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?
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.
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 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.
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.
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.
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.
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.
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?
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 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 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.
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?
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.
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.
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.
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 the governance of such services, and I would wish that to be one of the outcomes of any examination of the service review.
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.
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.
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.
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?
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
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.
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?
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.
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?
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.
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.
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.
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.”
It went on:
“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.
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.
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.
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.
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”.
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.
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—
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.
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.
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 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.
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.
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.
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?
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?
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.
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.
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.
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.
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.
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.
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 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.
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.
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.
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.
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.
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?
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.
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:
“Will the Minister promise to take a personal interest in ensuring that the situation is rapidly turned around?”
“I give the hon. Gentleman that commitment, because these are extremely important concerns.”—[Official Report, 20 February 2007; Vol. 457, c. 24WH.]
Yet it seems that the practice of allowing doctors to be admitted on to the performers list in that county continued for some time afterwards. The Minister says that that has changed now, but what guarantee do we have that any particular PCT will not have flaws in their system and allow a GP into the system who can then practise anywhere in the country? That issue surely needs to be addressed.
Does the hon. Gentleman agree that it needs to be addressed by ensuring that regulations are more effectively enforced and, if necessary, tightened up? That means that the Government have a role, contrary to the view of the official Opposition. Regulation may have to be tightened up in that area.
I am grateful for that intervention, and I agree that the rules have to be tight and effective. If a primary care trust allows doctors to practise, in effect anywhere in the country, by allowing them on to the performers list when they are not competent and cannot speak the language—in other words, in breach of the regulations that the Minister mentions—it should be a criminal offence on the part of the PCT. I would like the Government to commit to investigating that possibility, because there is a powerful case for it. There have to be consequences for a failure by the PCT in allowing an incompetent or dangerous doctor to practise in this country.
Criminal penalties involve someone having to pay a price, be that a fine, imprisonment or something else. What sort of penalties does the hon. Gentleman propose PCTs should be subject to? After all, patients would lose out if a fine were levied, because it would come from the budget. Who should be imprisoned or convicted of a crime? He needs to think that suggestion through.
Of course the idea requires thinking through, but trusts can be criminally liable, if they behave in a way that breaches the criminal law. Some sanction is necessary to concentrate the minds of decision makers, which were clearly not concentrated when allowing doctors into the system in Cornwall, as revealed in that debate.
As other hon. Members have said, the Department of Health commissioned a report on the performers list, which was published on the website last March. It said:
“We also concluded that there are unacceptable variations in the way in which PCTs in England currently operate the Performers List arrangements, and have made a substantial number of recommendations to improve the local implementation of the system.”
That report sat gathering dust for many months. I understand that Steve Field is now examining the report and making recommendations of his own, but for too long its recommendations have not been implemented on a national level, and I do not understand why not. Given the flaws in the system that the report revealed last March, the recommendations should have been implemented straight away.
Registration with the General Medical Council is another vexed issue. We have already heard that if doctors come from the European economic area, they have no obligation to prove competence or language skills before being registered by the GMC. However, doctors from the Indian subcontinent, who might have excellent training and skills, have to prove that they are competent and have language skills before they can be registered by the GMC. In my view, that is discrimination and should not be allowed.
It seems to me that there is an obligation on us all to argue the case for reform in Europe to ensure that the GMC can test for competence and language skills before any doctor from the European economic area practises in this country. The case for it is overwhelming, and it seems to me that if we believe in the principle of the freedom of movement of labour, which I fundamentally do, there must be a commensurate system of safeguards to protect patient safety. We are not talking about hairstylists; we are talking about people who could kill patients, if they are incompetent or worse. The system does not adequately protect patients in those circumstances. The GMC, when one talks to it, confirms that it is unhappy with the current European framework, and yet the system continues to fail to safeguard patient safety.
It is fair to say that the system and the quality of regulation around Europe are of highly variable standards. Many European countries have not yet split the trade union function, which here is performed by the British Medical Association, from the function of regulation. That is a conflict of interest, and yet under the current system we have to rely on a regulator that also acts as a trade union in another country to judge the competence of a doctor. That, to me, is not acceptable for safeguarding patient interests in this country.
A damning report on the quality of general practitioner training in Germany was published in Germany by a panel of invited international experts. It condemned the quality of GP training in Germany, and yet we have to rely on its system of regulation to prove that a doctor is competent to practise in this country. Reports in Germany demonstrate that we should not rely on that before accepting a doctor for registration in the United Kingdom. In my view, that needs to change. However, the fact that it is European law that needs to change should not stop us arguing the case for reform.
