Select Committee on Public Administration Minutes of Evidence

Examination of Witnesses (Questions 43 - 59)




  43. Could I, on behalf of the Committee, welcome you this afternoon. As you know, the Committee looks at cases arising out of Ombudsman's reports, which is why we have invited you from Healthcall to come along and look at some issues arising out of a number of complaints about Healthcall. I think it would be helpful if you were able to say a few words by way of introduction, although before that it would be even more helpful if I asked the Ombudsman to introduce and remind us of the cases that we are talking about.

  (Mr Buckley) As you say, my office has investigated a number of complaints involving organisations providing deputising services for GPs. Several of them have involved Healthcall Limited. Besides the special report on cases like E.515/97-98, published in March 1999, and which I should in fairness say was mainly concerned with the actions of the deputising doctor himself, I published three cases in full in the volume of Investigations Completed between October 1999 and March 2000. The case references are E.1927/98-99; E.1329/98-99; and E.516/99-00. In addition, I have published in summary form two cases involving other deputising services: the references are E.389/99-00 and E.3891582/99-00. I understand that the Committee is not so much concerned to discuss the details of individual cases as to explore the common themes which have emerged from them. These include: (a) extended periods between the time a doctor was called and when he or she actually visited the patient; (b) the quality of care provided by the doctor; (c) inadequate procedures that meant information was not passed quickly to a person with the qualifications to make an assessment of clinical need and priority; (d) occasions when too few deputising doctors were stretched across a very large geographical area, which contributed to delays; (e) procedures for calling upon more doctors either did not exist, or were not activated; (f) inadequate communication between the commissioning and deputising GPs. I welcomed the deputising agencies' assurances that those matters would be addressed and noted planned changes to induction, training and other procedures. My staff have had helpful discussions with Healthcall's Medical Director. Another general cause of concern was the arrangements for monitoring the quality of deputising services. Before April 1997, Health Authorities were responsible for this, and were required to have a Deputising Services Sub-Committee. Since 1997, the responsibility has passed to GPs, who are required to take all reasonable steps to satisfy themselves that any deputising services they use provide services which are adequate and appropriate. I believe that change is under consideration and you may wish to ask the Department of Health witnesses for an account of where we are. It became clear in the course of the investigations I have mentioned that some GPs monitored the quality of the service provided by those deputising for them, but others did not. In fact, the arrangements for monitoring out-of-hours services, whether provided by independent sector organisations like Healthcall or the GP-managed out-of-hours co-operatives, seemed to vary considerably. I therefore welcomed the opportunity to contribute to the Chief Medical Officer's review of out-of-hours services and the proposals that emerged from that review. Finally, there has been a more recent complaint which revealed some apparently widespread confusion about which of the parties to a complaint—the commissioning doctor, the deputising doctor or the deputising service—should respond to the complainant. Since this appeared to be an immediate concern, I drew the issue to the attention of the Department of Health, and I understand that the matter is receiving consideration. Finally, Chairman, although, as I say, I understand that the Committee does not wish to examine the detail of individual cases, may I nevertheless, through you, repeat the usual warning regarding the confidentiality of individuals who were involved in the cases.

  44. Thank you for that. Let me turn to Healthcall and ask perhaps Mr Burns, the Group Managing Director, whether he would like to say a few words by way of initial response.
  (Mr Burns) May I take the opportunity initially to introduce ourselves. My name is Robbie Burns. I am the Group Managing Director of Healthcall. I have been with Healthcall for about 15 months and assumed the role of Group Managing Director in February 2000. I will ask my colleague to introduce himself.
  (Dr Dun) My name is Dr Andrew Dun. I joined Healthcall at the end of 1999, at about the same time as Robbie Burns. For ten years prior to joining Healthcall, I was a GP in a partnership in western Wiltshire.
  (Mr Burns) May I tell the Committee a little bit about Healthcall? We are a health service provision company. The vast bulk of the business, the core business, is the out-of-hours deputising service. Currently we have just over 8,500 GP customers. We look after approximately 15 million patients every night across the United Kingdom from Scotland through Wales and into the south-west of England. I do not particularly want to say anything on the specific cases but, if you would like to go into some of the details of it, Chairman, we are more than happy to take questions.

