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Mr. Deputy Speaker: Order. Eighteen minutes remain before the debate is wound up, so I appeal to hon. Members to see if they can help each other in this respect.
6.22 pm
Mrs. Jacqui Lait (Beckenham) (Con): I will do my best to help, Mr. Deputy Speaker.
It is interesting that we have debated the problems of out-of-hours care. That follows endless debates over the years about abuse, or the increasing use, of accident and emergency services, the problems of single-handed doctors, the provision of GP services, and the wide range of options that exist for people to access health care outside the ordinary hours of a GP practice.
There are legitimate concerns about the out-of-hours care service. In defence of my own PCT, I should say that it is not a subject that has been raised a great deal with me, I am glad to say, but we have an extended 24-hour-a-day GP practice, a minor injuries unit, and a new accident and emergency department. However, we also have a high proportion of ageing single-handed practices, which is what has driven the breadth of provision.
Something profound is going on with people's access to out-of-hours care. Lest I be accused of being a hard-hearted Tory, I shall quote a comment from the hon. Member for South Derbyshire (Mr. Todd), who spoke about economic modelling in the health service. There is a demand, led by patients, for widening the different forms of provision. By concentrating on out-of-hours care today, minor injuries units in another debate tomorrow, or NHS Direct in a debate two weeks from now, we are not putting together the whole provision of out-of-hours care and ensuring that the models that we offer meet the demands of a patient-led service. That is what we would dearly like to move towards, and it is the basis of my Front-Bench team's proposals on that one issue of out-of-hours care. We are trying hard to take health care out of politics, and an NHS board would be able to look across health care provision to ensure that patient-led demand was met most appropriately.
As my hon. Friend the Member for Basingstoke (Mrs. Miller) said, there is a need for the out-of-hours service, for the terrified mother who has a child with croup, for the elderly person who suddenly has a fit, or for whatever the crisis might be. Those people cannot get to the extended GP service or to the minor injuries unit, and reaching A and E is even more difficult. However, we must bring into the debate how the ambulance service is used not just as an accident or crisis service, but almost as a social service.
I was out with an ambulance team when they were called to put an elderly gentleman back into bed after he had fallen out, and it became palpably obvious that he was lonely. He fell out of bed deliberately to get the ambulance team around-regularly, because they all knew him. That is an abuse of the ambulance service, but it highlights how the service should be part of a seamless out-of-hours service. By focusing on those different areas separately, we do not focus on how we can meet patients' demands, and that, more than anything else, is what the NHS should deliver.
6.27 pm
Dr. Richard Taylor (Wyre Forest) (Ind):
I shall try to be rapid. Out of hours comprises two thirds of the week, and most emergencies will therefore occur in
those two thirds, so it is important that we have high-quality, out-of-hours care. I am green with envy at the hon. Member for Basingstoke (Mrs. Miller), who still has the old system that good GPs used long before the GP contract came in. They knew that they could not cover in-hours care as well as out-of-hours care, so they got together, formed a co-operative-my own GPs did that-and, if there were 50 of them, three could be on call for a night on only one in 17 nights.
In the investigation by the Health Committee into out-of-hours care, it was recommended that such co-operatives have 80 GPs to cover holidays and time away, so that system could still be used. In the Committee's 2004 report on the out-of-hours service, we underlined the importance of GPs' expertise and knowledge. In a recommendation, we stated:
"It is therefore vital that they"-
"do not become disengaged from the process of redesigning GP out-of-hours services during this critical transition phase, and their expertise and local knowledge lost."
Existing GPs are absolutely crucial to redesigning the process.
We know, and many hon. Members have said, that in some areas there are excellent out-of-hours services, while in others they are pretty awful. I have experience of them when they are not so good. I am purposely not naming any names, but, if such services are run by a private company, we can never discover how the tender was awarded, because of commercial confidentiality, and one has the distinct impression that the contracts are awarded simply on price. That means that the skill mix is reduced, because we have to employ fewer doctors and more emergency care practitioners. Emergency care practitioners drive themselves around, so it is not necessary to employ drivers to drive GPs around. It is obvious that when the tender is based on price, economies are made. That is why in many parts of the country it is very hard to get local GPs to take part in these rotas, so we then have foreign doctors taking part.
I am grateful to the Minister for explaining the controls that are meant to be in place for vetting doctors who take part in out-of-hours care. It is crucial to tighten up these systems. The Health Committee hopes, before the general election is called, to have single session on vetting systems to see what can be done to improve things.
We cannot go back to the old-style system; people who have it are extremely lucky, where it is really working. A GP who recently wrote to The Independent bewailing the changes and the surrender of 24-hour responsibility admitted that we cannot go back because GPs are becoming deskilled. Sitting in a GP's surgery looking after patients whom one knows very well with a condition that one knows very well is entirely different from having five to 10 minutes, in difficult circumstances, trying to work out if somebody is extremely ill or not.