Surely there needs also to be a system for training and assessment when a doctor arrives in this country. If he or she arrives for his or her first weekend shift, surely before that shift is undertaken, there should be full training, both in-hours and out-of-hours, in that local system, before they are permitted to practise in that area. Surely the training should include a full understanding of the “British National Formulary”—the guidance provided on prescribing. The drugs used in this country are often different from those used overseas, and yet we have nothing to require a doctor to understand what drugs are available in this country and what the official guidance is on prescribing. That, again, is surely unacceptable.
Surely there should also be an absolute requirement for induction, to work with GP surgeries locally to understand how the system works locally and to have an induction in out-of-hours care before such doctors are given responsibility for patient safety.
I can give an example of the problem to which my hon. Friend is referring. Practice differs in rural areas from urban areas. We have had doctors from overseas, and even UK doctors, who say, “Oh, I don’t do stitching, because that is not done in general practice in some areas.” In a rural area, however, it has to be, because otherwise the patient might have to travel 60 miles for treatment elsewhere.
Absolutely. My right hon. Friend makes the point very well; before a doctor can practise in a particular rural area, with its particular distances between patient and hospital, they must be able to undertake the work to provide a proper service to those patients. He makes that point extremely well.
Surely it is also the case that, when a doctor in the UK practises, they have to undergo an enhanced criminal records check, but that is not the case with a foreign doctor coming to work in the UK. That foreign doctor might have committed offences elsewhere in Europe, but there is no effective check before they are allowed to practise in this country.
I want to deal briefly with what happens when something goes seriously wrong. When a doctor is suspended in any European country, there is no obligation on the regulator in that country to notify other regulators in Europe or to pass on information to them. The General Medical Council dealt with that in a letter to me, stating:
“Our central concern is that disclosure arrangements for this information are voluntary, and rely on individual regulators being able to build effective mechanisms for co-operation between themselves…There is no legislation at European level that requires regulators to share information about a doctor (or other healthcare professional) when action is taken with regard to their registration.”
The letter continued:
“We have argued that, in addition to the right to receive treatment in another member state, patients should also have the right to safe and good quality healthcare and, as part of this, the right to know that the doctors (or other healthcare professionals) who treat them are safe and fit to practise. Without a legal duty to proactively exchange fitness to practise information, there is a risk that a doctor who held registration in more than one jurisdiction could be barred from practising in one country, while continuing to practise in another.”
That is an horrendous situation, and it is not just patients in this country who are at risk; it is patients across the European Union, because of an inadequate system to safeguard patient safety. We should challenge that.
The GMC is arguing for the reform of directives in Europe. Indeed, it is already lobbying for that, pointing out two different mechanisms in its letter by way of amendments to such directives. I want to know whether the Government are arguing the case strongly in Europe for that change to happen, because it is essential that it should happen in order to safeguard patient safety. When someone is suspended in one European country, surely that suspension should apply across the entire European Union. If we allow people to move around Europe to work, there must be a commensurate safeguard, so that when one regulator decides that someone is not fit to practise or that there is a need to suspend them pending investigation, that suspension should apply across the board.
Can the hon. Gentleman not see that he is getting to the nub of why the previous system did not work? He will remember that before 2004 and the new GP contract, each GP was legally liable for the out-of-hours service, even if he or she did not provide it themselves. That meant that should a GP, in all good faith, take on a locum who happened to be a German or French national, that GP was responsible for checking whether that locum was registered and had the right qualifications, training and Criminal Records Bureau checks. For obvious reasons, GPs felt victimised when something went wrong, because the GP who had employed the locum was legally liable for that locum’s actions. That is precisely why GPs were so frustrated and angry about the previous system and why they voted so overwhelmingly to divorce themselves from out-of-hours care and hand it to the primary care trust, which at least had the power and a reasonable level of bureaucracy to enable it to address some of those issues, which, in all honesty, could not be addressed by individual practitioners in individual practices.
That is the reason why I have concerns about the Conservative proposition. I am not entirely sure whether the shadow Minister said that the commissioning GP would be legally responsible and accountable for any errors made by someone who had been commissioned to provide the service—I do not know whether he wants to intervene on me about that point.
He does not. That point looks like work in progress to me, but it is a critical issue. My problem with the analysis given by the hon. Member for Dartford (Dr. Stoate) is that accountability is lacking under the current system, too. When a PCT fails to safeguard patient safety by allowing a dangerous doctor or a doctor who cannot speak the language on to the performers list, as we saw in Cornwall, there is no comeback for that primary care trust. That surely has to change.
I am also concerned about the situation that exists under European arrangements. A doctor who commits an error for which he is potentially criminally culpable must surely be held to account in the jurisdiction of the country where that error occurred. We cannot guarantee that that will happen at the moment, and that must surely change. That will involve ensuring the effective operation of the European arrest warrant, but at present we cannot be confident about that either.
