§ 4.5 p.m.
§ Mr. Hugh Jenkins (Putney)
My present interest in the deputising services began with a letter from a Wandsworth borough councillor, Mrs. Jean Nicholas, who passed on a complaint from a constituent whose mother was suddenly taken seriously ill. The complaint said that she had to wait five and a half hours before a doctor arrived. The councillor passed the complaint on to the Executive Council and sent me a copy of her letter in which she described the harrowing experience of my constituent.
This was followed by a letter from the constituent who, in addition to filling in the details, told me of other cases of which she knew. At the same time she said that she was not complaining of any person in particular but of the system which in her experience worked very badly. I want to emphasise the point that my constituent is particularly anxious that no blame should be cast or appear to be cast upon her doctor with whom she is quite satisfied. She felt that more than once in her experience the deputising service had let her and the doctor down, as well as the entire health service. That is why I am not naming my constituent.
897 The Under-Secretary is aware of the name and the circumstances but it is right not to disclose the name in open debate because in doing so it might seem that I am throwing some form of complaint on the doctor, which is far from being my purpose.
I asked the Secretary of State to consider the general question. Meanwhile the clerk of the executive council replied to the councillor's letter saying, in effect, that there was no reason to suppose that there was any general problem and promising to look into the case if full details were supplied. I received a letter from the Under-Secretary explaining the provisions of the Act and making the point that as long as the arrangement was approved by the executive council it was for each doctor to make his own provisions for time off duty. It was for the executive council to be satisfied that the arrangements were working efficiently. It had no direct control over the deputising services.
I asked one or two Questions without getting much of an answer. I am sorry about that, because, perhaps unusually, the Questions were put down as part of a genuine search for information. But the Minister had no information and saw no reason to conduct an inquiry to obtain it. He apparently preferred not to know.
I also received a letter from a member of an executive council who felt that there was real cause for complaint and that the councils should be given more powers to control the commercial deputising services which he described as "a racket". He felt that some general practitioners were abusing the system and that more should be known of the extent of this abuse. He also thought that many patients were being neglected but were unwilling to complain because of an anxiety not to get on the wrong side of doctors, either in general or in particular. My own experience lends some colour to that belief.
It has been reported that some doctors on relief service sandwich 12-hour night shifts between regular day duties in a hospital. An inherent drawback of the system is that a deputising doctor can seldom have access to a patient's notes. If it is the case that some doctors are doubling-up deputising duties with hospital duties, the service must be less efficient than could be desired. I have 898 read articles in the medical Press which seemed to gloss over some rather serious allegations, some of them allegations of delay resulting in death. The allegations are glossed over with rather faint praise for the system. The suggestion seems to be that deputising services are good for doctors and must therefore be good for the National Health Service and the patients. That is not necessarily so, as was pointed out in respect of General Motors in the United States. It was said that what was good for General Motors was good for the United States, but "that ain't necessarily so", and it is not necessarily so in this instance.
Doubts have been expressed in another place, and I am not the first hon. Member to ask for an inquiry. My hon. Friend the Member for Batley and Morley (Sir A. Broughton)—himself a doctor— has also expressed concern. I have come to the conclusion that the matter should not be allowed to rest where it is. It seems probable that the deputising services would not emerge with an entirely clean bill of health from an inquiry. If that is probable, or even if it is possible, the sooner an inquiry takes place the better.
To what extent are executive councils carrying out the duties laid on them by the National Health Service Regulations 1972? They came into effect on 1st January 1973 and they consolidate previous regulations. They appear to me to spell out the responsibilities of executive councils more clearly, and, although it is apparently believed that they make no change, they seem to me to make some important changes of emphasis. For example, in paragraph 19(1) of Part 1 of Schedule 1 of the regulations, under the heading ofAbsences, deputies, assistants and partners ",councils are, for the first time as far as I can see, given wide powers in relation to the deputising services.