  45. Thank you very much. Someone who reads their way through these cases, because obviously we start with the cases, I think is appalled by what happened with people being kept waiting for hours before anyone came and in two cases people died. We do not know about the cause and effect. That brings home the severity of this. The Ombudsman in one of the reports talks about fundamental failings of Healthcall in relation to the issues. What do you think those fundamental failings are?
  (Dr Dun) Undoubtedly, the cases that the Ombudsman referred to in 1997 and 1998 showed a number of fundamental failings where we wholeheartedly agree with the Ombudsman. From the clinical perspective I think perhaps they could be summarised in terms of having inadequate prioritisation early in the proceedings. One of the comments which the Ombudsman and his team have referred to has been using operators—non-clinicians—to prioritise calls, which I wholeheartedly accept is not appropriate to modern, high quality out-of-hours care. We have put in place changes to remedy that. I think undoubtedly there were some failings in our organisational proceedings for passing calls swiftly from control centres out to clinicians, whether they be within the centre or out in the field. I think one of the other things which underlies much of the criticism which is absolutely right is that we were perhaps delivering at that time an out-of-hours service that required modernising. If I may elaborate on that, in the mid-Nineties, and certainly in 1995-96, Healthcall delivered primarily a home visiting service. I think it has become only too apparent from some of the developments in GP co-operatives—and, I am pleased to say, some of our changes—that modern, out-of-hours, primary care does not actually require a home visit to be delivered for all patients. There are other mechanisms of delivery such as clinical telephone advice and inviting patients, when it is clinically appropriate so to do, to come to primary care centres and hence to use initially working out of hours far more effectively. I wholeheartedly accept that there were some fundamental issues that the Ombudsman identified, which we feel, without in any way being complacent, we are working hard to change.
  (Mr Burns) To carry on from where my colleague left off, in the last year or 15 months we have introduced a number of changes to improve not only the clinical delivery of the service but also the operational delivery, both in terms of organising the technology and telephony we actually use and also fundamentally to retrain our operators in how to handle calls and the issue, as Dr Dun has stated, of making sure that those calls are passed swiftly to a clinician to undertake the prioritisation. We wholeheartedly accept the criticisms that are levelled in these cases but we believe we have made considerable progress in improving the delivery service that we offer our patients and our customers.

  46. The picture that we have here is of a service which sometimes takes calls inadequately and in one case did not understand the severity of the conditions; those calls are held for a long time by a non-medically qualified operator who fails to transmit those calls in any decent time to a medically qualified person; and that that medically qualified person, as we are told in some of these cases, may even not be in radio contact. In your view do none of those things apply?
  (Mr Burns) We have addressed all of those issues. We have undertaken a retraining programme of our operators; new operators that come in have a minimum of 100 hours training before they are actually on their own taking calls. Dr Dun can comment on the clinical prioritisation we have undertaken after consultation with our local medical directors, and we believe that we have come an enormous way since 1998-99. There is always going to be an instance when something unforeseen happens. We have an environment now in which every complaint is examined; we use that as a learning tool so that if there is an issue we make sure that is addressed so that we can actually ensure that we do not repeat the mistakes that were made in the past.

  47. Before my colleagues come in, can I press you on this because it is a fundamental issue. If there are system failures which you have identified in these reports, can you tell us, hand on heart, that they have been corrected now so that cases like this cannot happen again?
  (Mr Burns) They have been corrected. I think it would be foolhardy of me to say that they will not ever happen again in the future. We believe we have put the checks and balances in train to ensure that that risk is minimised right down to a level where, hopefully, it will never happen. I do not think I could say that it will never happen again. We have dramatically improved not only the training but also the telephony and the systems we have put in train since 1998-99.

  48. I am not sure you have quite got the point. It is not that cases do not happen, otherwise the Ombudsman would not be in business. The point is that, if cases are a consequence of failures of systems, they can be corrected. Have you corrected those failures in systems so that that dimension of these kinds of cases cannot recur?
  (Mr Burns) We believe we have. We are planning to do more things. With modern technologies we believe we can take that a stage further. We are constantly improving our systems and making investments in the systems. Yes, those fundamental issues we believe we have corrected.

  Chairman: I am sure we will want to explore some of those with you.

Mr White

  49. I represent Milton Keynes, so it is interesting that you are here! One of the things that has struck me of course was NHS Direct. It seems to me there is a number of lessons from your experiences that would be applicable to NHS Direct. Have you offered those to NHS Direct so that NHS Direct does not repeat the same mistakes you are making?
  (Dr Dun) We have been pleased to be involved with NHS Direct at both local and national levels and more importantly, if I may add, with the Government out-of-hours review team, which I believe has taken a wide range of opinions and experience, the good and the bad from all out-of-hours providers. Now the Government has a framework by which quality out-of-hours care, including the role that NHS Direct plays in it, can be transparently measured and there can be benchmarking between providers so that we can see the good and the bad and share best practice. Yes, we have communications at local and national levels with NHS Direct.

  50. One of the things that came across from reading the Ombudsman's report was the differing ways in various parts of the country the out-of-hours service is provided. You provide quite a number of services where there are local co-ops and services by individual GPs. How do you co-operate between you or is there competition? I could not understand how the system works. Is that not one of the problems? It sounds as though there are different standards in the contracts.
  (Dr Dun) Without doubt competition has been rife since the mid-Nineties between organisations like ourselves and particularly GP co-operatives. I am not sure that that competition has always worked in the best interests of patients. I do genuinely believe that the core of the out-of-hours review initiative fundamentally says that out-of-hours providers, including A&E, ambulance trusts and GP providers, must work together and collaborate. General practitioners of my generation and much younger are less keen to work out-of-hours than they have ever been. We make sure that we make best use of resources by working together.