There is a clear, powerful and overwhelming case for reforming the system of out-of-hours care. The head of the Royal College of General Practitioners, the highly respected Steve Field, said last autumn that there was a pressing case for the reform of out-of-hours care. That case is overwhelming. I have concerns about the proposition put forward by the Conservative party, and that is why I propose that the Royal College of General Practitioners, which is respected not only by practitioners but in this place, should be commissioned to carry out a review and to come up with proposals to reintegrate doctors into the provision—not the commissioning—of out-of-hours care locally, so that we can ensure that patient safety is protected.
Order. I remind the House that there is a limit of eight minutes on Back-Bench speeches. The Front Benchers have taken up the lion’s share of the debate, to the detriment of the interests of Back Benchers, but I hope that hon. Members will try to keep within that limit.
Thank you, Mr. Deputy Speaker. I shall endeavour to keep my remarks within your eight-minute time scale.
This has been an interesting debate that has raised important issues about the quality and delivery of out-of-hours services in general practice. The hon. Member for Boston and Skegness (Mark Simmonds) highlighted the problem well when he said that the present system was patchy. In many parts of the country, it is unacceptable. We need to do something radical to change that, to ensure that patients in every part of the country have access to good-quality out-of-hours services from whomever is delivering them.
The problem is that I do not agree with the hon. Gentleman’s analysis of what needs to be done. He seemed to imply that a return to the old GP commissioning system would somehow improve the situation and put things right. It could well do that in some parts of the country, but it is a rose-tinted view of the situation. This takes us to the nub of the problems that we had before 2004. Some GP commissioners are undoubtedly of extremely high quality and extremely highly skilled, and undoubtedly take a great interest in the service and do a first-class job, but the fact is that most GPs do not want directly to commission. A recent publication by David Colin-Thomé, the national director for primary care, acknowledged that many GPs were not skilled or interested in direct commissioning, and simply did not want to do it themselves. My worry is that compulsorily bringing GPs back into the commissioning role would work in some places but not in others. In other words, we might have a different patchwork, but we would still have a patchwork.
We need to consider why GPs were so keen to divest themselves of their responsibility for out-of-hours care in 2004. They voted overwhelmingly to end the situation in which they were legally responsible for what happened out of hours. I personally know GPs who had been on holiday and who received a complaint when they got back because of the actions of a deputy who had been doing the out-of-hours care for them. The GP, who might have been sunning himself in Spain at the time, was legally liable for the deputy’s actions. That was nonsense. It would not occur in any other situation; why should it occur in general practice? Let us also bear in mind the fact that, before 2004, most GPs did not deliver their own out-of-hours services. They contracted them out to deputising services, to co-operatives or perhaps to an in-town rota. Nevertheless, they were legally responsible for the services provided.
It is hardly surprising, therefore, that GPs decided that the situation was unsustainable. If we did the work ourselves, we were worn out the next day and not able to provide the top-quality service that our patients deserved. However, if we divested ourselves of the service and gave it to, say, a commercial service, we remained legally responsible. We were never able to sleep soundly in the knowledge that someone else was truly responsible for our patients. The situation clearly could not continue. It was affecting recruitment and retention, and GPs were retiring early because they simply could not keep it up any longer. The situation was untenable and could not continue indefinitely.
The Government therefore, quite rightly, renegotiated the contract in 2004, and made primary care trusts responsible for the delivery of these services. In most cases, the PCTs simply continued to contract with the same bodies that had already been providing the out-of-hours care. In my area, for example, an organisation called Grabadoc, which covers Greenwich and Bexley doctors on call, was almost entirely staffed by GPs before the 2004 contract, and it got the contract to continue to provide the same service, so almost nothing changed. The only thing that changed was that the responsibility was taken away from the individual practices. That is how it should be.
If anything needs to be learned from this afternoon, it is that we should be much tougher in regulations—I agree with the Minister—to ensure that primary care trusts can be held accountable to deliver the service that they contract. They are legally responsible to provide the service, so it is up to them to monitor it. It is then up to the CQC, perhaps, to monitor whether the PCTs are doing their jobs. If not, they need to be held to account in whatever way is deemed appropriate. That is not a matter for this afternoon, but it needs to be done properly.
In the limited time available, I also want to say that the situation is not all bad. It is easy to concentrate on situations in which something has gone wrong, a patient has suffered harm, or a patient’s family has waited an unnecessarily long time for a service, and to assume that the service is generally not very good, but that is not the case. We must differentiate carefully in-hours care, when a GP, who is generally known to the patient, will provide a service with a wide range of back-up, practice nurses, diagnostic equipment, access to colleagues within the hospital or community services, and the full armamentarium of interventions. Out-of-hours provision has never been like that. It has always involved an individual practitioner, generally on their own, making an assessment of a patient they probably do not know, and trying, with the limited resources, interventions, diagnostics and treatments available to them, to provide an emergency service for that patient. It has worked well over the years, and some of the evidence is quite interesting.
