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I expect the report to show, among other things, that not only have things improved since 2004, but that decentralised controls on PCTs have led to an unacceptable variation in their enforcement-a similar conclusion to
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the CQC report in October-and that more action is needed to ensure that PCTs perform their control obligations under the 2004 regulations. Before I go on to say a few more words on regulations, I shall give way to hon. Members who have indicated a wish to intervene.

Norman Lamb: I am grateful to the Minister for giving way again. He talked about the regulations that were in place, with which PCTs were obliged to comply by applying the performers list. What are the consequences for the primary care trust of failing to comply with those regulations? The consequences could be fatal.

Mr. O'Brien: The fatality relates to the patients, but the primary care trusts would clearly be in breach of their legal obligations, and they would then be subject to NHS disciplinary action. Whether they would be prosecuted on a criminal basis is a separate matter; the situation would involve a breach of civil regulations, so the PCT would be answerable through the NHS.

Mark Simmonds: The Minister mentioned that some primary care trusts were clearly not fulfilling their obligations under the current regulations. He may be coming on to this point, but what specifically will he change to ensure that PCTs abide by the regulations, that such tragedies are prevented and that service improvements take place?

Mr. O'Brien: I am indeed going to come on to that.

Mrs. Jacqui Lait (Beckenham) (Con): My hon. Friend the Member for Boston and Skegness (Mark Simmonds) mentioned that doctors from the European Economic Area do not have to take a language test, and I seem to remember that that comes from the directive on the free movement of workers. Will the Minister clarify whether they still do not have to?

Mr. O'Brien: They do not, and that is an important point. A doctor from the EEA-comprising the European Union and a couple of other countries-does not have to carry out a language test for the GMC; other doctors from outside the area do. However, the PCTs are therefore obliged to ensure that a GP who is employed to provide out-of-hours care or other services can speak good English. The PCT can insist on tests and on the provision of evidence to show that the individual GP speaks good English.

A general examination of a number of PCTs has shown that some have not carried out the level of tests and checks that they are legally obliged to undertake on a person's ability to speak English. If someone applies in Nottingham or Leeds, for example, they will undergo checks. Other PCTs were not carrying out checks. I understand that Cornwall was not carrying out adequate checks, but I am told that it is now. That issue needs to be clarified.

The PCT is not the only body that must check whether someone speaks English before they go on the performers list: the employer should, through its contract, have an obligation to ensure that the doctor is not only a competent clinician, but able to speak English and communicate with the patient. It seems pretty basic to me.


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Mr. Todd: My right hon. and learned Friend's response provoked me to add my name to the debate, so he will get more value from my words than he might otherwise have had. May I draw his attention to the concern of those suffering from motor neurone disease? I, along with two other Members who are present, sat through presentations from sufferers of that condition who had used the out-of-hours service. It is a rare condition, but the lack of knowledge displayed by the person with whom they were dealing made that experience deeply distressing. The training level and protocol strength that the out-of-hours service uses must be radically reviewed in that context.

Mr. O'Brien: My hon. Friend makes a very good point, which I shall certainly take on board. I look forward to hearing his further contribution, if Madam Deputy Speaker so wishes, during the course of the debate.

I now turn precisely to the level of regulation. This Government take patient safety so seriously that we have strengthened the regulations on health care providers, but the hon. Member for Boston and Skegness made it clear that the Opposition oppose further regulation. There is always a question as to how prescriptive regulation should be and where the balance should lie: should we try to control more from Whitehall with more interventionist regulation? However, one cannot run everything from the centre. Despite what some people say, Nye Bevan did not make himself responsible for every bed pan dropped in Tredegar. We rely on local managers, and the policy needs to be in place so that they know what they have to do; then the regulators must be there to check that local managers know what has to be done and implement it. Nevertheless, we cannot guarantee that human fallibility, negligence or failures may never arise.

