Prepared: 18:49 on 9 February 2010
Does the Minister share the GMC’s view that patients should have a right to safe and good-quality health care across the EU and to safe doctors? If so, these reforms are necessary. Does he agree that training in UK prescribing practice and medicines use—along with an induction and assessment—is essential before a doctor from overseas starts to practise in out-of-hours care? Will those requirements be part of the minimum standards? Does he agree that providing for a minimum number of local GPs on duty, particularly in widely dispersed rural counties, must be part of those minimum standards?
A European arrest warrant was issued in the Dr. Ubani case, but it failed to be effective because of action taken by Germany’s authorities to prosecute him on a minor charge in that country. Co-operation failed in that case, so is the Minister prepared to make representations to the Home Secretary to press for proper co-operation, because the European arrest warrant is of no value if it does not deliver justice in cases such as this?
Mr. O'Brien: Certainly I want to ensure that we learn all the lessons from this, but may I deal with the legal issue last? On the performers list, a report was published last March and officials have been consulting on how all that will be put in place. Where regulations need to be put in place, that will be done shortly, but the hon. Gentleman will appreciate that consultation with the relevant organisations needed to occur and that we wish to move forward with this as quickly as we reasonably can.
The hon. Gentleman mentioned holding to account those who have failed in the system, particularly Cornwall primary care trust. The main thing is that we get the system right; that we ensure that those who have failed will no longer be in a situation where failures can take place again; that we are able to examine how the system operates; and that the checks that will protect patients are the ones that occur.
I am not convinced about imposing a criminal offence on a PCT. I am not sure who in the PCT the hon. Gentleman wants this to be imposed on—is it the PCT’s chairman or its chief executives? I am also unsure as to what the penalty would be. We are talking about a criminal conviction, so does he want these people to be sent to prison? Does he want to fine them? Why would he convict them? These are people who have been employed to do a job, and appropriate disciplinary procedures are in place to deal with them if they do not carry out their job adequately. Boards can be dismissed, and chairmen and chief executives can be removed, so I am still to be convinced about his suggestion that a criminal penalty for these people is the best way of changing behaviour. I am also a bit cautious because we do not want to get into a situation with criminal law, which tends to be absolute in its implications, where people are reluctant to come forward and say that there is a problem in their system that needs addressing because they fear that they might get prosecuted if they were to do so. I am concerned about such implications.
As for the GMC carrying out checks, we were aware in 2004 that there was a problem as a result of the Medical Act 1983. That is why we put in place the requirement on PCTs to ensure that English was spoken—that is something that PCTs must do. There may be ways in which PCTs can work with the GMC to ensure that it can be satisfied that people are not only able to speak English, but competent. However, that needs some further discussion between the GMC and the PCTs. In other words, the GMC could act as an agent of the PCTs, but I wish to examine that. My main concern is to ensure that the checks are done—I am less concerned about who does them. I just want them done, because patients deserve safety.
As for ensuring that across Europe we have good and competent quality of care, we can discuss with other countries the need for them to improve the quality of what they do. We obviously have a limited amount of control over that, but what we can do is ensure that we have systems in place that enable people to become aware of information about doctors being disciplined or struck off elsewhere.
As far as minimum training and induction are concerned, I agree that, as part of minimum standards, we need to ensure that they are included in a national contract. There is a legal requirement now, through the national quality regulations, that those standards be applied, but in this particular case, they were not always applied. That is why I want the model contract, so that there is no doubt on that point.
Finally, the hon. Gentleman asked me about extradition and the European arrest warrant. It is indeed the case that an arrest warrant was issued. Unfortunately, it appears that the arrest warrant was issued on 12 March 2009 but the German authorities refused it on 24 March 2009 on the basis that they were already prosecuting the case. I cannot quite work out why they were doing that. It has been suggested that Dr. Ubani asked the German authorities to prosecute him first, so he could avoid extradition on grounds of double jeopardy. The CPS was concerned about that, because it wanted to prosecute him, and contacted Eurojust to query that on 26 March. On 21 April, Dr. Ubani was convicted, received a four-month suspended sentence and made a payment, although it is disputed whether it was a cost or a fine. I hope that that deals with some of the hon. Gentleman’s concerns, but we are concerned to engage further with the German authorities on this issue.