I have done some reading of The British Journal of General Practice, as Members would expect, and it clearly draws a distinction. A paper a year ago said:
“When dealing with acutely ill patients in usual in-hours clinic circumstances, the support provided by a competent team in familiar surroundings cannot be underestimated. Not only is the patient likely to be known to the practice, but triage, emergency equipment and diagnostic assessment can also be arranged most effectively”.
“In the out-of-hours situation, however, particularly if a home visit…is involved, the GP must deal with many of these aspects alone…clinical decision making is inherently more difficult because patients are much less likely to be known, and options for adequate diagnosis and subsequent patient care are more limited”.
It goes on to make the point that GPs vary considerably in their attitude to risk taking. Many GPs can handle far higher levels of uncertainty of risk than others, and therefore perhaps are better placed to make out-of-hours decisions. It is wrong to assume that all GPs are similarly skilled and competent and that all GPs will provide the same decision making in different situations. Certain types of GPs might be much better placed to make such decisions—that is the direction we are going in—and those GPs often become sessional doctors for co-operatives or out-of-hours services because that is their particular skill and interest. They can provide a better service. The situation is very complex, and one size does not fit all. There are different types of doctor in different parts of the country.
Another study carried out in south Wales, and published in the Emergency Medicine Journal in 2008, made a similar point. It found that 80 per cent. of patients were satisfied with the service they received from the out-of-hours service involved. Only a fifth of patients were dissatisfied with the service. The authors examined why those patients were dissatisfied, and concluded that it was due to
“a mismatch between patients’ expectations of the service and what the service actually provides to some specific user groups.”
They concluded that, generally, the service was adequate, but the communication between the patient and service provider was often poor. That point has wide relevance. Quite a few of the worries about out-of-hours care concern a failure to arrive at a clear definition of what an out-of-hours service should provide to patients. Better communication is essential if we are to address that and ensure that patients get the best of the deal.
Previously, most patients were reluctant to call their own doctor out to make a home visit at night, knowing that that doctor would have to carry on their normal surgery the next day. On the few occasions they did call the doctor out, expectations were generally modest. They were so grateful that their own doctor had come to see them that they were reluctant to put abnormal demands on that doctor. A lot of unmet need was out there, and it is wrong to assume that needs were being met because their own family doctor—
In the light of Madam Deputy Speaker’s ruling at the outset of this debate that the case of my constituent, Mr. David Gray, remains sub judice until the inquest on his death finishes next week, I shall not allude to it any further. However, I put on record my intention to pursue a proper debate on the circumstances surrounding his tragic death and subsequent developments at a later time and through other means. I am sure that Mr. Gray’s family will greatly appreciate the offer of condolences that the Minister made in his opening remarks.
Several cases in the media in the past years—and not just the case that is currently sub judice—have highlighted the failure of the out-of-hours care system. All too often, we hear similar stories of patients not receiving the out-of-hours care that they are entitled to under the NHS. Currently, the shortage of out-of-hours GPs is largely met by foreign doctors who register to work as supply doctors in England, but the system does not adequately ensure that these foreign doctors are fit for practice. Loopholes in the out-of-hours system have enabled some foreign doctors who should never have been allowed to work as GPs in this country to do so, at great cost to patients’ welfare and safety. In the absence of any root-and-branch reform of the system or a change of Government leading to GP commissioning as outlined by my hon. Friend the Member for Boston and Skegness (Mark Simmonds) in his opening speech, I should like to focus on the use of foreign doctors in out-of-hours provision and to suggest a few proposals for reform that might go some way to ensure that patients receive the high standard of care to which they are entitled under the NHS.
My first proposal is that an assessment of English language skills should be carried out on all foreign doctors, because too many patients complain of foreign doctors’ often limited knowledge of our language. We must ensure that all foreign doctors who register to work in Britain have a sufficiently good grasp of English to diagnose appropriately and to treat patients. Misunderstandings and unawareness can cost lives, particularly as many EU doctors are apparently unfamiliar with the strength of some drugs that are used in the NHS.
As the Minister confirmed, many primary care trusts require a high level of English proficiency before a foreign doctor can register as a GP. However, the system allows for loopholes to be exploited, as not all PCTs have such high standards. The loophole enables foreign doctors who would not pass the English requirement set by some PCTs simply to apply to others that do not have such stringent rules. Even worse is the fact that a doctor who fails an English test in one PCT can withdraw his application from that PCT, leaving no trace or record in the system, before re-applying for an English test at another PCT. Thus, there is no record of a list of failures or rejections. In other words, a doctor can tout himself around the system until he finds a weakness and gets a breakthrough. Once a doctor is registered with a PCT, he or she can work as a GP anywhere in the country, regardless of the language requirements in the particular PCT area in which he or she ends up practising. The registration of foreign doctors with PCTs is an area where requirements must be standardised in order to avoid applicants exploiting such loopholes.