Should we leave it to PCTs and employers to enforce safety practices and checks? Decentralisation is beneficial in the sense that it can deliver innovation and respond to local needs; it also sounds good and makes a good soundbite, as we heard from the hon. Member for Boston and Skegness. However, it can produce risks in some parts of the system if those parts do not deliver what they are supposed to. More regulation may therefore be needed in the case of out-of-hours care. I will be able to make some further announcements in a report that we will publish in due course.

We have recently made a number of significant changes. First, the Care Quality Commission has now replaced the Healthcare Commission, the Mental Health Act Commission and the Commission for Social Care Inspection as the single regulator for all health and social care. This more powerful and more effective system of regulation will help to ensure a more consistent approach to patient safety, no matter where people are being treated or cared for and no matter who they are being treated by, whether it be public or private sector providers. This system of stronger regulation is being rolled out. By April 2012, subject to legislation, all providers of out-of-hours care, including private companies, will need to register with the CQC, giving it a greater degree of scrutiny and independent oversight.

Secondly, we have changed the standard of proof for professional disciplinary cases from that of beyond reasonable doubt to the more flexible and more appropriate civil standard balance of probabilities.


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Thirdly, in November last year, we introduced a licence to practise. This will ensure that doctors must continue to meet the high standards demanded of the profession throughout their careers by requiring them to go through a process of revalidation every five years to prove that they continue to meet the standards. This will be the only systematic and comprehensive system to assure the quality of doctors anywhere in the world. As part of this process, doctors must also now present annual, clear, positive evidence of their fitness to practise against 12 standards based on the GMC's "Good Medical Practice".

Fourthly, from October, subject to regulations, health care organisations will have to appoint a responsible officer with a statutory duty to evaluate a doctor's fitness to practise and to monitor their conduct and performance. They will also monitor admission to the performers list.

Mrs. Maria Miller: Will the Minister give way?

Mr. O'Brien: Let me deal with a couple more points, and I will give way before I conclude.

The hon. Member for Boston and Skegness asked about the implementation of electronic patient records. More than 1 million core records have been created across a number of locations, including London. Early evidence points to improving out-of-hours care, ensuring that doctors have up-to-date information at their fingertips in situations where this is critical. It is not yet available across the country, but it is rolling out as we speak. With the IT systems and the changes that we are making to improve the quality of care, which the Conservatives have indicated that they are unhappy with, we are ensuring that that sort of information is more readily available.

In terms of the broader issues, the results of massive investment in the NHS in 2001 are now becoming clear. More than 98 per cent. of patients are being seen, diagnosed and treated within four hours of arriving at A and E. Three quarters of GP practices now offer extended opening hours-a move that was opposed by the Conservatives. New GP-led health centres are being opened in every PCT area, opening from 8 am until 8 pm, seven days a week, 365 days a year-also opposed by the Conservatives. Millions of people use NHS Direct for clear and accurate information about medical issues and to seek help by day or night. We plan to introduce a free 111 urgent care phone number, to go alongside the traditional 999. That will help with anything from making an appointment with an emergency dentist to directions to a late-night pharmacist or referral to an out-of-hours primary care GP.

The reforms that we put in place in 2004 have improved the quality of out-of-hours care for patients and were introduced with the support of the medical profession. We have brought the system from poor to good, but we have never claimed that it has got to where we think it should be. There is more that we can do, and we need to make it better. When I asked Dr. David Colin-Thomé and Professor Steve Field to report, I asked them to examine with care all the evidence in relation to out-of-hours care. They will make recommendations to strengthen the system of regulation and improve patient safety, and I look forward to sharing those recommendations with the House in due course.


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The Conservatives have indicated today that they want to return responsibility for commissioning out-of-hours care to GPs. I was particularly struck by the answer given to my right hon. Friend the Member for Rother Valley (Mr. Barron) when he asked what the responsibility implications of that were. It appears that responsibility for out-of-hours care is to be handed back to GPs. The Conservatives want to force a number of things on GPs, including hard budgets for patient care. GPs are concerned that forcing them to hold responsibility for out-of-hours care, on top of those hard budgets, could drive some practices to the wall, but the Tories would force those things on all GPs. The Government say that under practice-based commissioning, GPs can already take on the commissioning of out-of-hours care and budgets if they want to, but we will not force them to if they do not. It appears that there is a clear dividing line between the Conservatives and ourselves.