Several hon. Members rose—
Mr. Speaker: Order. The exchanges between the Front Benches have been wide-ranging and doubtless illuminating, but they have absorbed 32 minutes, which is almost unprecedented. The House will be conscious that after this there is a 10-minute Bill and much important business, including the final day in Committee for the Constitutional Reform and Governance Bill. Sixteen right hon. and hon. Members are seeking to catch my eye. I want to accommodate everyone, but if we are to make progress timeously, we need short questions and short answers.
Jacqui Smith (Redditch) (Lab): I welcome my right hon. and learned Friend’s emphasis on national minimum standards to ensure high-quality out-of-hours care for all patients, and the fact that local GPs will be involved in the design of the system. No GP has argued to me that they want to take back full responsibility, but they should be involved in the design. Does my right hon. and learned Friend think that, if new contracts are being let or contracts are being renewed, local GPs should also have a say in who receives those contracts?
Mr. O’Brien: I certainly hope that we will be able to engage our local GPs, through the various mechanisms that I mentioned, in looking not only at the rules and the best way in which services can be delivered locally, but at who gets those contracts.
Sir Patrick Cormack (South Staffordshire) (Con): Will the Minister reflect on the very wise words of the first family doctor I had when I was elected, who said that no true general practitioner can know his patient if he does not know him at home as well as in the surgery?
Mr. O’Brien: That is a good point to reflect on, but whether it is always possible to deliver in practice is another matter. GPs who are exhausted from working all day and then all night could end up being unsafe GPs.
Charlotte Atkins (Staffordshire, Moorlands) (Lab): Can my right hon. and learned Friend tell me how he expects PCTs to ensure that they are co-ordinating the out-of-hours service with other parts of the primary care system, including minor injury units and the ambulance service? The latter is especially vital in rural areas, where needy patients can be many miles from the out-of-hours provider.
Mr. O'Brien: My hon. Friend is entirely right. We need to ensure effective co-ordination between the ambulance service and out-of-hours provision to ensure that patients are well served.
Angela Browning (Tiverton and Honiton) (Con): In the guidelines and minimum standards recommendations, what is the ratio of doctor to population, and does it take account of geographical areas with a sparse population? Should that not be looked at, because there are parts of the country where people wait a long time? If the Minister is looking to improve standards, surely ensuring adequate coverage in the first place is one of the first things to consider.
Mr. O'Brien: Adequate coverage is indeed essential. As far as I am aware, there is not a ratio as such. However, we need to ensure that people do not have to wait a long time and that someone is available to come out within a reasonable time to ensure that the patient gets the necessary care. I have seen some of the statistics, as I am sure the hon. Lady has, on the numbers of patients and out-of-hours doctors. They vary considerably, and I want to engage with doctors’ organisations to ensure that we do not need such a minimum standard.
Mr. David Drew (Stroud) (Lab/Co-op): Does my right hon. and learned Friend accept that the last thing that we need is another group of professionals being forced out of the NHS, as would happen if the Conservative party’s proposals were taken seriously? Will he look at how we handle people with mental health problems and how they engage with the out-of-hours service, because there seems to be some variation across the country? In particular, what responsibilities do the different trusts that engage with such people have in the out-of-hours period?
Mr. O'Brien: My hon. Friend is right that there is a difference between the Conservative party and us. As I understand it, the former wants to transfer responsibility to GPs. We take the view, however, that we should not force that responsibility on to GPs, but that they should be more involved in how those services are commissioned.
It certainly is the case that, in some areas, out-of-hours mental health provision needs to be looked at with great care, because its quality is crucial, particularly when those with mental health problems have an episode that needs urgent attention.
Dr. Richard Taylor (Wyre Forest) (Ind): As I understand it, the basic fault with Dr. Ubani was that he did not even know the dose of diamorphine, which is why I am so pleased with the emphasis on the greater involvement of local GPs in the commissioning, design and, in some cases, provision of the service. Will the Minister therefore support me in supporting the bid for out-of-hours services in Worcestershire that has the approval of local GPs?
Mr. O'Brien: The discussion on the out-of-hours service needs to be with the local primary care trust, but the hon. Gentleman needs to ensure that local GPs and doctors are involved in some of those discussions.