To what extent are those powers recognised? Is it generally realised that apparently councils have greater powers than they used to have? To what extent are they utilising them? I cannot be absolutely sure about these matters because the regulations have not been debated in the House. At no time have we had an opportunity to discover precisely the division of responsibility 899 between the executive council, the doctor and the deputy.
The more one looks into this matter, the more obvious it is that it is high time for a full inquiry. I emphasise that no criticism is levelled against doctors. I believe that the requirement placed on doctors virtually to give their whole time to the service is impossible of fulfilment. Provision must be made for them to have reasonable rest, relaxation and holidays. We should not place the full burden of that requirement on the doctor. The duties of the executive councils should be spelled out more precisely.
In any event, we should know—and I am sure we do not know—whether the nature of the deputising service has been changing during the last few years. It is time that it was considered, so that we might be assured about it. Doctors will generally support such a proposal. The views expressed in the letters which I have received since this matter became public have been about 50–50. Seldom has anyone brought an attitude of impartial appraisal to bear on the question. Doctors have written to me and said, on the one hand, that the service is wonderful, or perfect, and, on the other, that it is absolutely disastrous and ought to be investigated, or done away with and replaced by something quite different. There are sharp differences of opinion among doctors themselves whether this service is or is not working well.
For this reason it seems to me that we should have an inquiry. Is it not the case that when a doctor is in doubt he advises his patient to have an examination, just to make sure? On this service, to, we should have an examination, just to make sure.
§ 4.15 p.m.
§ Mr. Laurie Pavitt (Willesden, West)
I know of only one death because of the deputising service—that of a young man early in his married life. I am grateful to my hon. Friend the Member for Putney (Mr. Hugh Jenkins) for enabling me to take part in the debate to raise three points which I think are important.
I support the Ministry's being far more active, not only in the changes that have taken place in the last few years but in the last few months, but I draw to the 900 Under-Secretary's attention the new phenomenon of takeover bids. For example, Birmingham and Liverpool locums have been taken over by Allied Investments. In view of the large numbers of doctors who contract out for a good deal of their time it is time for the Ministry to think not only in terms of an inquiry but of putting the whole thing under the National Health Service.
In spite of the regulations, to the best of my knowledge and belief there has been no circular since November 1966 on this matter, and as a result the amount of actual surveillance by executive councils is negligible. As the hon. Gentleman informed me in answer to a question quite recently, there is no need, when a deputising service changes hands, for it to be re-registered or looked at anew, and the same arrangements will continue whether or not a takeover bid has gone on.
What has gone wrong with the hon. Gentleman's negotiating arrangements on doctors' pay? What happens, as he knows, is that out of the general practitioner's £7,200 gross, £720 has been allowed by the review body, and passed by the Department, in terms of hours of contracted-out service. The average amount paid for a doctor who contracts out can be between £200 and £250. It seems pretty good trade union bargaining to get £720 out of the taxpayer, pay a deputising service about £200 to £250, and get a clear profit of £500. I am sure that Mr. Vic Feather would like some such deputising arrangement.
I ask the Under-Secretary not only to deal with the wider range of this matter, but, because this service has been under commercial hands far too long, to consider tightening up the regulations and to replace them with a far more efficient family doctor service, rather than merely locums coming from junior hospital doctors already overworked.
§ 4.18 p.m.
§ The Under-Secretary of State for Health and Social Security (Mr. Michael Alison)
I am grateful to the hon. Member for Putney (Mr. Hugh Jenkins) for drawing attention to the question of doctors' deputising services, and I am glad that, as sometimes happens on these occasions, a familiar contributor to these debates, the hon. Member for Willesden, West (Mr. Pavitt) has also made some 901 pertinent points. I appreciate the temperate and constructive way in which both hon. Members have tackled the subject, lifting it very much above the level of personalities to the level of questions of policy, about which I shall try to give satisfactory answers.
