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Out-of-Hours GP Services

Volume 505: debated on Tuesday 9 February 2010

With permission, Mr. Speaker, I should like to make a statement about out-of-hours primary care following the conclusion of the coroner’s inquest last week into the care of Mr. David Gray, who died on 16 February 2008. First, and I am sure that I will be joined by the whole House in this, I should like to extend my sincere condolences to the family of Mr. Gray. This was a tragic case, and I am deeply sorry for their loss. I understand that litigation has arisen out of this issue and I shall therefore direct my remarks primarily to the wider policy issues.

Concerns about out-of-hours primary care were raised with me last summer. I then met primary care professionals to understand the issues in greater detail and to consider what action we might take to improve out-of-hours services for patients. The Care Quality Commission’s interim report on out-of-hours care in Cambridgeshire, published on 1 October 2009, also expressed concerns over the quality of care provided. By that time, on 23 September, following discussions with them, I had formally asked Dr. David Colin-Thomé, the national director for primary care at the Department of Health, and Professor Steve Field, chairman of the council of the Royal College of General Practitioners, to lead jointly a review of the current arrangements for the local commissioning and provision of out-of-hours services.

The report, which I published last Thursday, considered the commissioning and performance management of out-of-hours services, the selection, induction, training and use of out-of-hours clinicians, and the management and operation of the medical performers lists on which doctors must register in order to practise in England. The report acknowledges the fact that there is an unacceptable variation in the quality of out-of- hours services across the country, and it sets out 24 recommendations, including that primary care trusts should review the performance management arrangements that they have in place for their out-of-hours services, to ensure that they are robust and fit for purpose; that the Department of Health should issue guidance to PCTs to help them decide whether a doctor has the necessary level of English to be added to their medical performers list; that the Department of Health should develop and introduce an improvement programme for PCTs to support the commissioning and performance management of out-of-hours services; that out-of-hours providers should consider their recruitment and selection processes for clinical staff to ensure that they are robust and follow best practice; and that strategic health authorities should monitor the actions taken by PCTs in response to the report and in carrying out appropriate performance management of out-of-hours providers.

The report’s recommendations are an important reminder, to PCTs and providers, of their pre-existing obligations to provide patients with safe and effective out-of-hours services. We have accepted the recommendations in full, and we intend to go further still. I have announced additional improvements to out-of-hours GP services. We will review the existing national quality requirements, and introduce and mandate national minimum standards that all out-of-hours providers will be required to meet. We will introduce a model contract based on these national minimum standards for out-of-hours provision that PCTs and the providers of out-of-hours services must use. The Department will work with national medical organisations to develop a national database and consider what data should be placed on it. We will tighten existing controls to ensure that PCTs meet their legal obligations and that providers employ competent clinicians to practise as out-of-hours GPs. SHAs must ensure that PCTs are meeting their obligations and we will, in turn, hold SHAs to account for this.

There is already a clear legal requirement under the National Health Service (Performers Lists) Regulations 2004 for PCTs to refuse a doctor’s inclusion on their performers list if they are not satisfied with their level of English. We will direct PCTs to review their procedures and to make certain that they have a clear policy in place for assessing the English language skills of everyone applying to be added to their local performers list. Finally, we will require PCTs to involve local GPs in the design of out-of-hours services through local medical committees, RCGP groups and faculties, clinical executive groups and practice-based commissioning consortiums.

Officials in the Department of Health will continue to work with the NHS to implement these measures. The NHS chief executive, Sir David Nicholson, wrote to all NHS organisations last Thursday to bring Dr. Colin-Thomé’s and Professor Field’s report to their attention. Sir David sought assurances that they are meeting their obligations as highlighted in the report. Along with Sir David Nicholson’s letter, the Department of Health has issued new interim guidance to PCTs to assist them in complying with their obligations to ensure that all doctors admitted to their performers list have the necessary English language skills.

