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Mark Simmonds:
It sounds as though an excellent model is being used in my hon. Friend's constituency. We do not think it appropriate to impose from the centre one model to fit across the whole of the country; we think that that is a mistake that this Government
have made. Different local solutions will be provided in different local areas. The important thing is that GPs are involved in commissioning, in ensuring the delivery of service and in ensuring that the service mechanism in place is delivering the best patient outcomes for their particular patient groups
Mark Simmonds: I will give way a little later, but I wish to make some progress because I know that many other hon. Members wish to speak in this debate.
The Conservative position increasingly seems to be being accepted by many other organisations. The NHS Alliance agrees that GPs are best placed to deliver out-of-hours care and recognises the importance of local responsibility for out-of-hours services. The Royal College of General Practitioners is rightly concerned about the quality of services and has called for a "comprehensive review" of out-of-hours and weekend care and for local GPs to be involved in commissioning. Even the BMA, which was mentioned by the hon. Member for South Derbyshire (Mr. Todd), has said in its briefing for this debate that it believes that local GPs should be involved in commissioning out-of-hours care. We welcome that support, because the current system is unsustainable and is not working consistently everywhere as it should be. It must be clear to the Government that the system requires improvement.
I wish to raise one further issue-the performers list. That list of doctors who are allowed to practise in the UK is maintained by the primary care trusts. There is a need for more stringent checks on the clinical and communication standards of foreign doctors coming to work in the UK. To be fair, the Department of Health produced a very good report early last year entitled "Tackling Concerns Locally: the Performers List system". It is a sensible, well written paper that addresses some of the concerns, but it needs to be implemented-it is not being implemented everywhere.
The Secretary of State and the Ministers need to be aware of the real concerns of the General Medical Council, and I have a couple of quotes that I want to read to the House. The GMC believes
"that the current legal framework is unsatisfactory."
"the current system does not adequately safeguard patient safety."
These are very serious issues that the Department and the ministerial team need to look at urgently.
Mr. Kevin Barron (Rother Valley) (Lab): The hon. Gentleman might know that I spent nine years as a lay member of the GMC. Does he think that if doctors were commissioning treatment for patients, they would have any professional responsibility for what happened to those individuals?
Mark Simmonds:
I support the mechanisms that are in place at the moment-the list that the GMC holds and the providers lists for which the primary care trusts are responsible. There have been failings in the past in that when a primary care trust has rejected a particular doctor for a failure, for example, to be able to communicate in English, that information has not been passed on either to other primary care trusts or to the GMC, which would then be able to regulate and to strike that doctor off the list. In the European Union area, when a
doctor is suspended in Germany, for example, that information cannot be passed to the GMC or to PCTs in this country.
Mr. Barron: I completely agree with the hon. Gentleman on the issue of English language testing and the need to be able to communicate with patients. However, my question is if a doctor commissions services for a patient, are they professionally responsible for those services?
Mark Simmonds: Clearly, there has to be a professional responsibility for the provision of health care that that doctor has provided, but it must fit a regulatory structure. That is part of what the GMC is there for.
The Government need to make immediate changes to improve out-of-hours and patient care. Primary care trusts must monitor and performance manage their out-of-hours contracts much more robustly to ensure that they are offering a high-quality, cost-effective service to patients. Strategic health authorities must take a more proactive role in assessing and monitoring primary care trusts, out-of-hours contracts and performance management. The national quality guidelines need to be reviewed, as they are too generic and do not allow local services to be tailored to local needs. A system in which GPs lead commissioning would make a significant contribution to addressing that issue. The performers list must be reviewed to ensure greater co-ordination and communication between PCTs and the GMC to alert them to doctors who are not suitably qualified. There must also be much greater encouragement and analysis of patient feedback.
In conclusion, this service is ultimately about patients-patient care, patient outcomes and patient safety. If we are to move to a patient-centric national health service, the level of out-of-hours service provided to the public must, in some areas, improve dramatically and respond to the local needs and requirements of patients. Only if local GPs commission out-of-hours care for their patient groups will patients receive the service they deserve 24 hours a day, seven days a week. If this Government do not act, after the next general election-if we are given the chance-we will.
4.53 pm
The Minister of State, Department of Health (Mr. Mike O'Brien): I beg to move an amendment, to leave out from "NHS" to the end of the Question and add:
"welcomes the improvements in out-of-hours and urgent care services over the last 12 years; notes that the Carson report in 2000 identified the need for the reform of out-of-hours care which was carried out in 2004; further notes that by the start of 2004 only five per cent. of patients saw their own GP out of hours; acknowledges that GP organisations say that they do not want a return to the system which existed in 1997; understands the continuing need to improve the quality of out-of-hours care; notes that the Government commissioned the first national out-of-hours benchmark to help primary care trusts and providers improve the quality and productivity of out-of-hours services and to reduce local variation; recognises the improvement in healthcare after the introduction of the GP contract in 2004, which has significantly extended weekend and evening opening of surgeries for routine, bookable appointments; recognises that over 77 per cent. of GP practices now offer extended opening hours and that every primary care trust is developing a new GP-led health centre, open from 8 am until 8 pm, seven days a week, 365 days a year; and welcomes plans for people who need urgent care to be able to dial 111 for advice 24 hours a day, seven days a week.".