As well as having these English language tests, it is crucial that the applicant’s medical competence is assessed before they can register in the UK. Before being registered, doctors should be required to provide documentation to show that they have experience of working as a GP and that they have undergone specific training in general practice. All the applicant needs to do at the moment is to provide a licence to show that they are allowed to practise in their own country, regardless of whether they have actually ever worked as a general practitioner. I do not believe that that is enough, and more stringent rules are needed in this area to ensure the best possible care for patients.
Compulsory training and induction in England before foreign doctors are allowed to work as GPs is also crucial to ensure a high level of patient care, a point made by the hon. Member for North Norfolk (Norman Lamb). That is not currently a legal requirement, and it would be interesting to hear of any plans the Government have to introduce compulsory training and induction for foreign doctors.
The General Medical Council must consider introducing more stringent assessment before recognising medical qualifications from other EU states. Doctors from EU countries do not have to undergo the same assessment of their competence as doctors from other countries, not only those from India—that country has been mentioned—but those from countries such as Australia and the USA. It is necessary that the medical competence of doctors from EU countries should also be assessed, as medical training and types of drugs used vary across Europe. Criminal record checks should also be mandatory for all foreign doctors applying to work in our NHS and the country of origin should be obliged to supply information of previous malpractice by a doctor to the authorities in this country. At present, this is entirely voluntary, but there have been cases of doctors who have been convicted of malpractice in their own country being allowed to practise as out-of-hours GPs in our NHS.
A national database of foreign doctors applying to work as a GP in Britain should be introduced that would hold information on language skills, levels of medical competence, criminal record checks, malpractice in the country of origin and whether the doctor has ever been rejected by, or withdrawn their application from, any PCT. Finally, as a general rule, doctors should be accountable to the laws of the country in which they practise. The Government must work with other countries to ensure that any doctor accused of malpractice, negligence or worse in this country is not allowed to escape justice being served for the crimes that they have committed.
I hope that the Government will urgently consider the proposals for reform of the out-of-hours care system that I and many other hon. Members have proposed in the debate this evening. I call on the Government to ensure that foreign doctors are properly assessed and scrutinised before they are allowed to work as GPs in this country. We have witnessed too many cases where patients have been let down by the system and we need a complete overhaul of the provision of out-of-hours care in order properly to ensure the safety and well-being of patients. Until the Government bring in urgent and sweeping reforms to this system, people’s lives will be at risk. Too many patients have had to pay with their lives already.
I had not expected to speak in this debate, but the robust handling of interventions by my right hon. and learned Friend the Minister has led me to say a little more than I would otherwise have done.
Let me first say something about the position in my constituency. When the out-of-hours service was removed from GPs and transferred to PCT commissioning, the initial results were simply horrendous. I received large numbers of complaints over poor handling of calls, lengthy delays and so on. However, I should immediately add, by way of comfort, that the PCT—not rapidly, but over time—addressed those concerns and there has been a significant improvement in the services offered in South Derbyshire. Some location changes mean that there is now an outpost in Swadlincote that serves the urban area and its environs, so a GP can reach patients in the main population hub of the area rather more rapidly than they could under the old model. There is evidence that change can take place, but I still receive complaints and we still have further to go.
My original reason for wanting to intervene focused on the experience that I and other hon. Members had yesterday of listening to carers of those with motor neurone disease who have called out-of-hours services in their areas and the frankly very poor treatment that they have received. The most extreme example, which resulted in an apology and, I think, disciplinary action against the person involved, involved someone with NIV—non-invasive ventilation—which is the breathing system that supports someone and keeps their lungs functioning. The carer was asked to remove the mask to test that person’s breathing so that the person on the other end of the phone could validate what they were saying. That was after the individual’s notes had been passed to the out-of-hours service, so they should have been perfectly aware of the condition from which that person was suffering.
Clearly, as I said in my intervention on the Minister, protocols for rare conditions—cases in which crises can readily occur out of hours—need to be strengthened so that the training level for dealing with very specific conditions is satisfactory.
There is no way to turn the clock back and, even if there were, it would not be wise so to do. Others have already covered some of the reasons for that, but I shall expand on one. The hon. Member for Boston and Skegness (Mark Simmonds) opened for the Opposition but, despite what he said, I do not think that most GPs would want the legal and financial responsibility for commissioning services to be transferred back to them.