The Conservatives claim that they are concerned about the NHS, but in 1997, 18 years of a Conservative Government had left it on its knees and struggling, including out-of-hours care. When we increased national insurance to improve the NHS, including out-of-hours and urgent care, the Conservatives opposed it. When we set a four-hour target for accident and emergency patients to be seen and treated, discharged or admitted, they opposed it. When we created GP-led health centres offering extended hours to patients, they opposed it. When we extended GP practice opening hours, which has now happened for patients at 77 per cent. of practices, the Conservatives opposed it. When we introduced the target for patients to see a cancer specialist within two weeks of referral, they opposed it. They want to set the clock back on the NHS and its reforms and remove the targets that have improved services.

We have never said that the NHS has resolved its problems-far from it. With our policy of "good to great" we have said precisely the opposite: there is still more work to be done on the NHS. We have got it from poor to good, and we now need to get it from good to great. We need to ensure that we reform out-of-hours and urgent care as part of that change. We have shown our willingness to tackle the problems in the NHS and are not satisfied with the current state of things, which is why we commissioned proposals to improve out-of-hours care.

In the coming months, we will expose the complete vacuity of the Tories' policy. Their claims of over-regulation are the opposite of the truth, which is that we need tough regulation in this area. The Labour Government have shown that we can deliver it. We are the Government who care about the NHS and who will deliver improvements in the NHS.

5.23 pm

Norman Lamb (North Norfolk) (LD): May I first join the Minister in expressing my deepest sympathy to the families of those whose deaths are subject to the inquest that you referred to, Madam Deputy Speaker?

It is clear that what the hon. Member for Boston and Skegness (Mark Simmonds) said is right, and that the quality of out-of-hours care is not good enough across the whole country. Standards are variable, and there are insufficient safeguards to protect patient safety. It is fair to say that there are very good services in some parts of
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the country, and they should be recognised. It is also right that cost is not the key factor; some good services are provided at a relatively low cost and some poor services are clearly expensive to the local health economy.

It is also right to point out that the reform that was introduced alongside the GP contract in 2004 was flawed in its implementation. My right hon. Friend the Member for Berwick-upon-Tweed (Sir Alan Beith) made the legitimate point that an assumption seems to have been made at the time that there was a pool of doctors in every locality who would be readily available to provide out-of-hours care. Of course, the truth was very different.

In many parts of the country, including my right hon. Friend's area and my area of Norfolk, the out-of-hours services has had to rely to a greater or lesser extent on doctors being flown in from overseas. That is not acceptable. It often means someone flying in on a Friday evening ready for a weekend session, tired and too often not sufficiently cognisant of the local health arrangements. That failure of the 2004 reform needs to be recognised.

However, it would be wrong to imply that everything was good before 2004. I am worried that the Conservative proposal to return commissioning responsibility to GPs appears to be a return to what was happening in many parts of the country before 2004. In 2004, immediately before the reform, few patients saw their own doctor out of hours. In most cases, GPs were entering contractual arrangements with other bodies, often co-operatives, to provide that care. That seems to be exactly the commissioning arrangement that the Conservatives propose. I agree that reform is necessary, but I am concerned about a knee-jerk reaction and going back to a previous system, which clearly had serious flaws and was greatly criticised at the time.

Why is out-of-hours care so important? Self-evidently, critical decisions often have to be taken outside the normal hours that GPs operate-often in the dead of night, often in very rural areas. It is vital that patients can rely on high-quality care at those times of need. It is critical that we provide the reassurance to people that, when a crisis occurs in the middle of the night and they make that phone call, they will get a responsive service and that the GP who is available to turn up is of a sufficient standard. Concerns were expressed that the whole rural county of Suffolk is served by two GPs out of hours. Surely we can all agree that that is unacceptable for providing a trusted service.