Madam Deputy Speaker, you have already referred to the inquest in relation to two deaths and I am sure that the House will want to join me in sharing our deepest sympathy with the families of those involved. I do not propose to comment any further on these sad matters until the inquest is concluded.
The Government have made some important changes to out-of-hours and urgent care services. I welcome the opportunity to debate them with the House today. Let me make it clear that out-of-hours care is better than it was in 2004, but it clearly needs further reform. Regulation, in particular, needs much more central drive. I shall return to that point, because it is a clear difference between me and the hon. Member for Boston and Skegness (Mark Simmonds), who, in his speech, willed the end but not the means. It is important that we ensure that we have a system that delivers for patients, and that means making sure that there is effective regulation in place.
Before 2004, doctors were responsible for the care of their patients 24 hours a day, but growing demands put that system of out-of-hours care under increasing strain. Most GPs worked on a rota basis in local co-operatives, seeing other doctors' patients. Locums were often employed by practices, and some areas employed private companies.
At the beginning of 2004, about 5 per cent. of GPs provided out-of-hours care for their own patients. We need to be a little cautious about the myths that sometimes surround this matter. The National Audit Office has said that the figures show that the myth that GPs saw only their own patients needs to be challenged. Some of them did that, but the number was relatively small.
Doctors who saw their own or other doctors' patients as part of a rota were sometimes left exhausted the following day. Before 2004, doctors often turned up for home visits or surgeries exhausted and sleep-deprived, thus putting patients at risk. Dr. Laurence Buckman of the British Medical Association said last week that the old system meant many doctors were tired and therefore potentially dangerous to patients, and that it was for that reason that the BMA and the GPs it represents would resist taking back personal responsibility for delivering care out of hours. I shall return to the question of personal responsibility later.
Complaints about the old system were building by 1997. By 2000, the level of complaints from the public led the Government to conclude that the existing model of out-of-hours care was unsustainable. Dr. David Carson was asked to conduct a comprehensive, independent review of out-of-hours services in England. His 22 recommendations, accepted in full by this Government, formed the basis for our 2004 reforms of the GP contract with regard to out-of-hours care. The contract released tired GPs from the burden of out-of-hours care and introduced the quality and outcomes framework to incentivise quality.
The reforms were monitored, both by the Department and independently, in May and July 2006, November 2007, September and November 2008, and September 2009.
Sir Alan Beith: The Minister has described how the Government came to hand over to PCTs the responsibility for commissioning doctors to replace GPs. Where did they think those doctors would come from?
Mr. O'Brien: It was clear that many areas would provide the service through various rotas among doctors' co-operatives, which would be commissioned by the PCT and centrally co-ordinated. Other areas would use companies to provide the services, but in a minority of cases the service would continue to be provided by GPs who wished to opt out of the system and run their own provision. The aim was to ensure a greater degree of co-ordination in the provision of out-of-hours care that would give patients the increased access that they needed.
Sir Alan Beith: But where were the doctors to come from?
Mr. O'Brien: The right hon. Gentleman repeats his question from a sedentary position. Most out-of-hours services are provided by doctors who specialise in them, or by doctors working on a rota basis for co-operatives or private sector organisations. Some of those doctors work during the day, but they are obliged to ensure that they do not get to the level of tiredness that was evident before 2004.
I mentioned that there were various independent and other reviews. The 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, and that it
"compares well on cost and quality against the rest of the UK".
In 2008, the Healthcare Commission's report on urgent and emergency care entitled "Not Just a Matter of Time" added:
"There have been significant improvements over recent years in the ... number of out-of-hours GP services meeting national quality requirements."
"These achievements have taken place despite the pressure from the significant growth in demand for many of these services."
The spending by PCTs on out-of-hours services has risen from £209 million in 2004 to £378 million last year. It is clear that the quality of out-of-hours care for most people is better than it was in 2004 but in some areas, owing to regulation, it is not yet good enough.
Mr. Andrew Lansley (South Cambridgeshire) (Con): What is the measure?
Mr. O'Brien: The shadow Secretary of State, who has not deigned to lead this important debate, and did not bother to lead the previous one either, insists on chuntering from a sedentary position and asking what the evidence is. If he looks at the evidence in NAO reports and at the reports that we are going to publish in due course, he will see that it is clear that the standard of care has improved, but it still has a long way to go. We have never said-let me make this clear-that the NHS is a perfect organisation. Indeed, only a short time ago, we published a policy statement about going from "good" to "great". In the next five to 10 years, we need to move the NHS from where it was in 1997, when the hon. Member for South Cambridgeshire and his party were responsible for it, and it was on its knees. We have raised it from its knees, and it is standing up. It is good, but it must now become great. There are real issues that we still need to resolve in the NHS, and we are the first to say so.
