HC Deb 03 March 2004 vol 418 cc303-11WH 3.30 pm
Sandra Gidley (Romsey) (LD)

I welcome the opportunity to highlight the important issue of out-of hours medical services in my locality, and I shall begin by setting the scene.

As MPs, we all receive complaints from time to time, and that is par for the course, because life simply ain't perfect. However, alarm bells ring when we suddenly receive a cluster of complaints about a service that has hitherto ticked over in the background without coming to our attention. Alarm bells certainly rang when I received complaints about the out-of-hours medical services, and it rapidly became clear that all was not right.

Most of the letters highlighted the service—or lack of it—that patients received when they, tried to obtain the services of a doctor at the weekend and in the evening. As the Minister will be aware, GPs are currently responsible for providing out-of-hours emergency cover, but many, particularly in my area, have opted out of the scheme and paid a deputising service to take over. In my part of Hampshire, that service is provided by an organisation called Primecare.

It might be helpful if I outline some of the problems. First, patients must play a game of telephone hurdles, and the typical scenario is as follows. The patient rings NHS Direct for advice and is told to ring their GP. When they do so, an answerphone service asks them to contact the out-of-hours service—probably Primecare. The patient rings the number, which is for a call centre in Birmingham, and encounters someone called a call taker, who asks them a few questions and refers them to a triage nurse. The nurse then rings back. Indeed, there is a standard governing such things. I do not think that it is being met, and although that is not the main complaint, what if the patient calls from a call box? Not everyone has a phone at home, so ringing patients back is not without its problems. That aside, the patient is then given an indication of how long—be it one hour, two hours or four hours—they might have to wait for a home visit. Some hours later, the doctor might contact them again to see whether they still need a home visit and to ask further questions.

There are, therefore, several phone calls, not all of which would be necessary in a joined-up service. It is immediately apparent that that is not a good use of resources, but I shall return to that later when I discuss how the system is likely to change in July, when primary care trusts take over responsibility for providing out-of-hours services.

In many cases, patients are asked to attend an out-of-hours centre. One constituent was asked to travel from Longparish to Southampton—a journey of approximately three quarters of an hour—and that person told me of a young relative who had had a similar experience. In that case, family members were so concerned that granddad decided to take the child to the minor injuries department in Andover. When they said which surgery they were from, they were told that the child would be unable to see a doctor, because staff were fed up with seeing patients from that surgery.

The practice manager has said that anyone who is concerned about the length of time that Primecare takes to respond should attend accident and emergency and call an ambulance if they are not fit enough to travel by car. Indeed, it is quite a common feature of the correspondence for people to be told, "If you are concerned, call an ambulance." Sometimes, Primecare staff deliver that advice. In that respect, the Minister might not be aware of an Adjournment debate that I secured on the response times of the Hampshire ambulance service. The service is now heading in the right direction and is just starting to hit its targets, so it can do without unnecessary pressures from another part of the health service. It is easy to see that an extra burden will be placed on the system if people are regularly advised to call an ambulance. If patients are being made to wait for too long, they will be tempted to call an ambulance. I have spoken to paramedics who have also mentioned occasions when deputising services have asked paramedics to visit and assess on their behalf, and occasions when inappropriate requests for an ambulance have been made, some when the medic has not even seen the patient face to face.

I am also aware of an occasion when a call from a GP was rerouted to a deputising service. That service did not have the GP on its list and so refused to provide a response. What other option does a sick person have under those circumstances than to call for an ambulance? This clearly has a knock-on effect on patient emergency care, and I ask the Minister to investigate this for himself.

There are others who are reluctant to call out an ambulance under any circumstances. Another of my constituents had a stomach ache, went to the NHS Direct website and was quite alarmed to be given the advice that he should ring 999 for an ambulance. He thought, "I only have a stomach ache. It seems a hit extreme. I will just call the doctor. I do not want to call out an ambulance unnecessarily." He contacted Primecare. The triage occurred, but the patient, despite having gone through the NHS Direct protocol and come up with a 999 response, was advised to go to a walk-in surgery, as there might be a long wait to see a doctor. My constituent lived alone, some distance from the surgery, and there was no one he felt able to ask for a lift. He decided to wait. He had originally rung the out-of-hours service at 2.30 in the afternoon and received a telephone call at 8 pm advising him that he would probably have to wait a further three hours. At half past 11, some nine hours after the initial call, a doctor arrived and immediately called an ambulance.