My hon. Friend the Member for Dartford (Dr. Stoate) set out some of the legal issues involved. I think that they would be intimidatory, but—and I was looking for some degree of consensus on this in one of my interventions—I think that GPs could have a much stronger role in the governance of the out-of-hours service being offered.
At the moment, there is GP representation on the professional executive committee of a PCT, but that is far too modest a function in the commissioning process. A governance board should be established to drive quality issues when a service is commissioned. That board should also be involved in the critical issue that I am now going to come to—the relationship between the various parts of the NHS in the area.
Knowledge transfer is critical. When an out-of-hours service is offered in an area, doctors must be able to access information about patients. Earlier, I gave the example of a person with MND for whom the GP had taken the trouble to ensure that relevant information was passed on. That process should be integrated into the commissioning of the out-of-hours service, because it is critical that those who must answer a call and deal with distress have a clear idea of what the caller is suffering from and of how best to respond. That means that we need to strengthen NHS information systems. I have been a strong supporter of investing in health information systems, in spite of the difficulties that have been encountered. We must continue to get across the message that, without a robust means of transferring information within the NHS, problems are all the more likely to occur. We should always make it clear that we will never utterly eliminate risk, but we must try to ensure that the people who have to deal with crises know what they are dealing with and whom they are talking to.
I was interested in the contribution from my hon. Friend the Member for Dartford; for a start, it is nice to hear a Member of Parliament speaking about something that he knows about. He presented interesting evidence about the different relationship between patients and out-of-hours services that arose as a result of the change in the contractual function. I think that patient behaviours are substantially influenced by that relationship.
Essentially, the argument is that people who know their GPs will not want to ask too much of them. They know that providing out-of-hours services is difficult, so they exercise some restraint on the demands that they place on the system. However, those demands may be rather different if people believe that the services are provided by some quasi-state function with which they have no relationship whatever. It is worth thinking about how economic models apply in these circumstances, and how we might try to learn some of the lessons.
Finally, the hon. Member for Basingstoke (Mrs. Miller), who is waiting to speak, made a very wise point about integrating out-of-hours services with the acute sector. From time to time, the acute trust in Derby has suggested establishing an out-of-hours service for my community in South Derbyshire that is adjacent to the accident and emergency function, with the aim of trying to provide common standards of treatment. It is perfectly obvious that inadequacies in out-of-hours care drive additional and often inappropriate demands on A and E services. There is therefore a shared interest in establishing common methodologies for examining demand, and common methods for dealing with patients when they arrive in distress and requiring treatment.
As in many cases, there is in this House a huge amount of common interest and opinion on this matter. Although I do not agree with the model proposed by the Opposition, and will not be voting for their amendment, I think that, if they reflect harder on some of the points made in the debate, they will see that there is much more to build on in terms of reform than might have appeared to be the case when the hon. Member for Boston and Skegness first started to speak.
Many people were shocked when they read the media stories on the issues that we are discussing. Although we cannot go into the details of those stories, it is important to recognise the concerns.
The change in the GPs’ contract in 2004 is one of the root causes of the problems that we are discussing, as nine out of 10 GPs elected to opt out of providing after-hours services. The Government simply have to accept that that was a misjudgment, and that that should not have been allowed to happen. The consequences that we are now dealing with and discussing have fallen on some of the most vulnerable people in the community. We have not spoken much about patients and the primary users of those services but, as hon. Members know, the elderly and children account for 80 per cent. of them. It is important to recognise that the problems with which we are dealing are often experienced by the people least well placed to cope with them.
The problems with out-of-hours services, access and quality have only been compounded by cuts in other primary health care and public health services. The Minister will be aware of the problems in my part of the country caused by cuts to health visitor services—those problems have been experienced in many other constituencies, too—which puts more pressure on GPs and on out-of-hours services. As hon. Members have said, the result of difficulties accessing out-of-hours services is an increasing reliance on hospital accident and emergency departments. Imperial college London recently produced a report showing a 41 per cent. increase in short hospital stays by children under 10 between 1996 and 2006, often for chronic problems such as asthma and other respiratory problems, fever, and other things that could have been dealt with if out-of-hours services were more readily available. In some parts of the country, those services are simply not available.
We cannot blame parents for seeking medical care for their children when they are in distress. All of us who have small children know that sometimes it is difficult to recognise whether a problem is severe or not. Access to primary medical care through the GP out-of-hours service in non-traditional office-hour times is vital, and an overhaul requires a great deal of thought. There are questions hanging over the out-of-hours service. For example, PCTs monitor response times, but do not consistently monitor the quality of care offered to patients, and the recent inquiry by the Care Quality Commission has produced some worrying findings.