Mr. Anthony Wright (Great Yarmouth) (Lab): I accept that there have indeed been improvements. Although I disagree fundamentally with the Opposition motion, which is a step backwards, there are particular problems in my area, where Take Care Now failed on two occasions in the last week to deliver a doctor on time. Only on Saturday, a family friend called the out-of-hours service at 9.30 am, but the doctor did not arrive until 5.15 pm. Does my right hon. and learned Friend accept that we need significant improvements in those areas before we can say that we have a very good service? I reiterate that turning the clock back is not the way forward.
Mr. O'Brien: My hon. Friend is quite right-we cannot turn the clock back. We need to improve the quality of care provided by out-of-hours services, and that is what we are committed to do. I do not want to comment on the organisation to which he referred, because there are issues relating to the inquest that is under way. Generally, however, we accept that the way primary care trusts make provision must be improved. I want to discuss levels of control, because the Opposition have suggested that there is a lack of control.
Mr. Todd: Will my right hon. and learned Friend give way?
Mr. O'Brien: If my hon. Friend will forgive me, I need to make progress, as other Members wish to contribute to the debate.
Patients must have confidence in all the medical care they receive, regardless of when, where or from whom they receive it. There are three key levels of control on the quality of GPs. First, the General Medical Council certifies whether someone has the appropriate qualifications. Whether they are a foreign national coming from the EU or otherwise, we must look at how we recognise those qualifications. Secondly, PCTs, which commission NHS providers, have legal obligations under the 2004 regulations to check GPs before they go on the performers list. That is not optional, as I am sure the hon. Member for North Norfolk (Norman Lamb), who will speak next, if you wish him to do so, Madam Deputy Speaker, ought to know. It is a legal requirement, and the National Health Service (Performers List) Regulations 2004 state clearly in regulation 6(1)(e) that the grounds on which a PCT may refuse to include a performer in its performers list include
"any grounds for considering that admitting him to its performers list would be prejudicial to the efficiency of the services, which those included in that list perform."
The regulations also state that a PCT "must" refuse to include a performer on the list if
"it is not satisfied he has the knowledge of English which, in his own interests or those of his patients, is necessary".
Norman Lamb: Can the Minister specify the consequences of breaches of the regulations which allow a doctor to practise, to go on to the performers list and potentially to cause risk to patients?
Mr. O'Brien: If a doctor did not carry the required level of knowledge and the ability to speak English, they could, if they were not competent, be referred to the General Medical Council. That is a professional issue. The GMC is able to deal with it and take action to remove that person's right to practise if that is appropriate. However, there are two other levels of control.
Mr. O'Brien: It is important that Members understand there is not only the GMC, which was mentioned by the hon. Member for Boston and Skegness, who spoke for the Opposition. The second level of control is the primary care trust which commissions the services. It must put in place robust arrangements to ensure, through the contracts, that out-of-hours services are using GPs who are fit to practise and can deliver appropriate and skilled medical practice, including the ability to speak and understand English.
PCTs were reminded of those duties in the Healthcare Commission's national review of urgent and emergency care in 2008-
Mark Simmonds: Will the Minister give way?
Mr. O'Brien: No. I shall make progress, then I will give way to some people. I say a few words and am then interrupted almost immediately. There are others on the Back Benches who want to make a contribution, so if the hon. Gentleman will forgive me, I will give way to him a little later.
PCTs were reminded of these duties in the Healthcare Commission's national review of urgent and emergency care, which again concluded that out-of-hours care had improved, but warned that PCTs should scrutinise their out-of-hours care more closely to meet their legal responsibilities to provide safe, high-quality care.
The third level of control is the employer. This can be the PCT or, more often, a company or co-operative contracted by the PCT. The employer should be contractually bound by the PCT to check qualifications and ensure that the GPs it employs are competent. That is part of the basic controls. In October 2009, the CQC issued an interim statement on its inquiry into the provision of out-of-hours services by Take Care Now to remind PCTs that they were already obliged to have in place robust arrangements for commissioning and for performance and contract management. The CQC emphasised the need for PCTs to assure themselves that all out-of-hours GPs, including locums, are fit to practise.
Mr. O'Brien: Out-of-hours providers were also reminded of the need to ensure rigorous recruitment, induction and training arrangements for medical staff. Dr. David Colin-Thomé, the national clinical director for primary care, followed this up with a letter to all PCT chief executives. The quality of out-of-hours care is good for most patients, but as we know from the CQC report, there are clearly some serious issues to address.
Dr. Colin-Thomé and Professor Steve Field, the chairman of the Royal College of General Practitioners, were asked by me in September to examine all the various reports-there are a number of them, going back to Carson-and to make further recommendations on how primary care out-of-hours services could be improved. It is my intention to publish that report as soon as the current inquest has concluded and I have informed the coroner of that.
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