPs about their influence on the out-of-hours service has to take account of the fact that some GPs have more than one level of interest in the out-of-hours service.

  Q28  Dr Taylor: The system you are setting up is entirely different; it did not exist with Take Care Now?

  Mr Bates: No, it did not exist with Take Care Now.

  Q29  Dr Taylor: There was no local GP monitoring of that?

  Mr Bates: Not in the way that we are proposing now. On an ad hoc basis we have actually had our own GPs going in and doing unannounced visits to the service so we have had other arrangements, but this would be a more permanent and more powerful central body of GPs working with the new provider's medical director to continually spotlight what was the quality of service.

  Q30  Dr Taylor: Do you have any teeth if you have worries about quality?

  Mr Bates: Absolutely. Forget any GP management body. The contract terms are voluminous, to such an extent, I have to say, that when I look at some of the contracts that PCTs are placing now, they are so voluminous that breaches of contract every day are almost inevitable. We are making it too difficult and putting in too much detail for some of providers. However, we have the teeth, if necessary, to cancel contracts. In our particular case, because of our peculiar circumstances, we are putting in place arrangements which would allow us to review the on-going nature of the contract after six months, so we put in a special clause.

  Q31  Charlotte Atkins: Dr Wilson, what would you say the arguments are for commissioning out-of-hours services from GP co-ops as opposed to commercial, profit-making providers?

  Dr Wilson: If we say these are primary medical services, which is what they mostly are (there are other things which are added to them) those are services which are normally provided by GPs. If we look at what is the product, the product is a consultation with a GP or another primary healthcare worker. That product is the same thing which is normally delivered during the day because GPs do urgent and unscheduled care during the day. At its basic level, if you like, I think there is a reason there for commissioning the service from GPs. The GP co-op is a collective group of GPs and should have at its heart the interest we have heard about in Worcestershire and the professional interest in delivering a good service in the same way they do during the daytime. Putting it together into a co-op simply means it is large enough to be able to do some of the other things that you cannot do on a practice basis like running a call centre or being able to deliver proper reporting to the PCT on a contract basis as well. On an efficiency basis—I would extend this to any other not for profit arrangement—in our co-op all the money that comes in is spent on running the service. There are no shareholders to pay; the money is within the NHS. It is an irksome matter to me that my organisation is classified as not being part of the NHS because it feels like part of the NHS, it operates as part of the NHS but I accept why it is classified that way. I think with a commercial company its priorities may not be the same. If you are commercial company of course—and we are a company too—there are things that you have to do. You cannot trade at a deficit. If you are a company with shareholders I presume your shareholders would not be happy if you were not turning in a profit and producing dividends or producing some assets for the company or, for instance, perhaps your scheme is that you grow big enough and then you can sell yourself to some other organisation and make a profit that way. A GP co-op is inhibited and cannot sell the goodwill in the organisation whereas if you are a commercial you can buy and sell goodwill in these services. There is much more of a commercial market which to me produces less stability. The fact is that we are a co-op in Birmingham and as long as the GPs are still there and opted-in we will still be there so there is some stability there for the NHS. I talked about whether we would take a risk if we just had a three-year contract, if we were a commercial company which had a three-year contract which might come to an end, we would be looking at where else we could have contracts, we would be managing our risk, we perhaps would not have invested as heavily in the local health economy as we are, also interested in it. Would we have taken the risk that we took with the flu pandemic when it hit us with a big explosion last year; probably not, and we were providing services into areas and to patients whose contracted provider is actually a commercial organisation. I think there is something about embedding in the local health community. I do not know whether that answers your question.

  Q32  Charlotte Atkins: Do you cover the whole of Birmingham?

  Dr Wilson: No, we cover most of Birmingham; we are not the main provider to one of the PCTs. We provide a small part of the service but we are not the main provider in one of the PCTs. Only about a third of our GPs have actually opted-out so the city is a patchwork in a way but we cover most of the patients in Birmingham either with our opted-in co-op or through our contracts with two of the PCTs in Birmingham. We are the contractor for Solihull where half of the doctors are opted-in and half are opted-out.

  Q33  Charlotte Atkins: Would you say that profit providers are trying to cut corners and compromise safety? You were talking earlier about having to compromise on your diamond service, as it were. What is your view? Do you think profit providers do tend to cut corners?

  Dr Wilson: I do not think anyone sets out to cut corners. If you are aiming to be any sort of a provider you want to be providing a good service because your ability to go and sell your product somewhere else depends on your reputation. If you were making clothes and they fell to bits on the first wearing people would not buy them again and they would not buy them somewhere else. I do not think anyone sets out to cut corners. I think people do set out to provide an attractive offering and if the offering depends on certain things then that is what people will produce. My own organisation has quite low cost contracts—the benchmarking exercise pointed that out—so we cannot do things in the way we would like to do them. I cannot have as many doctors on duty as I would like to have because there simply is not enough money to pay more. We all have to cut corners. Frankly, if I had to find X amount out of the budget every year to pay the shareholders that would mean I would have to cut corners unacceptably. Where do you move from economies to cutting corners?