I could easily spend the remaining time outlining further stories, but I will leave it at that, apart from reinforcing the point that most of the complaints have been about the protracted nature of the process, the pressure to travel to an out-of-hours centre when unwell, and the length of time it has taken to secure a home visit and for a health professional to arrive. I have met representatives from Primecare and there is some focus on trying to improve the service being provided, but it is still not good enough. There was a Radio Solent phone-in this morning and the lines were red hot with people ringing in from all over the area with similar experiences.

What is of more concern to me at the moment is that the new GP contract means that the primary care trust will be taking over responsibility for out-of-hours medical services. I am beginning to wonder, having done some research, whether this is an opportunity that is likely to be squandered. I have been told that the four primary care trusts in the area—Southampton City, Eastleigh and Test Valley South, Mid-Hampshire and New Forest—are liaising on the provision of a new service. I wrote to the primary care trusts that serve my constituency in December last year. I also wrote to the ambulance trust.

Most responses try to provide a bland reassurance, but there were some worrying responses tucked away. For example, Chris Evenett, chief executive of Mid-Hampshire PCT, said: As part of this development work, being co-ordinated across three PCTs in mid and west Hampshire, we are assessing demand. It is fair to say that there has not been a robust activity monitoring of out of hours provision in the past and therefore we have to develop estimates based on best available information. John Richards of Eastleigh and Test Valley South PCT seemed to have slightly more information about what was going on in his particular primary care trust. He told me that there were approximately 14,000 calls each year to the out-of-hours service, 40 per cent. of which required some sort of face-to-face consultation. He went on to describe how he thought the service might develop. He said: The plan is comprehensive and includes call centre facilities, communications hub, primary care centres, transport and visiting … Initially the service will be GP-led but, over time, we hope to increase the involvement of nurses, paramedics and others to ensure that patients are seen by the most appropriate health care professional. Sounds okay.

The response from Brian Skinner of Southampton City PCT was quite interesting, because he stated: As a primary care trust we have seen an increase in the visit rate from 15% of our total out of hours activity to 25%in the last two years. It is too early to say at this stage whether the effects of the changes we are currently making to the service are reducing the demand for visits. It should be noted that an out of hours GP can carry out the equivalent of 1.5 visits per hour as opposed to a GP or nurse in a primary care centre who can see seven patients per hour. He went on to mention that there had been a number of new initiatives, such as walk-in centres and NHS Direct, which had to be monitored to assess the impact on the demand for services.

The letter of 19 January from Claire Severgnini, the chief executive of Hampshire Ambulance Service NHS trust, was of the greatest concern. She says: The ambulance service has seen an increase in demand as a consequence of the changes and particularly to poor systems Primecare have in place. More positively, Claire Severgnini mentioned a new initiative called "see and treat", which is being piloted. She says: increasingly we could provide care in the community and minimise the number of patients being brought into already busy A & E Departments. The obvious question is where we go from here. It might be useful to refer to the Carson standards, which were produced in an attempt to provide a minimum standard of service for out-of-hours care. They are what local service providers should be taking into account when developing new services, and to which they should aspire.

In March 2000, Dr. David Carson produced a report, which states: the purpose of out-of hours services in primary care …to meet those urgent patient needs that cannot safely be deferred until the patients own GP practice is next open. It also recommended that All patients should have access to the same high quality, out of hours services, regardless of the part of the country in which they live. I am not sure that that is happening.

Recommendation 1 states: A new model of integrated out of hours provision should be accessed by patients via a single telephone call, routed in the first place through NHS Direct, passed where necessary to the appropriate providers of out of hours services in that locality. I have already described the problems. The verdict is that that has failed.

Recommendation 3 states: Sufficient primary care centres should be provided to enable out of hours providers to meet the Quality Standards set out in the review. Current provision is very patchy, which may explain the difference in the figures for Test Valley and for Southampton, which has better provision. People do not want to travel a great distance when they are ill, which is overlooked. My constituents in particular will miss out, because, I believe, none of the planned centres will be based in my constituency.