Quality of care is at the heart of what hon. Members have discussed today. The Minister said that there were three levels of quality control: the General Medical Council, PCTs and, indeed, the employer. However, as my hon. Friend the Member for Boston and Skegness (Mark Simmonds) pointed out, the GMC has said that the existing framework does not adequately safeguard patients in the system, so there is a serious flaw if people who are given the task of quality control question whether it is working. The Minister stressed the fact that legal responsibility lies with the PCT. In an intervention, however, I was surprised to hear him question whether that was enforceable. Indeed, if it was enforced, the financial consequences might fall on the taxpayer. If there is no clear responsibility and no clear consequences, I fear that we will not see any change in the quality of care offered to some of our most vulnerable constituents.
My hon. Friend the Member for North-East Cambridgeshire (Mr. Moss) made an extremely powerful and moving contribution, and gave an excellent list of recommendations that the Minister should consider to reform the system so that we get the changes that we need. The hon. Member for Dartford (Dr. Stoate) discussed the different services provided in the NHS, and made a distinction between in-hours and out-of-hours services. Yes, I believe he is right to say that there will be different expectations of what might be delivered by those services, but my constituents and people throughout the country will expect the same quality of service, whether it is in hours or out of hours.
A number of hon. Members mentioned overseas doctors. That is at the heart of what we are debating. The Minister talked about improvements in fitness to practise for British doctors, but did not seem to move on to how that would affect the quality of doctors coming in from overseas. The hon. Member for North Norfolk (Norman Lamb) spoke about CRB checks. He is right to say that overseas doctors coming in from any country, even within the UK, will not have had an effective CRB check.
Before I move on to the situation in my constituency, which I would like to highlight to the Minister because I think it is an excellent model of working, I shall pick up on the issue of fragmentation within the NHS. We now have, by my calculation, five different ways of accessing NHS services. The Minister spoke about the new 111 service, a telephone service for non-acute calls. We also have NHS Direct, the 999 service, GPs in their normal office hours, and out-of-hours services. As we move forward, we should be careful about how patients understand the way in which those different elements work together. It is a maze of different ways of accessing the NHS. From talking to those who provide services in my constituency, I know that that is becoming a matter of concern.
My constituency has a very high-quality out-of-hours service, which could be a model for other areas. The Hantsdoc service, which has been provided for the past 14 years in Basingstoke, looks after about 30,000 patients a year and is a partnership of local doctors working with the PCT in the community. They work closely with the hospital and are located in the fractures unit to reduce the unnecessary admissions that might otherwise occur. Doctors who are located centrally can see three times as many patients, and the service is open throughout the week and the weekend, when doctors’ surgeries are not available. I recently visited and spoke to patients, who were extremely satisfied with the service that they had received.
I agree with my hon. Friend the Member for Boston and Skegness when he says that there is no one answer to out-of-hours services and no one model, and that that should be driven by what is required in a the community, but I offer the work of Hantsdoc as one model that has worked for 14 years and served my constituency well.
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.
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”—
primary care organisations—
“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.
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.
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?
The Minister would be surprised if I did not mention out-of-hours dentistry, which is in crisis—dentistry is in crisis during the day and at night. If the Minister went to A and E units at night and talked to patients, he would find a huge number who are there simply because they cannot get a dentist during the day. We know that in excess of 1 million patients cannot access NHS dentistry, but when people are in pain and turn up at A and E, we need to ensure that the skill base is available for them.
My hon. Friend the Member for Basingstoke (Mrs. Miller) mentioned walk-in centres integrating with A and E. I have seen that in action and it absolutely works around the country and releases a lot of the pressure from existing A and E units. I am sure all hon. Members visit their A and E units—I am lucky enough to go and visit very many. Many patients could have been seen at a minor injuries unit, but they go to the A and E because they feel safe. Many in A and E wanted to get a GP appointment but could not, and many are sent to A and E after a long call to NHS Direct, when they could have been triaged in a much better way.
Working as an integrated service is crucial if we are to have the out-of-hours and urgent care that we need. The Government disagree with our policies—that is their prerogative—but they should call an election and let the public decide.
I too wish to say how well this debate has gone. There have been improvements in out-of-hours services in the last 12 years. They are good, but they are not great. They have let some people down and we need to improve them further. That is why we have asked Professor Steve Field, the chairman of the Royal College of General Practitioners, and Dr. David Colin-Thomé, the director of primary care services in England, to review the out-of-hours service. The report by the Quality Care Commission will also be presented shortly. We have more work to do on out-of-hours services and we intend to improve them. We need to ensure that PCTs and employers do the checks that are needed.
The hon. Member for North Norfolk (Norman Lamb) said that he wanted to see checks on language and professional competence, and that those should be carried out by the GMC. He claimed that that would require changes to the EU directive. We cannot wait that long. The issues need to be addressed now. PCTs have a legal responsibility to ensure competence in the English language and the practice of medicine. Employers should also have that responsibility, and we need to ensure that that is done. Reform of the EU directive is not necessary to achieve that.