It is clear that in some areas out-of-hours services are not as good as they could or should be. However, as Professor Field’s and Dr. Colin-Thomé’s report acknowledges, even when GPs were responsible for the care of their patients 24 hours a day, only 5 per cent. of them actually provided out-of-hours care for their own patients. Those GPs that did so were often left dangerously tired and exhausted. The system was unsafe. In fact, by early 2000, the level of complaints from the public was so great that the Government asked Dr. David Carson to conduct a comprehensive review of out-of-hours services in England. His recommendations formed the basis of our 2004 reforms, which have led to significant and independently verified improvements in out-of-hours care.

Most of our out-of-hours care is today provided by local GPs working on rotas for co-operatives or companies and, the case of Dr. Ubani notwithstanding, most of the service is good. A 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. In 2008, a Healthcare Commission report on urgent and emergency care added:

“There have been significant improvements over recent years in the...number of out-of-hours GP services meeting national quality requirements.”

Although it is clear that the quality of out-of-hours care for most people is better than it was in 2004, it is still not good enough. I hope that the recommendations set out in the report by Dr. Colin-Thomé and Professor Field, along with the additional measures I have set out, will let Mr. Gray’s family know that lessons will be learned, and I hope that we will give patients the level of out-of-hours primary care that they expect and deserve.

May I join the Minister in extending my sincere condolences to Mr. Gray’s family?

I thank the Minister for the courtesy of giving me sight of his statement prior to his making it at the Dispatch Box. I suspect, however, that it is with great reluctance that he has come before the House today and that he has done so only because of significant pressure.

It needs to be said that good out-of-hours care is being provided in some parts of the country, but it is clear from the coroner’s report into the terrible tragedy of David Gray in February last year, and from the additional report by Dr. Colin-Thomé and Professor Field released last Thursday, that there are significant failings in the provision of out-of-hours care in some parts of England, providing unsatisfactory levels of patient care and, ultimately, putting patients’ lives at risk. There have been several tragic deaths, and we must all do everything we can to ensure that that never happens again.

The Government’s decision to allow almost all GPs to opt out of involvement in out-of-hours care in 2004 was a significant and serious mistake. The current structure of out-of-hours care is at best patchy and has been described by the Public Accounts Committee as “shambolic”. The Government were consistently warned that there were ongoing failures in the system, with reports not only by the PAC but by the National Audit Office and by the Select Committee on Health, twice, highlighting serious concerns and failings, yet no effective action was taken. All those reports, and the two released last Thursday, are critical of the patchy provision of out-of-hours care.

The list of defects and non-performance is extensive: increasing numbers of complaints about out-of hours care; primary care trusts failing to monitor the quality of care and not reviewing or assessing contracts; inadequate performance measurements; strategic health authorities not monitoring PCT performance, and in some cases not engaging in the process at all; out-of-hours care used too often as a holding bay; insufficient skills for commissioning out-of-hours services; some PCTs ignoring and shunning GPs’ involvement and advice; a lack of clarity on responsibility between commissioners and providers; significant additional pressure and attendance at accident and emergency and pressure on ambulance services; little or no integration of out-of-hours care with urgent care; non-implementation of selection, induction and training of foreign doctors; very poor response times; and a lack of a coherent and consistent approach to the inclusion of doctors on the performers list.

It is clear that there were failures at SHA, PCT and provider level. There were failures to assess foreign doctors’ language, communication and formulary skills, to involve GPs in the commissioning of services, to monitor, review and assess out-of-hours care, and to assess and learn from patient experience. In some parts of the country, that litany of failures has been detrimental not only to patient care but to patient safety, culminating in the shocking death of David Gray.

The Minister has said that he will implement all the recommendations of the Colin-Thomé and Field review. Will he do the same for the coroner’s recommendations? What will be the time scale for the implementation of the recommendations of the review? In other words, what is the longstop date for its total implementation? What action will the Minister take to ensure that SHAs review PCTs’ progress in that area? SHAs need to do more than just consider what action should be taken. How will he ensure that PCTs properly and regularly review out-of-hours contracts, involving local GPs and, I note with interest, including local GP consortiums? Rigorous monitoring should be taking place everywhere, looking at the quality of clinical decisions, the efficiency of call handling, the adequacy of staffing, doctors’ training and patient outcomes.

