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Question put forthwith (Standing Order No. 31(2), That the proposed words be there added.

Question agreed to.

Main Question, as amended, put and agreed to.

Resolved,

    That this House wishes to see the quality of life improve for the 700,000 people in the UK with dementia; pays tribute to their families and carers and all those who campaign and fundraise for dementia charities; welcomes the Dementia Strategy launched in 2009 which contains a programme of work to transform services for those with dementia over five years and is backed by funding of £150 million over two years; notes that the Government will shortly publish the report of the Nutrition Action Plan Delivery Board; rejects the use of tube feeding on any grounds other than clinical need; welcomes the independent clinical review of anti-psychotic drugs which contains recommendations for the reduction in the use of these drugs for people with dementia; further welcomes the appointment of a National Clinical Director for dementia to promote better care and provide leadership for the implementation of the strategy; welcomes the creation of a Ministerial group to develop dementia research; recognises that the enactment of the Personal Care at Home Bill will help some 400,000 people with the highest need; supports the Government's proposals to create the National Care Service, the first national, universal, entitlement-based system for care and support in England; and acknowledges that the Government's Dignity in Care campaign is working to engage local people in a social movement and to put dignity of those in care at the heart of services.


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Out-of-Hours Care

Madam Deputy Speaker (Sylvia Heal): I inform the House that Mr. Speaker has selected the amendment in the name of the Prime Minister.

Before we start the debate, I should remind the House that an inquest is still taking place into the death of Mr. David Gray and the role in that death of Dr. Daniel Ubani. The House's sub judice rule prevents us from debating the matters awaiting decision in the courts. There must, therefore, be no direct reference to that particular case this afternoon. When the inquest is over, there will be opportunities for Members to raise the issue and the lessons learned in the House. May I also advise the House that an eight-minute time limit will be imposed on Back-Bench contributions?

4.27 pm

Mark Simmonds (Boston and Skegness) (Con): I beg to move,

    That this House supports family doctors as the bedrock of healthcare services in the NHS; recognises the need for high-quality out-of-hours care; believes in simpler, reliable access to urgent care and primary care on a 24 hours a day, seven days a week basis; regrets that the Government's 2004 GP contract has not achieved this and has in many places divorced GPs from the service provided to their patients; is concerned that services are variable and the burden on accident and emergency services has increased as a result; is deeply concerned by failures in the out-of-hours system; calls on the Government to allow GPs to take responsibility for commissioning of both out-of-hours care and urgent care services; and further calls on the Government to publish its report on out-of-hours services which has been submitted to the Department of Health.

Let me start by thanking you, Madam Deputy Speaker, for that statement. We are all keen to learn the lessons of the inquest and we await the results with interest.

It is important that the House understands how we have arrived at the current structure of out-of-hours care, which is at best patchy and has been described by the Public Accounts Committee as "shambolic". In 2004, the Government renegotiated the GP contract and effectively allowed 90 per cent. of GPs to opt out of providing out-of-hours care. It has become clear that the Government mismanaged the contract, which passed responsibility for commissioning out-of-hours care to primary care trusts, away from general practitioners. That has undoubtedly undermined patient care and safety in some areas.

Out-of-hours and urgent care are valuable and vital services. Out-of-hours care alone is used by 9 million people in England every year. Such services provide essential health care between 6.30 pm and 8 am, and at weekends and on bank holidays for people who require medical advice and assistance, but are not so unwell as to require a visit to accident and emergency. The current system in England, which is commissioned by primary care trusts, has led to huge variations, enormous disparities in compliance and significant cost differences. The system is three times more expensive in some areas than in others, but most importantly, there are enormous variations in the quality of patient care. The most obvious and clear difference is that where local GPs are involved in the provision of out-of-hours care, the service is significantly better.


