Prepared: 18:38 on 9 February 2010
Out-of-Hours GP Services
3.35 pm
The Minister of State, Department of Health (Mr. Mike O'Brien): With permission, Mr. Speaker, I should like to make a statement about out-of-hours primary care following the conclusion of the coroner’s inquest last week into the care of Mr. David Gray, who died on 16 February 2008. First, and I am sure that I will be joined by the whole House in this, I should like to extend my sincere condolences to the family of Mr. Gray. This was a tragic case, and I am deeply sorry for their loss. I understand that litigation has arisen out of this issue and I shall therefore direct my remarks primarily to the wider policy issues.
Concerns about out-of-hours primary care were raised with me last summer. I then met primary care professionals to understand the issues in greater detail and to consider what action we might take to improve out-of-hours services for patients. The Care Quality Commission’s interim report on out-of-hours care in Cambridgeshire, published on 1 October 2009, also expressed concerns over the quality of care provided. By that time, on 23 September, following discussions with them, I had formally asked Dr. David Colin-Thomé, the national director for primary care at the Department of Health, and Professor Steve Field, chairman of the council of the Royal College of General Practitioners, to lead jointly a review of the current arrangements for the local commissioning and provision of out-of-hours services.
The report, which I published last Thursday, considered the commissioning and performance management of out-of-hours services, the selection, induction, training and use of out-of-hours clinicians, and the management and operation of the medical performers lists on which doctors must register in order to practise in England. The report acknowledges the fact that there is an unacceptable variation in the quality of out-of-hours services across the country, and it sets out 24 recommendations, including that primary care trusts should review the performance management arrangements that they have in place for their out-of-hours services, to ensure that they are robust and fit for purpose; that the Department of Health should issue guidance to PCTs to help them decide whether a doctor has the necessary level of English to be added to their medical performers list; that the Department of Health should develop and introduce an improvement programme for PCTs to support the commissioning and performance management of out-of-hours services; that out-of-hours providers should consider their recruitment and selection processes for clinical staff to ensure that they are robust and follow best practice; and that strategic health authorities should monitor the actions taken by PCTs in response to the report and in carrying out appropriate performance management of out-of-hours providers.
The report’s recommendations are an important reminder, to PCTs and providers, of their pre-existing obligations to provide patients with safe and effective out-of-hours services. We have accepted the recommendations in full, and we intend to go further still. I have announced additional improvements to out-of-hours GP services. We will review the existing national quality requirements, and introduce and mandate national minimum standards that all out-of-hours providers will be required to meet. We will introduce a model contract based on these national minimum standards for out-of-hours provision that PCTs and the providers of out-of-hours services must use. The Department will work with national medical organisations to develop a national database and consider what data should be placed on it. We will tighten existing controls to ensure that PCTs meet their legal obligations and that providers employ competent clinicians to practise as out-of-hours GPs. SHAs must ensure that PCTs are meeting their obligations and we will, in turn, hold SHAs to account for this.
There is already a clear legal requirement under the National Health Service (Performers Lists) Regulations 2004 for PCTs to refuse a doctor’s inclusion on their performers list if they are not satisfied with their level of English. We will direct PCTs to review their procedures and to make certain that they have a clear policy in place for assessing the English language skills of everyone applying to be added to their local performers list. Finally, we will require PCTs to involve local GPs in the design of out-of-hours services through local medical committees, RCGP groups and faculties, clinical executive groups and practice-based commissioning consortiums.
Officials in the Department of Health will continue to work with the NHS to implement these measures. The NHS chief executive, Sir David Nicholson, wrote to all NHS organisations last Thursday to bring Dr. Colin-Thomé’s and Professor Field’s report to their attention. He sought assurances that they are meeting their obligations as highlighted in the report. Along with Sir David Nicholson’s letter, the Department of Health has issued new interim guidance to PCTs to assist them in complying with their obligations to ensure that all doctors admitted to their performers list have the necessary English language skills.
It is clear that in some areas out-of-hours services are not as good as they could or should be. However, as Professor Field’s and Dr. Colin-Thomé’s report acknowledges, even when GPs were responsible for the care of their patients 24 hours a day, only 5 per cent. of them actually provided out-of-hours care for their own patients. Those GPs that did so were often left dangerously tired and exhausted. The system was unsafe. In fact, by early 2000, the level of complaints from the public was so great that the Government asked Dr. David Carson to conduct a comprehensive review of out-of-hours services in England. His recommendations formed the basis of our 2004 reforms, which have led to significant and independently verified improvements in out-of-hours care.
Most of our out-of-hours care is today provided by local GPs working on rotas for co-operatives or companies and, the case of Dr. Ubani notwithstanding, most of the service is good. A 2006 review of out-of-hours care by the National Audit Office said:
“England is at the forefront of thinking internationally”
on out-of-hours care. In 2008, a Healthcare Commission report on urgent and emergency care added:
“There have been significant improvements over recent years in the…number of out-of-hours GP services meeting national quality requirements.”