The Minister will be aware that the General Medical Council is very concerned about the ability of foreign doctors from within the European economic area to practise in the UK. It believes that

“the current legal framework is unsatisfactory”

and that

“the current system does not adequately safeguard patient safety.”

The Minister must ensure that he completes the immediate implementation of the Department of Health report “Tackling Concerns Locally”, which has been collecting dust in the Department since March 2009. Will he address the concerns of the GMC and lobby for a change to EU law, to ensure proper skills and language testing for doctors who wish to practise in the UK? Will he consider including in the process of revalidation locums and doctors from the EEA who are working in the UK, and will he ensure that access to the performers list is tightened and that there is a much greater flow of information between PCTs and the GMC? As far as I understand from what the Minister said, there is still no mechanism in place to ensure that a doctor struck off in another EU country cannot practise in the UK.

To put it mildly, this is not the Government’s finest hour. It has taken the tragic death of Mr. Gray for action to be taken, despite persistent and consistent previous warnings. This is a serious situation that will be resolved only when the Minister accepts that in some geographical areas the system of out-of-hours care has failed; when, as the Royal College of General Practitioners recommends, a comprehensive review of out-of-hours care takes place; and when the Government accept, for the sake of patient care and safety, that responsibility for commissioning out-of-hours services must be with GPs.

I certainly agree with the hon. Gentleman that we must ensure that we do all we possibly can so that this sort of incident never happens again. That is why we responded to a series of reports and ensured that after the Carson review on out-of-hours services, we changed things—it was clear that the system that existed before 2004 was unsafe; therefore, changes were put in place.

We do not want a situation in which we return responsibility to GPs for the management of out-of-hours care, as appears to have been suggested. Dr. Laurence Buckman of the British Medical Association has been very clear on that. He said:

“The old system meant many doctors were tired and therefore potentially dangerous to patients and it is for that reason that the BMA, and the GPs it represents, would resist a return to doctors taking back personal responsibility for delivering care out-of-hours.”

On another occasion, he said:

“The current out-of-hours system desperately needs improving, but we can’t go back to where we were before 2004 where doctors were on call 24 hours a day, meaning many were operating in a constantly sleep-deprived state.”

We need to ensure that we deal with some of the issues that exist in the current system. I think we all, as parliamentarians, need to confront the issue of decentralisation of power. We have been pushing down responsibilities to PCTs. That is all very good, and there is a broad consensus in the House that that should happen—the closer to the patient, the better—except some PCTs are more capable than others of doing a good job. That presents us with the question how best to manage that. We have taken the view that we need to bring about two changes. First, we need much more central involvement by the Department of Health in ensuring that PCTs have minimum standards, through a model contract. All PCTs must ensure that providers comply with that contract. Secondly, we need to get local GPs more involved—that does not mean giving responsibility back—so that they can monitor the quality of the out-of-hours service that is being delivered.

The hon. Gentleman set out the concerns expressed in the report by Dr. Colin-Thomé and Professor Field. I remind him that that report was commissioned not after the coroner’s report last week, but on 23 September last year. Indeed, discussions on it took place with those involved before that time, because we knew that we needed to ensure that we improved out-of-hours care. I want to have further discussions with the doctors’ organisations on some of the coroner’s recommendations, but in a broad sense, we accept them. We must go through some of the detail with the doctors’ organisations on how that will be done.

When can we put those changes in place? I have said very clearly to officials that I want it done by the end of the year. I want to be sure that we have got the system right by then at least. I was asked how that would be monitored. For the next six months PCTs will be required to have on the agenda of every board meeting, at least once a month, the quality of out-of-hours care and its improvement. That will be monitored by the SHA. Thereafter, PCTs need to take a higher level of responsibility for it.

There are three checks on foreign doctors from the EEA. First, the GMC checks their medical qualifications. Secondly, since 2004 the PCT is responsible for checking that they speak English and that nothing is known about them that undermines their medical capability. Thirdly, the employers are responsible for ensuring that the GPs whom they employ not only speak English, but are clinically competent. In some cases it is clear that some PCTs have been a weak link. Some have not always complied with their responsibilities.