  51. One of the things, it seems to me, is that the pressure on out-of-hours services is putting more pressure on A&E departments. Does that not lead to some of the complications we have seen in these reports?
  (Mr Burns) One of the issues raised in the out-of-hours review, which is absolutely appropriate, is that a lot of patients presenting at A&E do not require secondary but primary intervention. Therefore, there is a move to try and co-locate many primary care centres alongside A&E departments and, as Dr Dun has said, to share resources, so that we do not have patients travelling across towns to get to their primary care centre but they go to the one most convenient to them. We certainly welcome this initiative. We already have a couple of primary care centres in A&E departments. This momentum is now beginning. I am sure that, as the out-of-hours review is implemented, we will see a much more comprehensive service delivery framework for the patients.

  52. With whom is your contact these days?
  (Dr Dun) As we sit now, mostly with individual general practitioners. However, during the last year there has been quite a move towards primary care groups and trusts. Interestingly as well, we do have a good number—between 10 and 20—of formal contractual arrangements with co-operatives where we have started to collaborate. That is not universal across the country and it is mostly with GPs but there is a real move towards primary care trusts.

  53. If I phone up, I do not know who is going to come and see me. Is that correct?
  (Dr Dun) When you phone up your current general practitioner, unless that call is routed to a provider that tells you who you are going to get to come and see you, I think that is right, yes.


  54. Take us through Brian's call and through the system so that we get a sense of this. Brian is having pains in the middle of the night. He makes a call to his GP. The GP has a contract with you. Take us through the system.
  (Dr Dun) When Mr White makes his call, currently we have some quality standards around how we should respond to that call in terms of the chance of him hitting an engaged tone and the speed of response. Obviously minimum standards have been set down now nationally and one has to do that. If Mr White were to ring Healthcall, he would be answered by a trained operator but not a clinically-trained operator. At that stage, the operator who is trained in taking some fairly basic information, demographic information and symptom information, has a simple choice to make. If there are potentially immediately life-threatening conditions, we have in common with ambulance trusts identified the most commonly presenting immediately life-threatening conditions that require a 999 response. We are required to report centrally in the out-of-hours review how many of those immediately life-threatening conditions we identify within a minute.

  55. Pause there for a second. Here is Brian with these dreadful pains of the kind that MPs get routinely, in the middle of the night, and he phones this person who is not medically qualified. He describes the pains. Does this person then have to decide if it is urgent?
  (Dr Dun) No. There is a lay script that has been tested with clinicians and ambulance trusts. High on the list of immediately life-threatening conditions might be a heart attack if there is central chest pain. The operator would be able to ask some fairly basic simple questions and would instigate a 999 response for Mr White. All other callers are invited to attend one of our primary care centres or they are passed—which I believe is a fundamental improvement from the case on which the Ombudsman comments - to a clinician for a prioritisation decision. Then the outcome from either that prioritisation decision or the operator's discussion with Mr White would effectively lead to three mechanisms of delivering a service to Mr White. He would be advised by, in most cases within Healthcall, a qualified GP, although four per cent of our workforce are triage nurses; and he would be advised on self-care and self-help, perhaps rather similar to NHS Direct. He would be invited to one of our primary care centres or surgeries or a home visit would be arranged. Priority for the home visit would then be set, obviously in negotiation with the patient, by a clinician and not, as in the cases which Mr Buckley identified, by a non-qualified operator.

Mr White

  56. I have a condition whereby I am allergic to penicillin. If I took penicillin, it would kill me, which is why I wear a medico bracelet. My doctor knows about that but how would you know about it?
  (Dr Dun) Currently we do not. One of the weaknesses in the current arrangements, and perhaps until electronic health and patient records exists, is that, unless your GP informs us—and the classic example is in the care of the terminally ill where all out-of-hours services ought to be providing better quality care—or unless you told us the specific circumstances about your penicillin allergy, we would not be aware of it until one of our clinicians spoke with you and hopefully gleaned that information from you. To conclude, the end point of Mr White's consultation interaction with us would be either telephone advice by a clinician, an appointment to come to a primary care centre or surgery to see a qualified GP, or a home visit could be arranged.

  57. How does that information get back to my GP?
  (Dr Dun) This is an area on which the out-of-hours review has set down clearly that they expect us to make sure that the next day by 9 a.m. your GP is aware: (a) that you have made contact with us; (b) what you presented with; and (c) what we did about it.

  58. Would your statistics show that you have achieved that?
  (Dr Dun) In terms of getting information back, currently in the branches that are computerised—and that is about 50-per-cent of our network—we deliver that every time. I will get the information on the others back to you. I know that we do not get there every time. That is an area we have to address urgently to meet the requirements of the out-of-hours review.


  59. To wrap up that story, the key issue in the case that we have looked at was the failure to get this information into a clinician's hands over any tolerable time period. You are saying now that although the initial call goes to a non-clinically qualified person, it then goes straightforwardly and immediately into a clinician's hands and he makes these decisions.
  (Dr Dun) I would not in any way want to mislead you. As with some of the NHS Direct centres when they do not have nurses answering the call but operators, we endeavour to put calls through to clinicians. I would have to say that on the majority of occasions the clinician instigates a telephone call back to the patient. I would not want to appear to be deceiving and say that the call immediately goes through to an advising clinician. The clinician rings the patient back in most cases. I believe that is pretty normal for most out-of-hours providers, whether a deputising service, GP co-operative or other.

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2001
Prepared 2 July 2001