More worryingly, I have been told that there are differences of opinion between the four PCTs, even though they are supposed to be liaising with each other to provide a service. Eastleigh, Test Valley South and Mid-Hampshire PCTs want to direct as many people as possible to the Winchester and Southampton PCTs. However, Southampton City PCT, where the Southampton hospital is based, does not want the service to be based in the hospital, but prefers to direct people to the two walk-in centres. New Forest PCT wants to use separate locations.

What hope do we have for a decent service by July if the PCTs cannot even agree where they want the service to be based? I strongly believe that consideration should be given to basing t service at Romsey hospital, which was used by GPs when they provided the service. The verdict is "Fail". If a he Minister is inclined to say "Pass", will he say what journey time he believes is reasonable for anyone wanting or having to access these services?

Recommendation 9 states: A fully integrated out of hours service should be planned by the PCT/G in each locality, bringing together all appropriate service providers. There is total lack of co-ordination in the provision of community-based minor injuries management. There are walk-in centres, minor injury units, community care centres and proposed diagnostic and treatment centres, all of which have little or no night provision. I have described the series of telephone hurdles that one encounters before one can access the service.

It would be sensilb1e to co-ordinate more efficiently the expertise of NHS Direct, the out-of-hours providers, the emergency services and the PCTs. The lack of co- ordination between PCTs is particularly worrying. I have learnt that some PCTs intend to fill the void with paramedics, while others intend to use community nurses. I do not have a problem with that, but there has been no work force planning exercise, and no thought has been given to consistency of training and standards. Again, the verdict is "Fail".

Recommendation 19 states: Other than in exceptional circumstances, patients should he able to receive the medication at the same time and in the same place as the out of hours consultation". I am not sure that that happens at the moment, as I have received a number of letters stating that, when the local supermarkets that have pharmacies shut, which on a Sunday happens at 4 o'clock, it is almost impossible to obtain medication. The demise of the neighbourhood chemist living above the shop has added to the crisis. My area local pharmaceutical committee has developed a community pharmacy on-call scheme, which works with NHS Direct. That is clearly to be welcomed, but it does not meet the provision in recommendation 19 of the Carson standards. Verdict: "Fail".

Recommendation 22 states: The fully integrated model of out of hours provision set out in the Review should be achieved by all GPs and out of hours providers by 2004". I will concede that when the recommendations were made, the change in the GP contract was probably but a twinkle in a Minister's eye. Even when allowances for that are made, I can only despair at how things seem to be shaping up. There is an inadequate grip on what is needed. Nobody seems to know who will be able to travel and who will require a home visit, and there seems to be too little forward planning about training the necessary staff. The guidance of the strategic health authority seems to be absent.

We have a golden opportunity to provide a service with well-staffed local centres, augmented by a mobile fleet of health professionals including nurses and paramedics. Access to the service would be by a single phone call. The service provider should be able to coordinate that with NHS Direct and the ambulance service. Future changes should be communicated to all residents so that they are aware of what the most appropriate course of action is and what they can realistically expect if they are ill in the evenings or at weekends.

I finish by returning to Primecare, where I started. It admits that it experienced a large number of problems when it moved its call-handling service from the Southampton area to the centralised area in Birmingham. That experience should not be allowed to repeat itself. We must learn from the mistakes of the past. Any new systems will have teething problems. In cases dealing with sick people who need an emergency response, we must make sure that the teething problems are not serious and do not cause worse illness, or even death.

3.47 pm
The Parliamentary Under-Secretary of State for Health (Dr. Stephen Ladyman)

I congratulate the hon. Member for Romsey (Sandra Gidley) on securing the debate. I know that it will be of great importance to her constituents. I also congratulate the staff of the national health service across the whole of Hampshire on their work. I thank them for their efforts to deliver high-quality services. I know that they are dedicated to producing good services for everyone and they deserve our admiration. No doubt they will take the hon. Lady's concerns on board and have a constructive approach in doing what they can to address them.