The GMC, as was pointed out, has indicated that it would like to do some tests on GPs who do out-of-hours work. It was clear from the Medical Act 1983 that the GMC could not carry out such tests, and it cannot do so under the directive which has been renewed but predates that. In 2004, therefore, the responsibility for ensuring that English was spoken was given to the PCTs. Most of them have delivered on that. Some have not, and that is what we need to change.

The EU law will be reviewed in 2012, so the directive will be reviewed in any event. We must ensure that we examine the detail of that. However, we cannot wait until then. We must put in place safety checks to ensure that this year the lessons of that tragic death are learned and that Mr. Gray did not die in vain.

I, too, thank the Minister for early sight of the statement, and I join in the expressions of sympathy and condolences to the Gray family. The two sons of David Gray, Rory and Stuart, want something positive to come out of their personal tragedy and I hope very much that that is the case. The system ultimately failed their father in allowing Dr. Ubani to practise in this country. Also, it failed the family by failing to ensure that he appeared before a court in the United Kingdom following a police investigation into what happened.

I welcome the report and the recommendations, but why the delay? A report on the performers list was published on the Department’s website last March. That is 11 months ago. Why has it taken this long for the Government to respond to those recommendations?

Will anyone be held to account for the failure of Cornwall PCT? The Minister says that there are legal duties, but they are of no value if nothing happens when they are breached. The House was informed in February 2007 of doctors working in Cornwall with inadequate language skills. That was before Dr. Ubani was registered by Cornwall. What action was taken and who will be held to account for that? Will the Minister consider introducing a criminal offence of PCTs failing to protect patient safety, in order to give some teeth to the regulations?

The greatest safeguard of all would be to prevent a foreign doctor who has inadequate language skills or competence from registering with the GMC. The EU directive allows a regulator to satisfy itself on language, but the Medical Act, as the Minister said, needs amending. Will he consider amending it so that, under existing directives, the GMC could test language skills? Will he agree to lobby for EU reform to protect patients, as the GMC accepts is necessary—first, to allow a test of competence; secondly, to require immediate notification of suspension across Europe; and thirdly, for suspension anywhere to apply everywhere that that doctor is allowed to practise under the freedom of movement of labour?

Does the Minister share the GMC’s view that patients should have a right to safe and good-quality health care across the EU and to safe doctors? If so, these reforms are necessary. Does he agree that training in UK prescribing practice and medicines use—along with an induction and assessment—is essential before a doctor from overseas starts to practise in out-of-hours care? Will those requirements be part of the minimum standards? Does he agree that providing for a minimum number of local GPs on duty, particularly in widely dispersed rural counties, must be part of those minimum standards?

A European arrest warrant was issued in the Dr. Ubani case, but it failed to be effective because of action taken by Germany’s authorities to prosecute him on a minor charge in that country. Co-operation failed in that case, so is the Minister prepared to make representations to the Home Secretary to press for proper co-operation, because the European arrest warrant is of no value if it does not deliver justice in cases such as this?

Certainly I want to ensure that we learn all the lessons from this, but may I deal with the legal issue last? On the performers list, a report was published last March and officials have been consulting on how all that will be put in place. Where regulations need to be put in place, that will be done shortly, but the hon. Gentleman will appreciate that consultation with the relevant organisations needed to occur and that we wish to move forward with this as quickly as we reasonably can.

The hon. Gentleman mentioned holding to account those who have failed in the system, particularly Cornwall primary care trust. The main thing is that we get the system right; that we ensure that those who have failed will no longer be in a situation where failures can take place again; that we are able to examine how the system operates; and that the checks that will protect patients are the ones that occur.