Let me make-or repeat-one or two positive suggestions. Pay and conditions across the country must be as nearly similar as possible. In its submission for this debate, the BMA says that in some areas funding for out-of-hours care is only £3 per head, while in others
it is £16. Are the best out-of-hours services those that are the best funded? We do not know, and a survey of that nature would be very helpful.
An absolutely vital move, for which I have been pushing since the tragedy in my constituency in 2007, is the 111 number. I think that the hon. Member for Basingstoke slightly misunderstood the importance of the 111 number, which is intended to bring together every other service apart from the emergency services. If someone knows that they need to call 999, okay, it is a matter of life and death, and that is what they do. If they live in my area, where there is no A and E department that they can walk into, they have seven or eight different alternatives. The whole point of the 111 number is that it is tied to the area that a person lives in, and with one call it tells them whether to ring NHS Direct, whether to go to the out-of-hours centre or whether to go to the minor injuries unit.
That system is absolutely ideal. If it is joined together with a really efficient triage system such as NHS pathways, which Ministers know all about, and which is being rolled out in some places, it could make a huge difference, particularly to people who do not have a local A and E department, and relieve the stress on A and E departments by ensuring that only the right people go there. Knowledge transfer, which has been mentioned, is crucial. Why cannot the triage people, as soon as somebody phones up, flash up their summary care record in front of them so that they know exactly what is going on?
Finally, I should like to clarify what the BMA said. For once, the BMA, which we in this place tend to think of as the doctor's union that thinks only of doctors, got it exactly right. I will read the very last bit of its submission:
"The BMA believes that standards of out-of-hours care could be improved if PCOs"-
"involved local GPs in...commissioning".
It states not that GPs should do the commissioning, but that they should be involved in it and advise the primary care organisation. It goes on to say that that involvement should happen so that
"high-quality, timely and cost-effective services can be developed that are sensitive to local circumstances."
I cannot understand any political party disagreeing with that.
6.34 pm
Nadine Dorries (Mid-Bedfordshire) (Con): The Minister was right to identify fatigue as a reason for the out-of-hours service as we know it having been developed. Many GPs were very fatigued and it was impossible for them to continue under the system that was in place. However, the current out-of-hours system was then imposed on them, so my constituents went from having GPs who had no room for manoeuvre and were fatigued to having an out-of-hours service in which GPs are working abroad in Poland, Germany and other countries and flying over here on a Friday night. That service is therefore being delivered by fatigued out-of-hours doctors. At the great capital expense of changing one system to another, there is absolutely no difference in the level of care for many constituents-they are being provided with care by fatigued GPs. In many cases the care is much worse because of the language barrier and various other reasons that we have heard today.
There are attempts to minimise the importance of the rise in complaints, but I do not believe that we can do so. As we know, the people who complain about the out-of-hours care service are those who are able and motivated to do so. We do not find the poor complaining, because they are grateful to get any help they can. The vulnerable, the needy and the elderly do not complain, because it is not in their make-up to complain about something that they see they are getting for free, such as access to the NHS. Yet the poor, the elderly and the vulnerable are the people who will use the service the most. There are also parents with children, and they have other things to see to. We can therefore probably accept that the number of complaints should be ramped up to take into account those who do not complain.
We have a system that is no better for patients than the one that the Government were trying to replace. Amazingly, it is evaluated by response times, not by the quality of care that is delivered to patients. What is the point in thinking that the service is good if a GP is there within 20 minutes, if the care that he delivers when he arrives is of poor quality? That is simply not good enough. Should not the primary evaluation be the care that is delivered when the doctor arrives at a patient's house?
The hon. Member for Dartford (Dr. Stoate) said-I am sure he will correct me if I am wrong-that different GPs provide different care throughout the country, which is true. They are providing different care in communities that have varying needs, with different health care provision commissioned in different ways by varying PCTs. I imagine that it is almost impossible for a doctor to come from overseas, be in a different area each time he arrives here and know what he is supposed to deliver and how he is supposed to access the ongoing care that his patients need. Does it not therefore make sense to have local budgets, provided to GPs so that they can commission their own care in the way they need to?
I understand the concerns that the hon. Gentleman raised from his very experienced position. However, there are contracts and then there are contracts. There are ways for local GP practices to commission care so as to protect themselves, so that they are not ultimately responsible for the care delivered. That problem of responsibility needs to be circumnavigated. It should not be a wall that we come up against and say, "You know what? We can't do it, because it means the GP is ultimately going to be responsible."
My hon. Friend the Member for Basingstoke (Mrs. Miller) talked about the services in her area. I have similar services in Bedford. Our accident and emergency facility in Bedford hospital makes provision for patients to receive the equivalent of out-of-hours care for a certain amount of time. That is a good way of triaging out the patients who can be seen by nurses and out-of-hours doctors because otherwise they impose a cost on the PCT. It is an excellent model, but it cannot be delivered in rural areas or in every community throughout the country.
I believe that, although many GPs do not want to return to a system whereby they are exhausted and expected to work all week and then all weekend, they would welcome being trusted again with a real budget to commission the care that they need. They know their patients, the type of care that they need and how best to
deliver a service locally. In many areas, GP practices are grouping together to provide their own out-of-hours service because they want to deliver a service locally that they know their communities need and appreciate.