Organised deputising services, as distinct from the deputising arrangements made direct between individual doctors, are now of quite long standing. The first London service was established in 1955 and the first provincial services in 1960, but in recent years the growth in the number of services has accelerated, and there are now 28 in active operation in the United Kingdom as a whole—24 in England—with three others about to start operation. It is, therefore, only right that we should take a careful look at the situation and make sure that these developments are consistent with the maintenance of the best possible service to the patient.
I will turn in a moment to the arrangements for controlling the use of deputising services by family doctors. But first it is worth reminding ourselves that the rapid growth to which I have referred in these deputising services would not have taken place unless they were widely recognised to have positive advantages.
If family doctors are to give the best service to patients it must be possible for them to have adequate time for rest and relaxation and also for post-graduate studies—a point which I am sure the hon. Member for Willesden, West would admit is valid. Moreover, apart from the indirect benefit to patients of the use of the deputising services, well-organised and properly-manned deputising services can often deal more efficiently and expeditiously with night and weekend calls than could the individual doctor, and in that way they directly benefit the patient.
The use of deputising services by family doctors in the National Health Service is subject to fairly close control. Since 1963, such doctors have been required by their terms of service to obtain the consent of their local executive council before entering into arrangements with a deputising service.
The executive council may impose such conditions on a doctor's use of a deputising service as it considers necessary. The council may at any time, in consultation 902 with the local medical committee, review any consent already given and it is required in any event to carry out such reviews periodically. I think that that answers the hon. Member's point about whether executive councils were likely regularly to review the arrangements. They are beholden to do so.
§ Mr. Alison
I would not accept that allegation without much more substantiation, but I will come on to a feature which I hope may allay the hon. Member's fears, at any rate temporarily. This is that, while executive councils have no direct control of the deputising services themselves, they are in a position, by granting or withholding consent, to regulate the extent to which doctors make use of them. Also, doctors themselves may cease to make use of a service if they have any reason to believe that it is unsatisfactory. We should not overlook the inherent sense of responsibility of general practitioners.
The Department gave general advice to executive councils in 1962 and 1966 about the matters to be borne in mind when considering applications to use a deputising service or reviewing the consents already given. In the ensuing years, this feature has been reinforced by the executive councils' own practical experience. The matters to be borne in mind are broadly of two sorts—the need to ensure on the one hand that the deputising service is efficiently run and on the other that the extent to which a doctor may make use of it is not inconsistent with his terms of service and his obligations under those terms.
Under the first heading come such matters as the number of duty doctors employed, the range and nature of their experience and the extent of any other commitments which they may have, which I think the hon. Member for Willesden, West particularly will want to know, the adequacy and accessibility of medical supervision and advice, for instance, for assessing the priority of calls and the arrangements, for example through the telephone service and radio controlled cars, for transmitting calls speedily.
The extent of the use which doctors may be allowed to make of deputising 903 services is, rightly, largely within the discretion of the executive council, but it has been made clear to those councils that consent should not be given to any standing arrangement under which a deputising service would care for the practitioner's patients every night and at weekends.
§ Mr. Hugh Jenkins
Would the hon. Gentleman not agree that it is desirable that these inquiries, which are made individually, should be public and that, if it is possible to put anxieties at rest, this should be done?
§ Mr. Alison
Routine enquiries to ensure that something which must be held to be likely to be functioning smoothly is indeed functioning smoothly should not necessarily be the subject of public statements or inquiries, except perhaps in individual cases or on the odd occasion when something goes wrong.
We have also suggested that regular meetings between representatives of the deputising services, the executive council and the local medical committee would be helpful in maintaining standards. This suggestion has been widely adopted.
Whilst we are in no way complacent about the possible hazards inherent in this situation, our experience so far has been that the number of complaints about deputising services has been very small in proportion to the number of calls they answer. Such criticisms as there have been—the hon. Member for Putney has mentioned one case and has made a discreet general observation—have been directed mainly to delay. This is so in the particular case which the hon. Gentleman mentioned.