I am not convinced about imposing a criminal offence on a PCT. I am not sure who in the PCT the hon. Gentleman wants this to be imposed on—is it the PCT’s chairman or its chief executives? I am also unsure as to what the penalty would be. We are talking about a criminal conviction, so does he want these people to be sent to prison? Does he want to fine them? Why would he convict them? These people have been employed to do a job, and appropriate disciplinary procedures are in place to deal with them if they do not carry out their job adequately. Boards can be dismissed, and chairmen and chief executives can be removed, so I am still to be convinced about his suggestion that a criminal penalty for these people is the best way of changing behaviour. I am also a bit cautious because we do not want to get into a situation with criminal law, which tends to be absolute in its implications, where people are reluctant to come forward and say that there is a problem in their system that needs addressing because they fear that they might get prosecuted if they were to do so. I am concerned about such implications.

As for the GMC carrying out checks, we were aware in 2004 that there was a problem as a result of the Medical Act 1983. That is why we put in place the requirement on PCTs to ensure that English was spoken—that is something that PCTs must do. There may be ways in which PCTs can work with the GMC to ensure that it can be satisfied that people are not only able to speak English, but competent. However, that needs further discussion between the GMC and the PCTs. In other words, the GMC could act as an agent of the PCTs, but I wish to examine that. My main concern is to ensure that the checks are done—I am less concerned about who does them. I just want them done, because patients deserve safety.

As for ensuring that we have good and competent quality of care across Europe, we can discuss with other countries the need for them to improve the quality of what they do. We obviously have a limited amount of control over that, but what we can do is ensure that we have systems in place that enable people to become aware of information about doctors being disciplined or struck off elsewhere.

As far as minimum training and induction are concerned, I agree that, as part of minimum standards, we need to ensure that they are included in a national contract. There is a legal requirement now, through the national quality regulations, that those standards be applied, but in this particular case, they were not always applied. That is why I want the model contract, so that there is no doubt on that point.

Finally, the hon. Gentleman asked me about extradition and the European arrest warrant. It is indeed the case that an arrest warrant was issued. Unfortunately, it appears that the arrest warrant was issued on 12 March 2009 but the German authorities refused it on 24 March 2009 on the basis that they were already prosecuting the case. I cannot quite work out why they were doing that. It has been suggested that Dr. Ubani asked the German authorities to prosecute him first, so he could avoid extradition on grounds of double jeopardy. The CPS was concerned about that, because it wanted to prosecute him, and contacted Eurojust to query that on 26 March. On 21 April, Dr. Ubani was convicted, received a four-month suspended sentence and made a payment, although it is disputed whether it was a cost or a fine. I hope that that deals with some of the hon. Gentleman’s concerns, but we are concerned to engage further with the German authorities on this issue.

Order. The exchanges between the Front Benches have been wide-ranging and doubtless illuminating, but they have absorbed 32 minutes, which is almost unprecedented. The House will be conscious that after this there is a 10-minute Bill and much important business, including the final day in Committee for the Constitutional Reform and Governance Bill. Sixteen right hon. and hon. Members are seeking to catch my eye. I want to accommodate everyone, but if we are to make progress timeously, we need short questions and short answers.

I welcome my right hon. and learned Friend’s emphasis on national minimum standards to ensure high-quality out-of-hours care for all patients, and the fact that local GPs will be involved in the design of the system. No GP has argued to me that they want to take back full responsibility, but they should be involved in the design. Does my right hon. and learned Friend think that, if new contracts are being let or contracts are being renewed, local GPs should also have a say in who receives those contracts?

I certainly hope that we will be able to engage our local GPs, through the various mechanisms that I mentioned, in looking not only at the rules and the best way in which services can be delivered locally, but at who gets those contracts.

Will the Minister reflect on the very wise words of the first family doctor I had when I was elected, who said that no true general practitioner can know his patient if he does not know him at home as well as in the surgery?

That is a good point to reflect on, but whether it is always possible to deliver in practice is another matter. GPs who are exhausted from working all day and then all night could end up being unsafe GPs.

Can my right hon. and learned Friend tell me how he expects PCTs to ensure that they are co-ordinating the out-of-hours service with other parts of the primary care system, including minor injury units and the ambulance service? The latter is especially vital in rural areas, where needy patients can be many miles from the out-of-hours provider.