While it is clear that the quality of out-of-hours care for most people is better than it was in 2004, it is still not good enough. I hope that the recommendations set out in the report by Dr. Colin-Thomé and Professor Field, along with the additional measures I have set out, will let Mr. Gray’s family know that lessons will be learned, and I hope that we will give patients the level of out-of-hours primary care that they expect and deserve.
Mark Simmonds (Boston and Skegness) (Con): May I join the Minister in extending my sincere condolences to Mr. Gray’s family?
I thank the Minister for the courtesy of giving me sight of his statement prior to his making it at the Dispatch Box. I suspect, however, that it is with great reluctance that he has come before the House today and that he has done so only because of significant pressure.
It needs to be said that good out-of-hours care is being provided in some parts of the country, but it is clear from the coroner’s report into the terrible tragedy of David Gray in February last year, and from the additional report by Dr. Colin-Thomé and Professor Field released last Thursday, that there are significant failings in the provision of out-of-hours care in some parts of England, providing unsatisfactory levels of patient care and, ultimately, putting patients’ lives at risk. There have been several tragic deaths, and we must all do everything we can to ensure that that never happens again.
The Government’s decision to allow almost all GPs to opt out of involvement in out-of-hours care in 2004 was a significant and serious mistake. The current structure of out-of-hours care is at best patchy and has been described by the Public Accounts Committee as “shambolic”. The Government were consistently warned that there were ongoing failures in the system, with reports not only by the PAC but by the National Audit Office and by the Select Committee on Health, twice, highlighting serious concerns and failings, yet no effective action was taken. All those reports, and the two released last Thursday, are critical of the patchy provision of out-of-hours care.
The list of defects and non-performance is extensive: increasing numbers of complaints about out-of hours care; primary care trusts failing to monitor the quality of care and not reviewing or assessing contracts; inadequate performance measurements; strategic health authorities not monitoring PCT performance, and in some cases not engaging in the process at all; out-of-hours care used too often as a holding bay; insufficient skills for commissioning out-of-hours services; some PCTs ignoring and shunning GPs’ involvement and advice; a lack of clarity on responsibility between commissioners and providers; significant additional pressure and attendance at accident and emergency and pressure on ambulance services; little or no integration of out-of-hours care with urgent care; non-implementation of selection, induction and training of foreign doctors; very poor response times; and a lack of a coherent and consistent approach to the inclusion of doctors on the performers list.
It is clear that there were failures at SHA, PCT and provider level. There were failures to assess foreign doctors’ language, communication and formulary skills, to involve GPs in the commissioning of services, to monitor, review and assess out-of-hours care, and to assess and learn from patient experience. In some parts of the country, that litany of failures has been detrimental not only to patient care but to patient safety, culminating in the shocking death of David Gray.
The Minister has said that he will implement all the recommendations of the Colin-Thomé and Field review. Will he do the same for the coroner’s recommendations? What will be the time scale for the implementation of the recommendations of the review? In other words, what is the longstop date for its total implementation? What action will the Minister take to ensure that SHAs review PCTs’ progress in that area? SHAs need to do more than just consider what action should be taken. How will he ensure that PCTs properly and regularly review out-of-hours contracts, involving local GPs and, I note with interest, including local GP consortiums? Rigorous monitoring should be taking place everywhere, looking at the quality of clinical decisions, the efficiency of call handling, the adequacy of staffing, doctors’ training and patient outcomes.
The Minister will be aware that the General Medical Council is very concerned about the ability of foreign doctors from within the European economic area to practise in the UK. It believes that
“the current legal framework is unsatisfactory”
and that
“the current system does not adequately safeguard patient safety.”
The Minister must ensure that he completes the immediate implementation of the Department of Health report “Tackling Concerns Locally”, which has been collecting dust in the Department since March 2009. Will he address the concerns of the GMC and lobby for a change to EU law, to ensure proper skills and language testing for doctors who wish to practise in the UK? Will he consider including in the process of revalidation locums and doctors from the EEA who are working in the UK, and will he ensure that access to the performers list is tightened and that there is a much greater flow of information between PCTs and the GMC? As far as I understand from what the Minister said, there is still no mechanism in place to ensure that a doctor struck off in another EU country cannot practise in the UK.
To put it mildly, this is not the Government’s finest hour. It has taken the tragic death of Mr. Gray for action to be taken, despite persistent and consistent previous warnings. This is a serious situation that will be resolved only when the Minister accepts that in some geographical areas the system of out-of-hours care has failed; when, as the Royal College of General Practitioners recommends, a comprehensive review of out-of-hours care takes place; and when the Government accept, for the sake of patient care and safety, that responsibility for commissioning out-of-hours services must be with GPs.
Mr. O'Brien: I certainly agree with the hon. Gentleman that we must ensure that we do all we possibly can so that this sort of incident never happens again. That is why we responded to a series of reports and ensured that after the Carson review on out-of-hours services, we changed things—it was clear that the system that existed before 2004 was unsafe; therefore, changes were put in place.