Sometimes it is simply the time taken for the doctor to arrive in response to a call. Deputising services commonly maintain contact between mobile duty doctors and a central headquarters by means of a radio link with a control room, so that the duty doctor does not in practice have to return to base before making a fresh call. Urgent calls arc given priority, being assessed by trained and qualified staff at the control point, where professional supervision is maintained. The time which may elapse before a call is answered depends largely on the demands on the service at the particular 904 time, just as would be the case with an individual doctor responding in the traditional way from his own surgery or practice.
In some cases delay in contacting a service has occurred because the caller has been unfamiliar with what we know as the telephone interception system, and before the operator has been able to intercept the call the caller has rung off thinking that the doctor is out and has made no arrangements for deputising. This particular difficulty is, I understand, likely to diminish greatly in the next year or two as the interception system is superseded by the automatic transfer of calls.
It is also sometimes suggested that the use of deputising services is not conducive to continuity of care of the patient, particularly as the deputising doctor will not normally have access to the patient's medical record. The hon. Gentleman made that point. This is a difficulty, however, which can apply to deputising arrangements among the partners of a large practice no less than to an outside deputising service. For the sort of emergencies that arise at night and at weekends, the important thing is to have quick attention from a good fully trained doctor, whether or not he knows the patient's medical history.
The hon. Gentleman has urged the need for further inquiry into the working of the deputising services. I ought first to mention that, apart from the continuing arrangements for monitoring the use of these services in each area concerned, some local areas have recently been the subject of special study. I mention in particular the survey of the British Medical Association deputising service in Sheffield in 1970, which was conducted by the Medical Care Research Unit of the University of Sheffield, with my Department's support, and reported in the British Medical Journal of 10th March last.
In the last few days I have also received a report by the Dewsbury Executive Council on a special inquiry which it has conducted into the deputising service operating in its area. Both these reports give favourable accounts of the deputising services concerned, even if some questions remain unanswered.
However, I entirely accept that, without in any way prejudicing the day-to-day 905 responsibilities of executive councils in this field, the time is ripe for us to have another look at the general principles governing the use of these services and to see whether the advice we have given needs to be modified in any way. The hon. Gentleman said that that was in 1966, and we are now in 1973.
In parenthesis, perhaps I should say that the hon. Gentleman complained that the latest set of regulations was not debated in the House. There were no changes of substance, but the regulations were, by definition, subject to the negative procedure. No hon. Member decided that they should be prayed against. That is the simple explanation of why no debate took place. A debate could have taken place.
I was saying that the time was ripe to consider whether we should have another look at the general principles. I am glad to be able to tell the hon. Gentleman and his hon. Friend the Member for Willesden, West that such a review is already under way. As they may know, a joint working party under the chairmanship of the Department's Chief Medical Officer, with members nominated by the General Medical Services Committee, the Royal College of General Practitioners and the Department, was recently set up to look at some aspects of the organisation of general medical practice. One of the first matters to which the working party has been giving its attention is this very question 906 of deputising services, and it is receiving evidence on the subject from representatives of the executive councils, the doctors using the services and the services themselves. I understand that it will also consider views expressed on behalf of patients.
In addition, the working party has available to it the reports of recent studies, such as those I have mentioned. This will, I am sure, provide the sort of comprehensive review which the hon. Gentleman has been seeking. In the light of the working party's report, which we hope to have by the end of the year, we shall, of course, consider whether we need to add to or modify in any way the previous advice we have given to executive councils on the subject.
I hope that in the light of the account that I have given of what is in the past, in the present and in prospect for the future, the hon. Gentleman will be a little more reassured than when he was first alerted to this question through a particular constituency case.
I will, with permission, consider separately the point about remuneration raised by the hon. Member for Willesden, West, since it is slightly out of the direct ambit of the debate, and drop him a line about it in due course.
§ Question put and agreed to.
§ Adjourned accordingly at twenty-eight minutes to Five o'clock.