My hon. Friend is entirely right. We need to ensure effective co-ordination between the ambulance service and out-of-hours provision to ensure that patients are well served.

In the guidelines and minimum standards recommendations, what is the ratio of doctor to population, and does it take account of geographical areas with a sparse population? Should that not be looked at, because there are parts of the country where people wait a long time? If the Minister is looking to improve standards, surely ensuring adequate coverage in the first place is one of the first things to consider.

Adequate coverage is indeed essential. As far as I am aware, there is not a ratio as such. However, we need to ensure that people do not have to wait a long time and that someone is available to come out within a reasonable time to ensure that the patient gets the necessary care. I have seen some of the statistics, as I am sure the hon. Lady has, on the numbers of patients and out-of-hours doctors. They vary considerably, and I want to engage with doctors’ organisations to ensure that we do not need such a minimum standard.

Does my right hon. and learned Friend accept that the last thing that we need is another group of professionals being forced out of the NHS, as would happen if the Conservative party’s proposals were taken seriously? Will he look at how we handle people with mental health problems and how they engage with the out-of-hours service, because there seems to be some variation across the country? In particular, what responsibilities do the different trusts that engage with such people have in the out-of-hours period?

My hon. Friend is right that there is a difference between the Conservative party and us. As I understand it, the former wants to transfer responsibility to GPs. We take the view, however, that we should not force that responsibility on to GPs, but that they should be more involved in how those services are commissioned.

It certainly is the case that, in some areas, out-of-hours mental health provision needs to be looked at with great care, because its quality is crucial, particularly when those with mental health problems have an episode that needs urgent attention.

As I understand it, the basic fault with Dr. Ubani was that he did not even know the dose of diamorphine, which is why I am so pleased with the emphasis on the greater involvement of local GPs in the commissioning, design and, in some cases, provision of the service. Will the Minister therefore support me in supporting the bid for out-of-hours services in Worcestershire that has the approval of local GPs?

The discussion on the out-of-hours service needs to be with the local primary care trust, but the hon. Gentleman needs to ensure that local GPs and doctors are involved in some of those discussions.

Will the Minister let the GMC test the competency and language abilities of EU doctors before they are registered? Will he put the lives of British patients before EU law?

It is not about EU law; it is about testing and ensuring that the tests are done by the people who are legally responsible for ensuring that GPs speak English before they provide out-of-hours care. That responsibility is currently with the PCTs. My concern is that those requirements be met—they are legal requirements, they ought to be being met now, and PCTs have been told that they must meet them.

Does not the Minister agree that, in the issuing of some contracts during the previous round, PCTs seemed to decide that they wanted to drive down costs above all other considerations for out-of-hours contracts? Some of those deals looked too good to be true, and have turned out to be too good to be true.

Funding for out-of-hours contracts has risen significantly in recent years. The spend by PCTs has risen from £209 million in 2004 to £378 million in 2008-09, so considerable funding has been put into it. However, the hon. Gentleman is right that PCTs have a responsibility above all to safeguard the patient. That is their primary responsibility. A secondary one is to ensure that they do it with value for money.

I regret to report to the House that my constituent Mrs. Marjorie Alderson had a difficult experience with out-of-hours care. I am particularly sad to say that she has since passed away, but her daughters have been active in highlighting the difficulties faced in Norfolk. I would particularly appreciate the Minister’s reassurance that he will look seriously at what it takes to attract doctors to work in the out-of-hours service. I have heard various comments from medical professionals to suggest that that is a particular difficulty.

May I extend my condolences to the family of Marjorie Alderson? As for attracting doctors, the hon. Lady is right: some parts of the country seem to be experiencing difficulties, whereas others are not. That is one of the points to come out of the report by Dr. Colin-Thomé and Professor Field, as well as my discussions with those in some out-of-hours services. I am not entirely clear, in that the issue does not seem to be funding or how much the GPs are paid. Rather, there seems to be a reluctance among GPs in some areas to get involved in out-of-hours services, whereas in other areas they are anxious to get involved. It is important to get to the bottom of that and identify exactly why the problem that the hon. Lady has identified is occurring.