We do not want a situation in which we return responsibility to GPs for the management of out-of-hours care, as appears to have been suggested. Dr. Laurence Buckman of the British Medical Association has been very clear on that. He said:
“The old system meant many doctors were tired and therefore potentially dangerous to patients and it is for that reason that the BMA, and the GPs it represents, would resist a return to doctors taking back personal responsibility for delivering care out-of-hours.”
On another occasion, he said:
“The current out-of-hours system desperately needs improving, but we can’t go back to where we were before 2004 where doctors were on call 24 hours a day, meaning many were operating in a constantly sleep-deprived state.”
We need to ensure that we deal with some of the issues that exist in the current system. I think we all, as parliamentarians, need to confront the issue of decentralisation of power. We have been pushing down responsibilities to PCTs. That is all very good, and there is a broad consensus in the House that that should happen—the closer to the patient the better—except some PCTs are more capable than others of doing a good job. That presents us with the question how best to manage that. We have taken the view that we need to bring about two changes. First, we need much more central involvement by the Department of Health in ensuring that PCTs have minimum standards, through a model contract. All PCTs must ensure that providers comply with that contract. Secondly, we need to get local GPs more involved—that does not mean giving responsibility back—so that they can monitor the quality of the out-of-hours service that is being delivered.
The hon. Gentleman set out the concerns expressed in the report by Dr. Colin-Thomé and Professor Field. I remind him that that report was commissioned not after the coroner’s report last week, but on 23 September last year. Indeed, discussions on it took place with those involved before that time, because we knew that we needed to ensure that we improved out-of-hours care. I want to have further discussions with the doctors’ organisations on some of the coroner’s recommendations, but in a broad sense, we accept them. We must go through some of the detail with the doctors’ organisations on how that will be done.
When can we put those changes in place? I have said very clearly to officials that I want it done by the end of the year. I want to be sure that we have got the system right by then at least. I was asked how that would be monitored. For the next six months PCTs will be required to have on the agenda of every board meeting, at least once a month, the quality of out-of-hours care and its improvement. That will be monitored by the SHA. Thereafter, PCTs need to take a higher level of responsibility for it.
There are three checks on foreign doctors from the EEA. First, the GMC checks their medical qualifications. Secondly, since 2004 the PCT is responsible for checking that they speak English and that nothing is known about them that undermines their medical capability. Thirdly, the employers are responsible for ensuring that the GPs whom they employ not only speak English, but are clinically competent. In some cases it is clear that some of the PCTs have been a weak link. Some have not always complied with their responsibilities.
The GMC, as was pointed out, has indicated that it would like to do some tests on GPs who do out-of-hours work. It was clear from the Medical Act 1983 that the GMC could not carry out such tests, and it cannot do so under the directive which has been renewed but predates that. In 2004, therefore, the responsibility for ensuring that English was spoken was given to the PCTs. Most of them have delivered on that. Some have not, and that is what we need to change.
The EU law will be reviewed in 2012, so the directive will be reviewed in any event. We must ensure that we examine the detail of that. However, we cannot wait until then. We must put in place safety checks to ensure that this year the lessons of that tragic death are learned and that Mr. Gray did not die in vain.
Norman Lamb (North Norfolk) (LD): I, too, thank the Minister for early sight of the statement, and I join in the expressions of sympathy and condolences to the Gray family. The two sons of David Gray, Rory and Stuart, want something positive to come out of their personal tragedy and I hope very much that that is the case. The system ultimately failed their father in allowing Dr. Ubani to practise in this country. Also, it failed the family by failing to ensure that he appeared before a court in the United Kingdom following a police investigation into what happened.
I welcome the report and the recommendations, but why the delay? A report on the performers list was published on the Department’s website last March. That is 11 months ago. Why has it taken this long for the Government to respond to those recommendations?
Will anyone be held to account for the failure of Cornwall PCT? The Minister says that there are legal duties, but they are of no value if nothing happens when they are breached. The House was informed in February 2007 of doctors working in Cornwall with inadequate language skills. That was before Dr. Ubani was registered by Cornwall. What action was taken and who will be held to account for that? Will the Minister consider introducing a criminal offence of PCTs failing to protect patient safety, in order to give some teeth to the regulations?
The greatest safeguard of all would be to prevent a foreign doctor who has inadequate language skills or competence from registering with the GMC. The EU directive allows a regulator to satisfy itself on language, but the Medical Act, as the Minister said, needs amending. Will he consider amending it so that, under existing directives, the GMC could test language skills? Will he agree to lobby for EU reform to protect patients, as the GMC accepts is necessary—first, to allow a test of competence; secondly, to require immediate notification of suspension across Europe; and thirdly, for suspension anywhere to apply everywhere that that doctor is allowed to practise under the freedom of movement of labour?