Mr. Peter Bone (Wellingborough) (Con): Will the Minister let the GMC test the competency and language abilities of EU doctors before they are registered? Will he put the lives of British patients before EU law?
Mr. O'Brien: It is not about EU law; it is about testing and ensuring that the tests are done by the people who are legally responsible for ensuring that GPs speak English before they provide out-of-hours care. That responsibility is currently with the PCTs. My concern is that those requirements be met—they are legal requirements, they ought to be being met now, and PCTs have been told that they must meet them.
Dan Rogerson (North Cornwall) (LD): Does not the Minister agree that, in the issuing of some contracts during the previous round, PCTs seemed to decide that they wanted to drive down costs above all other considerations for out-of-hours contracts? Some of those deals looked too good to be true, and have turned out to be too good to be true.
Mr. O'Brien: Funding for out-of-hours contracts has risen significantly in recent years. The spend by PCTs has risen from £209 million in 2004 to £378 million in 2008–09, so considerable funding has been put into it. However, the hon. Gentleman is right that PCTs have a responsibility above all to safeguard the patient. That is their primary responsibility. A secondary one is to ensure that they do it with value for money.
Chloe Smith (Norwich, North) (Con): I regret to report to the House that my constituent Mrs. Marjorie Alderson had a difficult experience with out-of-hours care. I am particularly sad to say that she has since passed away, but her daughters have been active in highlighting the difficulties faced in Norfolk. I would particularly appreciate the Minister’s reassurance that he will look seriously at what it takes to attract doctors to work in the out-of-hours service. I have had various comments from medical professionals to suggest that that is a particular difficulty.
Mr. O'Brien: May I extend my condolences to the family of Marjorie Alderson? As for attracting doctors, the hon. Lady is right: some parts of the country seem to be experiencing difficulties, whereas others are not. That is one of the points to come out of the report by Dr. Colin-Thomé and Professor Field, as well as my discussions with those in some out-of-hours services. I am not entirely clear, in that the issue does not seem to be funding or how much the GPs are paid. Rather, there seems to be a reluctance among GPs in some areas to get involved in out-of-hours services, whereas in other areas they are anxious to get involved. It is important to get to the bottom of that and identify exactly why the problem that the hon. Lady has identified is occurring.
Mr. Bernard Jenkin (North Essex) (Con): Has the Minister done any analysis of the disparities in costs between different out-of-hours contracts? Is he aware of the disparities between the costs that the Ministry of Defence pays? In one case it pays £20,000 a year for 17,000 soldiers, but in another it pays £278,000 for 20,000 soldiers, which is considerably more. Why should the Ministry of Defence pay for out-of-hours care for its soldiers when soldiers pay tax and should get that service on the national health service anyway?
Mr. O'Brien: The Ministry of Defence wants to ensure that particular facilities are available to it. Therefore, some want to fund those facilities themselves. That is, in a sense, a matter for the MOD. As for variations in cost between PCTs, that is an issue that we need to look into with care. I am satisfied that the broad run of PCTs is trying to get both value for money and a good quality of service, and that those PCTs are indeed delivering that. However, one or two PCTs are looking more at cost than at patient safety.
Mr. David Heath (Somerton and Frome) (LD): To bring the Minister back to rural areas, is not another factor the availability and accessibility of accident and emergency units? My constituency covers 900 square miles. There is not a single A and E unit in my constituency, nor is a single out-of-hours doctor based there. Do we not need better cover than the four cars that currently provide for the whole of Somerset? Should there not be an assumption that community hospitals will have at least an evening treatment centre, with a doctor available to look after people out of hours?
Mr. O'Brien: The hon. Gentleman has raised a number of issues. As for provision in his local area, the issue that we have faced over a number of decades is that power is being devolved. That means that we are very reliant on local PCTs to make local decisions. We can have minimum standards, but we cannot rewrite the entire framework in which PCTs operate—in other words, take away their flexibility to respond to local need. Getting the balance right is quite tricky, but it is important that we work on getting it precisely right.