If local people were unhappy with the service, would they not go straight to their GPs to complain? Is it not easier to complain to a GP if people are seeing him anyway, and they know that he is responsible for commissioning the out-of-hours care? Are not they likely to say, "I called out the doctor last Saturday, and I wasn't happy with what happened"? It is a much easier way for GPs to get to know what is delivered on the ground. They can then modify and adjust the service that they provide to suit their community.
Local budgets, practice-based commissioning, and GPs having a real responsibility for what they provide and how they provide it makes perfect sense for patient requirements, local needs and patients' ability to adapt that service if and when they want.
6.41 pm
Mike Penning (Hemel Hempstead) (Con): We have had an eminently sensible debate this afternoon. Hon. Members of all parties care about the quality of care that our constituents get. Sometimes we disagree slightly-and sometimes more than slightly-about how it is delivered, but we all care passionately.
Contributions have been measured and understandably passionate. I pay tribute to my hon. Friend the Member for North-East Cambridgeshire (Mr. Moss), who, like us all, would have loved to raise constituency concerns and effects on his constituency. His speech was extremely measured, and he will be a great loss to the House when he retires at the next election.
I am conscious that other hon. Members are retiring at the next election, and I apologise if I do not have time to respond to all who spoke.
The key to many of the contributions was safety-for our constituents and the patients who look to the NHS to give them the care that they deserve and that we would all expect. The problem with the existing contract is that many patients do not feel they are given the care that they deserve, whether they live in rural or urban areas. We have heard much about the different sorts of care that we are offered in rural as well as urban areas. My seat is both very rural and very urban, so I well understand the problems.
The hon. Member for South Derbyshire (Mr. Todd), who eventually decided to take part in the debate-I understand why, and I repeat that it was a sensible debate- made some important points. The first was about knowledge and records. Do people who are called out out of hours know the patients' concerns? We talked about multiple sclerosis, motor neurone disease and other conditions. It is imperative that that information is available when possible. That is why the link to the GP is so important.
As the hon. Member for Dartford (Dr. Stoate) knows, I often bow to his medical knowledge. He is a GP, and I serve on the Health Committee with him. I think he said that GPs grabbed the contract with both hands only to remove the risk and perhaps some of the tiredness from it. That is not quite right. GPs were offered a contract by the Government in 2004-frankly, if they had not bitten their arm off, they would have been silly,
because the financial benefits were huge. The contract was fantastic for GPs who had been working through the nights and at weekends. All they had to do was give up £6,000 a year-£120 a week. Nine out of 10 did that. I do not think anyone would take on such a work load for such a small amount of money. It is difficult for a hard-working MP who is also a GP to say that this is about tiredness. Surely he is exhausted when he leaves the House late at night or in the early hours of the morning and goes on to be a GP in the morning. The amount of work he does in his constituency must make him a very tired GP, which is worrying.
My hon. Friend the Member for Mid-Bedfordshire (Nadine Dorries), like many colleagues, touched on continuity and safety for patients and what they expect from the NHS. The debate has been very much about-I hope-patient-led services. The key is not what the NHS, GPs or NHS Direct want, but what is right and proper for patients. Quite rightly, we have talked extensively about GPs and GPs out of hours, but that is only part of what we should rightly talk about today.
My hon. Friend the Member for Beckenham (Mrs. Lait) said that we should have a debate not about NHS Direct, out-of-hours care and A and E, but about what a joined-up package would be. One problem with the existing PCT packages is that they are not integrated. There are myriad contacts out there-there are polyclinics and Darzi clinics, care clinics, walk-in units, GP surgeries in railway stations, NHS Direct and NHS Choices.
There are so many different things that it is not surprising that our constituents are confused, which is why I was over the moon when the Government adopted our policy of going to a second number, 111. The number is fine, but do the Government understand what it should involve? I was slightly concerned when my good friend, the hon. Member for Wyre Forest (Dr. Taylor), said that people could be given another number to call after they called 111. That is not the idea. The idea is that people should be triaged through the phone system. Once they have had the courage or fear, or felt the need, to pick up the phone, they should be able to triage right the way through. Once they have dialled 111, they should be able to go all the way through so they can find out which pharmacy is open that night, whether they need to go to A and E, or whether an ambulance should be called to them immediately.
I understand that none of the three pilots includes access through the web portal, which is wrong. We need to have a joined-up situation. We should offer a single 111 service, but it should be replicated on the web. At the moment, that is not included in the pilots. Will the Minister look at that, because it is very important?
Finally, if we want to talk about out-of-hours services, we must look at the emergency care single pathway. As I said, the 111 number is eminently sensible, and I am pleased the Government are using it, but we must look at what service is needed by our constituents when they phone up. Should we look at pharmacies, walk-in centres and social care? Should it be possible to tell people whether they need to make a GP appointment the next day, whether a paramedic needs to be sent straight away and whether that should be a single-responder?
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