Examination of Witnesses (Questions 1-54)
MR PAUL
BATES, MR
MIKE FARRAR,
MR ANTEK
LEJK AND
DR FAY
WILSON
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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