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Hon. Members may think that some of the problems are recent, but there have been failings in the Government's out-of-hours system since 2004. Only 9 per cent. of contracts were in place when the service began. Only 39 per cent. of PCTs ran a competitive tendering process to award contracts and, most concerning of all, failures in out-of-hours services have contributed to otherwise preventable deaths, including that of Penny Campbell in 2005. The House will recall that after that terrible tragedy the Prime Minister said that the NHS must

    "do better in the future,"

and that round the clock care had to improve, yet there is still no evidence of widespread improvement and in some areas the service is still very poor, as we have recently witnessed.

Additionally, at the inquest into Miss Campbell's death the coroner found that lack of access to patient notes had contributed to her death. The then Health Minister-now the Secretary of State for Culture, Media and Sport-asked all primary care trusts to review their arrangements for the transfer of information between clinicians, to ensure patient safety and continuity of care. It is my understanding that the review has still not been implemented and that many out-of-hours doctors cannot access patient records. It would be helpful if the Minister could confirm what has happened to the review.

There is growing concern about the quality of out-of-hours care in many parts of the country, as is demonstrated by the increased number of complaints about the out-of-hours service and the increasing dissatisfaction of patients. The Medical Defence Union recently calculated that there has been a 50 per cent. increase in complaints related to out-of-hours consultations, notified by its GP members.

However, the Minister may be pleased to hear that I am mildly encouraged by the fact that the groundswell of concern has led to some action. I understand that the Care Quality Commission is undertaking a review of out-of-hours services, focusing on areas where specific cases have been raised. Early evidence from the inquiry suggests that although primary care trusts monitor response times for out-of-hours services, they do not routinely monitor the quality of care provided or delivery against contractual requirements. It is clear that not all PCTs are aware of the level of service being provided, and in many cases contracts are not routinely monitored, reviewed or robustly assessed. Surely, there should be rigorous monitoring everywhere, looking at the quality of clinical decisions, the efficiency of call handling, and the adequacy of staffing and of doctors' training, as well as the all-important patient outcomes.

In the vast majority of cases, the contracts were built to national frameworks and were not designed to fit existing services, such as minor injury units, nor to meet the specific needs of local populations. For example, in rural Lincolnshire, where my constituency is, the needs are very different from those in central Birmingham, where I was discussing this very issue with local GPs last week.

Not only does the local quality of out-of-hours service provision vary around the country, the cost varies significantly, too. Of course, it needs to be recognised that the provision of those services is likely to be more costly in rural areas, but there seems to be no correlation between cost and rurality and cost and quality, despite
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costs per patient varying threefold. In 2007, the Select Committee on Health concluded that if every PCT provided its service at the same cost as the most effective service with similar characteristics, £134 million could be saved, which could then be reinvested elsewhere in front-line patient care.

Sir Alan Beith (Berwick-upon-Tweed) (LD): The hon. Gentleman recognises that it often costs more to provide those services in rural areas. Does he share my experience? In my area, we have to obtain doctors from a location more than 60 miles away. That is the situation after midnight in north Northumberland and it is simply not acceptable.

Mark Simmonds: I am grateful to the right hon. Gentleman for that intervention. He is absolutely right. There are similar issues in my Lincolnshire constituency. The most recent case relating to his experience that has come to light in the media was in Suffolk, where after midnight a population of 600,000 is covered by only two GPs. That is not acceptable-it is not the service the public in England expect.

Dr. Andrew Murrison (Westbury) (Con): Does my hon. Friend share my concern about the pressure that this problem can place on casualty departments? They are likely to receive default patients, as it were, who have failed to get adequate primary care services because of the difficulties with out-of-hours cover. They are also likely to have patients referred to them by locums who are not as familiar with local health care facilities as the local GPs. That is placing a great burden on many of our casualty departments, and they are facing a particular problem with elderly, vulnerable and chronically ill people, who really should not be sent to acute hospitals at all, if that can be avoided.

Mark Simmonds: My hon. Friend makes a very good point. He is absolutely right to say that there needs to be more co-ordinated and aligned commissioning by GPs to avoid these problems. I shall say a little more in a moment about the additional pressure being put on to accident and emergency units since the 2004 contract and the reconfiguration of out-of-hours services.