  Q34  Charlotte Atkins: Do you think that profit providers provide a less good service than perhaps co-operatives?

  Dr Wilson: I could not say that I have evidence for that at all, but I think there are factors which would lead them in that direction. A private provider is not necessarily going to provide a worse service than an NHS body which would perhaps put those to one side or a GP co-operative. I think there is something about a GP co-operative in that you have the professional leadership, you have the financial efficiency and you have the local interest and embedding into the local health economy. I think those are advantages but you might say that I would say that.

  Q35  Dr Stoate: I want to ask Mr Lejk a specific question about Dr Daniel Ubani. The current rules are that if a doctor is registered anywhere in the EEA they are entitled to go onto the GMC's Register. No question. However, in order to be a GP in this country they have to be on a performers list and, as we have heard before, that is the responsibility of Primary Care Trusts. In order get on a performers list the PCT must be satisfied of the clinical skills of that doctor and their performance in the language. What checks did your PCT make in putting Dr Ubani on the performers list?

  Mr Lejk: I think what we acknowledge is that at that time we were not as rigorous as we are now because we were making assumptions around the assurances that come from GMC registration and also, being an EU national, there was the whole debate about how you could apply the language test. We have now changed our system so that anyone who does not have a qualification from an English speaking country will automatically have to provide evidence of a language test.

  Q36  Dr Stoate: My question is not about what you do now. My question was what checks did you make because you were responsible to ensure his clinical standards and language skills were up to speed. What checks did you make?

  Mr Lejk: At the time we had no reason to feel that he was not competent.

  Q37  Dr Stoate: You had no reason to think that he was competent, either.

  Mr Lejk: Yes and we acknowledge that our systems were not as tight as they should have been so we have had to tighten them up since.

  Q38  Dr Stoate: Did you know at that time he had already been refused from another performers list?

  Mr Lejk: No, we did not.

  Q39  Dr Stoate: You made no checks about that at all.

  Mr Lejk: No, we did not.

  Q40  Dr Stoate: I suppose you have already answered this in a way, but what are you going to do to make sure it never happens again?

  Mr Lejk: Like I say, not only are we tightening up our arrangements around language competency, we are also not assuming that just because somebody is a qualified doctor that they are going to be fit to practise and have the skill level. We have set up a new panel with a medical director and myself who review all the cases including every 12 months reviewing those who are already on the list.

  Q41  Dr Stoate: What are you doing to ensure that they are qualified as a GP rather than just qualified as a clinician?

  Mr Lejk: We do follow-up checks. Not only do we look at what they have presented to us, but if we have any questions about whether their experience in another country is equivalent we will follow that up to make sure that there is an equivalence there.

  Q42  Dr Stoate: He was a cosmetic surgeon, how does that make him qualified to be a GP?

  Mr Lejk: As I say, under today's arrangements that would not have happened.

  Q43  Sandra Gidley: Dr Wilson, do you think there is too much reliance on locum overseas doctors in out-of-hours primary care?

  Dr Wilson: My organisation does not use them at all for various reasons so you might expect me to say yes because if there is any use then there should not be. That would not be quite fair. I think the survey that was done suggested that the way that overseas locums are used rather than whether they are used or not is what is important. The issue is really about cultural differences in practising medicine and there has to be an assurance that the doctor is able to deliver UK general practice or UK primary medical services. The question is that if they come from a medical culture that is different and they have not had any training and have not had at least some basic training in the organisation, how can that be? I would say that if it is being done without quite a substantial training there is too much. Oddly enough, since this happened, we have been approached by a number of doctors from overseas who have overseas GP accreditation and who are on performers lists and we are looking at the sort of training we might need to put in place to make those doctors safe and appropriate and we are working with the deanery on that.

  Q44  Sandra Gidley: Are you saying that you employ not just local GPs but GPs from all around the country?

  Dr Wilson: GPs from all around the country do not tend to come and say, "How about some work?" We have GPs from performers lists in different parts of the country who are living and working in Birmingham. We do not rely on the performers list at all in terms of looking at a doctor's suitability to work in our service.

  Q45  Sandra Gidley: Do you think the checks on overseas locum GPs are robust enough? I am getting the impression from what you said that the answer is no.

  Dr Wilson: I think the answer is that we would not rely on the checks that a PCT had carried out because we do not have an assurance about all the PCTs. We would check ourselves and the reason we do not use locum agencies is because we would be relying on someone else's checks. I think that is an employer issue.