Has the Minister done any analysis of the disparities in costs between different out-of-hours contracts? Is he aware of the disparities between the costs that the Ministry of Defence pays? In one case it pays £20,000 a year for 17,000 soldiers, but in another it pays £278,000 for 20,000 soldiers, which is considerably more. Why should the Ministry of Defence pay for out-of-hours care for its soldiers when soldiers pay tax and should get that service on the national health service anyway?

The Ministry of Defence wants to ensure that particular facilities are available to it. Therefore, some want to fund those facilities themselves. That is, in a sense, a matter for the MOD. As for variations in cost between PCTs, that is an issue that we need to look into with care. I am satisfied that the broad run of PCTs is trying to get both value for money and a good quality of service, and that those PCTs are indeed delivering that. However, one or two PCTs are looking more at cost than at patient safety.

To bring the Minister back to rural areas, is not another factor the availability and accessibility of accident and emergency units? My constituency covers 900 square miles. There is not a single A and E unit in my constituency, nor is a single out-of-hours doctor based there. Do we not need better cover than the four cars that currently provide for the whole of Somerset? Should there not be an assumption that community hospitals will have at least an evening treatment centre, with a doctor available to look after people out of hours?

The hon. Gentleman has raised a number of issues. As for provision in his local area, the issue that we have faced over a number of decades is that power is being devolved. That means that we are very reliant on local PCTs to make local decisions. We can have minimum standards, but we cannot rewrite the entire framework in which PCTs operate—in other words, take away their flexibility to respond to local need. Getting the balance right is quite tricky, but it is important that we work on getting it precisely right.

I should declare an interest: my brother works for the out-of-hours service in North Yorkshire, although we have not discussed the issue. Is not the heart of the matter the fact that only in the UK has the system of family doctors and GP services developed to the extent that it has developed here? No one else is in quite the same position—or, possibly, no one else is better qualified—to judge that the PCT is not qualified to judge whether a GP here, or a medically qualified doctor in Germany or another EEA country, is fit to operate our out-of-hours service. I am not sure that what the Minister has told the House today fundamentally addresses that point.

We need to ensure that doctors are properly qualified. It is a requirement that PCTs should not allow anything that might mean that the GPs they employ are not capable of being GPs. Therefore, we need to ensure that we have proper induction and proper training. We must ensure that GPs are capable of doing the work that they are employed to do. It is not so much a matter of the EU; rather, it is a matter of ensuring that if someone comes into an area, the PCT and the providers have done the checks and ensured that that GP knows what they are doing and are safe.

Why is the Minister so opposed to specifying a minimum ratio of medical personnel to population? Surely there is a level that is clinically unsafe, and we ought to specify it.

This is dependent on a number of factors, including the size of the area, the amount of time it takes to get to people, and the level of demand in the area. That is why the PCTs have to ensure that proper medical issues are looked at, and that the level of cover and provision is adequate to ensure that people get the quality of service that they need. Checks should be being done now, but I still want to consider whether we need a national minimum standard. The requirements for the ratios to be right from a medical point of view are already there.

Is the Minister satisfied that the greater use of our generally excellent ambulance service in some areas is not part of the problem?

I do not think that it is. There is a lot of increase in demand on the ambulance service, and we are working through some of the issues relating to that increase. Much of it, however, is occurring during the daytime, rather than at night. I would need to get more research done before I could answer in depth the hon. Gentleman’s question on whether that relates directly to the issues around the out-of-hours service.

The campaigning social issues journalist Aline Nassif revealed in the Croydon Advertiser last Friday that our population of 370,000 is covered by only three GPs between midnight and 8 am. Does the Minister really feel that that is clinically safe?

Decisions on clinical safety should be made by people who are clinically qualified, rather than by me as a Minister. It is a requirement for the PCT to ensure that there is appropriate clinical supervision of the provision, that there is an appropriate number of GPs for the population, and that the cover is safe. That is a legal requirement, and the PCTs should be doing that.