My right hon. Friend the Member for Rother Valley (Mr. Barron) chairs the Health Committee and is well known for his detailed opinions on health. I shall address his points throughout my speech. As my hon. Friend the Member for Dartford (Dr. Stoate) said, with obvious authority, responsibility for out-of-hours services lies with the PCT. The hon. Member for Boston and Skegness (Mark Simmonds) says that he would transfer responsibility for commissioning of out-of-hours services to GPs. They would therefore be liable in law for any failures by locums they employ, or any negligence or failures by an employed GP. It is no wonder that the BMA is concerned about Conservative policy, which would lay a similar liability on GPs to that which they had before 2004.
My hon. Friend the Member for South Derbyshire (Mr. Todd) spoke movingly about the care of long-term conditions. Such conditions require a different out-of-hours service. In many instances, they require a rapid response team, and many such teams are in place. They are multi-disciplinary, including paramedics and specialist nurses. The hon. Members for Basingstoke (Mrs. Miller) and for Beckenham (Mrs. Lait) also spoke of the need for health care teams with different skills, including physiotherapists, paramedics and nurses.
My hon. Friend mentions nursing. I am interested in the development of policy in that area. Does she intend to follow the Leader of the Opposition and meet the Nurses for Reform campaign group which advocates the wholesale privatisation of the NHS, including out-of-hours care?
From what I have read of that group, my hon. Friend’s remarks are very worrying.
The hon. Member for Wyre Forest (Dr. Taylor) spoke of the 111 system, which will be excellent. I am pleased to see that the pilots may be ready as early as May or June. He made a point about the BMA involving GPs in commissioning, but I would go further and look for more nursing staff to be involved in the commissioning of services.
As usual, the comments by the hon. Member for Mid-Bedfordshire (Nadine Dorries) did not disappoint me.
I thank all hon. Members who contributed to this debate and I know that they would want to thank NHS staff. Illness, accidents and ailments pay no attention to the time of day, so we must do all that we can to ensure that patients get the right treatment, at the right time and in the right place, and we must have a system of out-of-hours and urgent care that is achieving that goal. People can now access the NHS in more ways than ever before: through one of the 112 new GP surgeries in the areas with the fewest doctors and the greatest need, and through the new GP-led health centres, of which there is one in every primary care trust, open from 8 am until 8 pm, seven days a week, 365 days a year—there is an excellent one up and running in the heart of Hounslow, and the treatment for my constituents is second to none. People can also access the NHS through local pharmacies, some of which are now open seven days a week and into the night; through minor injuries units and urgent care centres, many of which are nurse-led; and through NHS Direct, either over the phone or online. With so many options to choose from, it is important to give patients and local communities the information to get the help that they need.
The hon. Members for North-East Cambridgeshire (Mr. Moss) and for North Norfolk talked about the patient, Mr. David Gray. Many have expressed their concern and sympathy about that case, and I would like to align myself with that and with the dignity shown by the hon. Member for North-East Cambridgeshire.
We owe the NHS a great tribute, but we also owe our patients and constituents right and safe care, whether in respect of long-term conditions or urgent dental treatment—many of our dental practices also operate out-of-hours services. Many dentists should be commended for their work rather than constantly criticised for a lack of commitment. They want to contribute to primary care in every way possible by being at the heart of our communities, and many want to, and will, work in the walk-in centres of the future. We are encouraged by the people who work in the NHS and, in particular, by how people want to work in communities. It has been difficult to correct the out-of-hours service, which before 2004 was not effective, but equally the schemes now in place will need the review to be led by Professor Stephen Field. When he reports back, which should be soon, I believe that we will act on it.
We have said that we will address the areas of change in relation to the European rulings, and that we will look at commissioning, because that is key to providing the correct services for all patients. Any GP working for out-of-hours providers is subject to the same checks as all other doctors working in general practice in England. Employers have a duty to ensure that all the doctors whom they employ are suitable for the provision of the services that they are employed to provide, and all doctors, including locums, must be on a PCT’s performers list before they can provide primary medical services.
Concerns about individual doctors can be investigated by the GMC, which can, when justified, remove a doctor from the medical register on fitness-to-practise grounds. All our services must be safe and of a high quality. They will be checked by the Care Quality Commission or the other regulators that will be needed. When I look at the extension of patient services since the resources that have been put into the health service, I feel confident that we will continue to improve our practices in every way possible for our constituents, and that is thanks to NHS staff and the commitment that they show.
Question put (Standing Order No. 31(2)), That the original words stand part of the Question.
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.
That this House supports family doctors as the bedrock of healthcare services in the NHS; 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.