Dr. Howard Stoate (Dartford) (Lab): I am listening with interest to the hon. Gentleman. As he knows, I am a practising GP. A matter of great interest to me is that of access to medical records out of hours. The situation is currently extremely difficult, because many practices use different types of software, which cannot "talk" to each other or to the outside world. How does he envisage that problem being solved? The obvious way is through the NHS Spine system and the use of summary care records, but what does he think is the best way of ensuring that the out-of-hours service has access to patient records?

Mark Simmonds: The hon. Gentleman is right to say that there needs to be much more co-ordination and co-operation on the flow of information. The review instigated by the then Minister of State into the terrible tragedy in 2004 does not seem to have been implemented. We need to ensure that there is a cross-flow of information, so that similar tragedies cannot happen in the future. I believe that some of the solutions that I will outline
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later will help to alleviate some of the concerns that the hon. Gentleman has, both as a practising GP and as a Member of Parliament.

Increasing concern is being voiced about primary care trusts' over-reliance on foreign doctors, who might not be familiar with British working practices or have the necessary language and communications to undertake the jobs safely. It is currently possible for a foreign doctor to pass a language test in one primary care trust even though they have no intention of working there, then to transfer to another PCT without a second test being taken. There is no standardised English and communications test for doctors from the European economic area who want to work in England; nor is there a mechanism for identifying those who have failed a test. That can result in EEA doctors providing out-of-hours cover in the UK without having undergone any testing in the area in which they are practising.

This is not new, however. The Government have been consistently warned about the increasing number of failures in the out-of-hours system. In 2000, the independent Carson review of GP out-of-hours cover-the bedrock of the reforms that the Government put in place in 2004-outlined the principle that out-of-hours services should meet patient needs and not be used simply as a holding bay until the GP practice reopens. Too often, however, that is exactly what happens.

In 2004, the Health Committee voiced its concern that many PCTs did not have the skills to commission services. It warned that GPs should not become disengaged from out-of-hours services, yet that is exactly what has happened. The Committee also highlighted the concern that, if out-of-hours cover were withdrawn or changed, or if access to it became more difficult, demand for urgent care would increase in other parts of the system, such as accident and emergency. That is exactly what has happened. Attendances at accident and emergency departments have risen by 10 per cent. in the past four years alone.

In 2006, an investigation by the National Audit Office found that most out-of-hours providers were not meeting all the national quality requirements, particularly on speed of response. That is continuing to happen. It was recently reported that only 6 per cent. of PCTs were assessing out-of-hours calls quickly and safely within the benchmark period of 20 minutes. In 2007, a further Health Committee report commented that

    "inadequate performance measurement means that some Primary Care Trusts do not know how good a service they are providing for their patients".

That is still the case: some PCTs are still not monitoring their out-of-hours providers' performance or reviewing the service regularly.

Most recently, the CQC, in its preliminary observations from its investigation into a specific provider, identified that trusts do not routinely look in detail at the quality of the care. The CQC also found that primary care trusts have not had a consistent approach to the inclusion of doctors on the performance list, which may have led to some of the problems under discussion. If I have time, I will return to that theme later.

That is a damning list of warning signals, which have not been resolved. There is, however, a solution to the problem. A growing consensus exists on what needs to be done to tackle the problem. The Government appear
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to be becoming isolated and alone in not recognising the solution to what is, bluntly, currently a mess. Clearly, the Government made a serious error by removing GPs from responsibility for out-of-hours care. We must urgently review the whole system, as well as returning responsibility for commissioning the service to GPs. That will rebuild the link between GPs and out-of-hours services and result in better co-ordination of primary care services.

The GP-patient relationship is vital for the performance of the national health service and for improving patient care and outcomes. The Opposition are not advocating a return to a Dr. Finlay style of medicine, with GPs being responsible for their patient list around the clock. However, we recognise that GPs are closest to the communities and patients they serve and are therefore best placed to lead commissioning for a service that best meets patients' needs.