Miss Anne McIntosh (Vale of York) (Con): I should declare an interest: my brother works for the out-of-hours service in North Yorkshire, although we have not discussed the issue. Is not the heart of the matter the fact that only in the UK has the system of family doctors and GP services developed to the extent that it has developed here? No one else is in quite the same position—or, possibly, no one else is better qualified—to judge that the PCT is not qualified to judge whether a GP here, or a medically qualified doctor in Germany or another EEA country, is fit to operate our out-of-hours service. I am not sure that what the Minister has told the House today fundamentally addresses that point.
Mr. O'Brien: We need to ensure that doctors are properly qualified. It is a requirement that PCTs should not allow anything that might mean that the GPs they employ are not capable of being GPs. Therefore, we need to ensure that we have proper induction and proper training. We must ensure that GPs are capable of doing the work that they are employed to do. It is not so much a matter of the EU; rather, it is a matter of ensuring that if someone comes into an area, the PCT and the providers have done the checks and ensured that that GP knows what they are doing and are safe.
Dr. John Pugh (Southport) (LD): Why is the Minister so opposed to specifying a minimum ratio of medical personnel to population? Surely there is a level that is clinically unsafe, and we ought to specify it.
Mr. O’Brien: This is dependent on a number of factors, including the size of the area, the amount of time it takes to get to people, and the level of demand in the area. That is why the PCTs have to ensure that proper medical issues are looked at, and that the level of cover and provision is adequate to ensure that people get the quality of service that they need. Checks should be being done now, but I still want to consider whether we need a national minimum standard. The requirements for the ratios to be right from a medical point of view are already there.
Bob Spink (Castle Point) (Ind): Is the Minister satisfied that the greater use of our generally excellent ambulance service in some areas is not part of the problem?
Mr. O'Brien: I do not think that it is. There is a lot of increase in demand on the ambulance service, and we are working through some of the issues relating to that increase. Much of it, however, is occurring during the daytime, rather than at night. I would need to get more research done before I could answer in depth the hon. Gentleman’s question on whether that relates directly to the issues around the out-of-hours service.
Mr. Andrew Pelling (Croydon, Central) (Ind): The campaigning social issues journalist Aline Nassif revealed in the Croydon Advertiser last Friday that our population of 370,000 is covered by only three GPs between midnight and 8 am. Does the Minister really feel that that is clinically safe?
Mr. O'Brien: Decisions on clinical safety should be made by people who are clinically qualified, rather than by me as a Minister. It is a requirement for the PCT to ensure that there is appropriate clinical supervision of the provision, that there is an appropriate number of GPs for the population, and that the cover is safe. That is a legal requirement, and the PCTs should be doing that.
Point of Order
4.22 pm
Mr. Mark Harper (Forest of Dean) (Con): On a point of order, Mr. Speaker. I know how much importance you place on timely answers being provided to questions posed by Members of the House. Could you give me some advice on how I might ensure that the Department for Work and Pensions does a little better at answering its questions? I have tabled 30 questions that have now passed their due date without being answered. To be fair, most of them are due to be answered in February, but the worst instance dates back to 30 November last year. The most embarrassing example is from 14 December, when I asked the Secretary of State how many and what percentage of questions tabled for written answer on a named day had had a substantive answer. Every other Department has managed to answer that question in a timely manner, but I suspect, given that I have not had an answer from the DWP, that its response will be “Not very many”. What can I do to get more timely answers?
Mr. Speaker: I am grateful to the hon. Gentleman for his point of order. I understand why he feels disquiet about this matter. I wondered for a moment whether we were going to get a Cook’s tour of his questions to which Ministers had so far failed to respond. He is right to say that I attach a premium to prompt and informative answers from Ministers to questions from hon. Members, whether those questions are written or oral. He is a keen student of these matters and a regular and substantial tabler of questions, and he will also be aware of the developing system of transparency, whereby it can readily be seen at a glance whether a question has been answered or not.
I would like to say, perhaps a little speculatively, to the hon. Gentleman that I have found, over the years, that when a Member complains about an unanswered question or letter, either through a further question on the Order Paper or by raising a point of order on the Floor of the House, that often serves speedily to concentrate the minds of Ministers. There are a number of Ministers on the Treasury Bench at the moment, and I feel sure that they are listening attentively to the point that the hon. Gentleman has just made. I hope that that is helpful.
Mr. Harper: I am grateful.
Mr. Speaker: Good. If there are no further points of order, we shall move to the presentation of Bills.