Sir Alan Beith: In a situation that often arises, when a family with a sick child has to decide whether to ring the out-of-hours doctor, who may arrive in two hours from 60 or 70 miles away and may then call an ambulance, they tend to call the ambulance straight away, because at least the child will then be taken to hospital, even if that is not the right clinical decision.

Norman Lamb: My right hon. Friend is right. That can result in unnecessary admissions to acute hospitals, which are already overburdened. There have been significant increases in admissions to accident and emergency. In an intervention from the Conservative Benches on the hon. Member for Boston and Skegness, the point was made that, if we end up with transfers of care to acute settings, it is more inconvenient for the patient and costly for the health service, and thus wholly counter-productive.


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The hon. Member for Great Yarmouth (Mr. Wright) made the point that in the recent past in his area, his constituents had to wait hours for a doctor to turn up at their time of need. Just imagine the anxiety that those people go through while waiting for a doctor to arrive. I am sure we all agree that that is not acceptable.

The best situation-I draw the distinction between the provision of care and the commissioning of care-is surely when, as far as possible, GPs who have an involvement in the local primary care system are involved in the provision of out-of-hours care. Some doctors could work shorter hours in in-hours time and commit to out-of-hours care. That happens in some places.

We must recognise, however, that doctors are under significant pressure, and that one reason why the change was made in the first place is that we were finding it difficult to recruit doctors because of the commitment to 24-hour care. Any reform must recognise those pressures and understand that we cannot push doctors over the edge. Exhausted doctors are also not good for patient care.

Mr. Robert Syms (Poole) (Con): The hon. Gentleman makes a good point. However, there are also a lot more women doctors both in hospitals and among GPs-that is one of the major changes in the profession-and they may have family obligations. It would be difficult for them to give the same level of out-of-hours care when they have children to look after.

Norman Lamb: That is a very fair point. I was previously a solicitor. Some women solicitors joined a rota to provide out-of-hours support under the legal aid scheme. It is not impossible, but I recognise that there are constraints, and I accept the hon. Gentleman's point.

We can all agree that the concerns about the use of foreign doctors in out-of-hour care need to be addressed. I fully understand the sub judice nature of the current inquest, so I will not refer to it, but I will refer to the current framework, which I think is inadequate to protect patient safety. A doctor must get on to the performers list before he or she can practise in any given area. However, once a doctor is on a performers list, in any part of the country, they have access to practise anywhere around the country. Failures by one primary care trust could be fatal in any part of the country, not just that area.

Back in February 2007, my hon. Friend the Member for Truro and St. Austell (Matthew Taylor) expressed concerns about Cornwall and Isles of Scilly PCT in a debate in Westminster Hall. He highlighted specific cases of constituents who had to deal with doctors out of hours who could not understand their patients. Surely that is unacceptable. Of one case, he said:

    "Mr. and Mrs. T were gobsmacked when their daughter was seen by another overseas agency doctor who not only found it difficult to understand her-this has been an issue with the overseas doctors employed-but relied on an electronic word converter to communicate with the patient."-[ Official Report, 20 February 2007; Vol. 457, c. 4WH]

That is utterly shocking. How did that doctor get on to the performers list in Cornwall? As I asked the Minister earlier, what are the consequences of the abject failure of that PCT to prevent that doctor from practising out-of-hours care in Cornwall?


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Mark Simmonds: The hon. Gentleman makes a very powerful point. Is he aware that rumours are circulating among GPs that one or two PCTs have a reputation for giving easier access to the performers list? As a result, GPs who cannot communicate, and who perhaps do not understand the medicines that are used in the UK, have been able to get on to the out-of-hours circuit and provide care for patients.

Norman Lamb: I am aware of that and I am grateful to the hon. Gentleman for raising it.

At the end of that debate, my hon. Friend asked the Secretary of State, who was then a Minister:


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