Mr. Mark Todd (South Derbyshire) (Lab): May I draw the hon. Gentleman's attention to the letter from Dr. Laurence Buckman of the British Medical Association, which is reproduced in the Library pack for this debate? Dr. Buckman's solution is not the one that the hon. Gentleman has just outlined. Does he differ from the BMA on its approach to the problem?

Mark Simmonds: I will come to a comment from the BMA in a moment, but the hon. Gentleman should be cautious: he will be aware that the gentleman to whom he has referred has recently been quoted as saying that the prevalent view among GPs is that the Labour party is the enemy of the NHS. I hope to have an informed debate about out-of-hours care this afternoon, to ensure that Ministers in the Department of Health understand the seriousness of the failings currently occurring.

Norman Lamb (North Norfolk) (LD): I agree with much of what the hon. Gentleman has said about how the system works at present, but what makes him feel that the approach that he advocates will be different and qualitatively better than what existed before 2004? There were serious concerns about how it operated then, and those concerns led to a movement for reform of the system.

Mark Simmonds: The fundamental difference between what we propose and what happened before 2004 is that we do not necessarily advocate compelling GPs to be responsible for caring for their patients 24 hours a day, seven days a week. What we are advocating, and what we believe is essential if we are to improve out-of-hours and urgent care, is the vital role of GPs in commissioning such services, in which far too often they are not involved at present. There is a direct correlation between excellent and good out-of-hours provision and the involvement of GPs in providing the service, which they should clearly be allowed to do if they so wish. Sadly, some of the tragedies in the recent past occurred when GPs were not involved in such provision.

Mr. Todd: May I ask the hon. Gentleman, I hope helpfully, to distinguish between commissioning and governance in his approach? He wants GPs to commission such services, but I very much doubt whether that is what they want. They very much wish to be involved in
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the governance of such services, and I would wish that to be one of the outcomes of any examination of the service review.

Mark Simmonds: I am grateful for that intervention, but I disagree with the hon. Gentleman. I travel extensively around England to have discussions with GPs and I have encountered genuine enthusiasm for the control of real budgets for commissioning not only out-of-hours care and urgent care, but a wider range of services on behalf of their patient groups. There is no doubt in our minds that the GP-patient relationship is key, that GPs most understand the patients for whom they are responsible and that GPs are, therefore, much better placed to commission their services than primary care trusts.

Norman Lamb: I wish to pursue the point that I raised a little earlier. The hon. Gentleman said that things are different this time because he is talking about commissioning, but I understand that prior to 2004 commissioning was, in effect, being undertaken in many cases; GPs were not providing it directly, but they were making arrangements with other organisations, possibly co-operatives. That arrangement seems similar to what he is proposing now.

Mark Simmonds: We propose that GPs will commission out-of-hours care, but there will certainly not be a compulsion for them to provide that care, unless they have a desire to do so. Prior to 2004, the argument made by GPs and their representatives was that they did not want to provide out-of-hours care because of an issue relating to recruitment into the profession. That argument has gone away, and I detect, from talking to GP representatives and GPs who are practising, a change of view in the past year or 18 months; there is now a recognition that in many parts of the country out-of-hours provision is not working as GPs would desire for their patients and a definite wish to get involved in commissioning. I therefore think that the Conservatives are on exactly the right lines.

As to the solutions, we require not only an urgent review, but the returning of responsibility for commissioning to GPs. That would rebuild the all-important link; as I have said, GPs are much better placed to commission these services, as they understand their patients' needs most. These services should be commissioned alongside other services, such as accident and emergency services and those dealing with minor injuries, to ensure an integrated model for urgent care, which does not exist at the moment.

Mrs. Maria Miller (Basingstoke) (Con): The out-of-hours service in my constituency is delivered in a central location in my local hospital-it is delivered right next to the accident and emergency department. That means that people who could be better served by out-of-hours services can be redirected, thus providing them with better care and, importantly, saving the hospital money. Does my hon. Friend think that that is the sort of model that other areas should be adopting?


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