  Q46  Sandra Gidley: You alluded earlier to the fact that you did not want six lots of KPIs; is there a problem in that each PCT seems to be going off and merrily doing their own thing?

  Dr Wilson: There are 90-odd PCTs and we do not know what they are doing. They may all be doing a fantastic job, but our little organisation does not have time to set up a quality assurance process. I know what the GMC does so I know how far I can rely on what the GMC does; I do not know what different PCTs do. I know what some of the local ones do, but how would I know what a PCT in the North West does.

  Q47  Sandra Gidley: It would make it easer for everybody if there were more standardisation?

  Dr Wilson: Yes.

  Q48  Dr Taylor: Antek, you have said your predecessors really accepted that GMC registration was pretty well good enough and did not go into it much more than that.

  Mr Lejk: I think it was more than just that but I was not personally involved at that time .

  Q49  Dr Taylor: We have the paper from the GMC and I am quoting: "The GMC cannot by law test the language proficiency of European doctors or carry out any assessment of medical knowledge and skills". I am addressing this to Mike, if I may, should one of our strongest recommendations be that somehow, however it can be done, GMC registration takes into account not only language ability but clinical competence because we gather that this chap Ubani trained in Germany, did just his training then we believe—this is only an allegation—went straight into work as a cosmetic surgeon so had no experience in general practice at all, therefore he did not know the dose of diamorphine. Should we be somehow trying to help the GMC so they could test for language and clinical competence?

  Mr Farrar: My sense is that the architecture that we currently have goes an awful long way. You have the beginning of the process with the GMC registration; you have the PCTs with their performers lists and you have the providers who really should, because of all the points about professional quality, be looking after that. We can focus a lot of attention on more architecture and in my view you can always improve that and make it tougher. The real quality gain for me in this is going to come from looking at the handovers where our out-of-hours services pass on patients to other people and make sure that information is transferred; look at the coherence of out-of-hours services against all other aspects and bring in the multi-disciplinary working that you get during the day. I think the biggest quality gains that we could have would be in that respect. I accept we are looking specifically at one key question here which related to this tragic incident and I think you would want to try to tighten that if you could, but my sense is that good implementation of the architecture that we have got would actually get us quite a long way towards the aim you have. I know you are interviewing the GMC afterwards and I would be very interested to know whether or not they feel that they could do with something else in that mix. I certainly would not be against it but I do not think it is where you will get the biggest step change in quality of out-of-hours care because I think those other things I mentioned can do more.

  Q50  Dr Taylor: You could not see the representative of the GMC but his head was shaking very vigorously when you were making those comments. I cannot help thinking that there has to be some way of excluding a doctor who does not know the basic dose.

  Mr Farrar: Yes, of course. You would want somebody to be as fit to practise as possible, I am absolutely clear about that, but I think in the overall impact on the quality of care we should also be focussing on those other things.

  Q51  Chairman: Mike, you have been around long enough to know that until the changes in the European Union just a few years ago most of the doctors who are coming in now from the wider European Union would have to have sat a test of their medical competence with the regulatory body. Did you think that was wrong when it happened? Do you think it should be overridden effectively by a decision in the European Commission?

  Mr Farrar: That is an interesting question to put to me; I should be phoning a friend really.

  Q52  Chairman: You are a practitioner; I just read these things, although I did have a history as a member of the General Medical Council. That has been the big change.

  Mr Farrar: The NHS has been reliant on overseas medical input for many, many years.

  Q53  Chairman: And been reliant on tests by the regulator.

  Mr Farrar: We have benefited massively from that. It does not seem to me too difficult to make sure that people coming to this country who are capable of practising are subjected to a test on language and I do not think that should just be in the medical profession.

  Q54  Chairman: It is not just language, it is the other skills as well.

  Mr Farrar: In terms of skills I think there is a question to ask about the standards that we expect of our doctors where people are medically qualified overseas. Slightly more controversially, I think in that mix somewhere there is an element of arrogance about the quality of medical standards that we produce compared with others. Just to give you one experience where at one point there was some concern about South African doctors providing some of the care in ISTCs, some of the practices that the South African doctors had brought were very, very good and in fact better than some of the services that we were providing, but at the time that was introduced there was a sense that medical training in South Africa would not be at the standard we have. I think we have to be careful about what fitness to practise is. We have to set our standards high and we should have tests on some of those things, but we should not have an automatic assumption that somehow anybody trained in this country is fabulous and anybody trained abroad is worse.

  Chairman: I do not normally pass comment but I completely agree with some of those sentiments. I have visited and spoken to South African doctors who look after my constituents as well. I have no problem but of course they had to make sure they were fit and proper to practise in the UK while other doctors do not necessarily have to do that. Could I thank all of you very much indeed for coming in and opening this first session. I know we have over-run a little bit but thank you very much indeed.

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