All hon. Members rightly attach great importance to developments in the national health service in their constituencies and in the ability of local people to access high-quality health services as and when they need them. The need for access is particularly important in the evening and at the weekend, when many people feel isolated from convenient local health services. That is why, in March 2000, the Department of Health commissioned an independent review of GP out-of-hours services. The report that followed, "Raising Standards for Patients: New Partnerships in Out-of-Hours Care", also known as the Carson report, resulted in the Government endorsing the view that a new, modern and integrated out-of-hours service was a crucial component in delivering safe and reliable health care. That new model of service is set to ensure that a high-quality out-of-hours service is available to everyone, irrespective of where they live and who provides it.

We have put in place new quality standards and are working towards close integration between NHS Direct and GP out-of-hours services. By 2004, a single phone call to NHS Direct will be a one-stop gateway to out-of-hours health care. Calls will be passed on, if necessary, to the appropriate GP co-operative or deputising service. I was pleased to hear that NHS Direct gave the correct advice to the hon. Lady's constituent immediately. I would encourage all constituents to act on, and not second-guess, the advice that it gives because it is starting to produce advice to a very high standard.

GPs have a statutory responsibility to provide out-of-hours care before 8 am and after 6.30 pm and at weekends and bank holidays. The majority of GPs, as is the case in the hon. Lady's constituency, delegate that responsibility either to a GP co-operative or to a commercial service, so patients do not usually see their own GP for an out-of-hours consultation.

From April 2004, subject to PCT approval, GPs can choose to hand over responsibility for out-of-hours care of their patients to their local PCT. PCTs will have a legal responsibility to ensure that patients are well cared for out of hours and continue to be offered safe, fast and convenient care, delivered to nationally set quality standards. Strategic health authorities will performance-manage PCTs in the transition period. We are in discussions with SHAs to ensure the robustness and sustainability of PCT plans. I will ensure that the SHA serving the hon. Lady's constituency is sent a copy of Hansard so that its staff can read her comments. However, as her speech raised many matters for her local SHA and PCT, I encourage her to engage with them and make known her concerns so that they can act on them.

The opt-out was a key factor in our being able to win support for the contract among doctors. It enables GPs to opt out to improve their working lives and it will have a positive impact on GP recruitment and retention and increase capacity in primary care, which will be important to our constituents. It will also provide PCTs with a greater opportunity to commission an integrated service that brings together out-of-hours services with emergency care, NHS Direct and ambulance services, and covers the whole range of unscheduled care. The hon. Lady is right to identify it as an opportunity to get out-of-hours services right in her constituency.

The vast majority of practices in the hon. Lady's constituency have said that they intend to opt out of their responsibility for their patients' care out of hours, opting instead for transferring that to the PCT. It will contract a commercial provider that is able to offer a single point of access and a thoroughly integrated service to ensure that care is offered to the patient on a case-by-case basis by the most appropriate health care professional.

Sandra Gidley

I understand that the planned service will not provide a single point of access using NHS Direct. If people ring NHS Direct they will be referred directly, which is a step in the right direction, but they will not be encouraged to ring it in the first instance. I do not know whether that is a capacity problem or whether sufficient thought has not been given to it.

Dr. Ladyman

I cannot tell the hon. Lady exactly why she has been given that information. I can only tell her that it is our ultimate intention to make the NHS a one-stop shop. In planning the out-of-hours service with the commercial provider, the PCT must ensure that it is working to achieve those objectives. Perhaps there are local reasons why the PCT does not think that appropriate in her constituency, and it must meet her, as constituency MP, to discuss that further. This is a matter for local planning and consultation.

In many places, elements of the out-of-hours services are already configured in the way that I described, with existing out-of-hours providers typically covering areas encompassing more than one PCT. In those circumstances, it is easy to understand why co-operation and co-ordination among PCTs is essential and why certain economies of scale have led to the development of a cost-effective and more comprehensive and integrated service.

PCTs should build on the strengths of existing providers and work closely with them and other PCTs to plan their out-of-hours provision. SHAs will support them in that process. The aim is to introduce out-of-hours services that provide care that meets the quality standards and provides a basis for integrated networks of unscheduled care, including out-of-hours care. The PCTs, supported by SHAs, should develop commissioning solutions that fit local circumstances and meet the priorities.

We now have 34 exemplar sites that test current models of integration and partnership working. They provide single-call access to out-of-hours primary care services through NHS Direct and cover 10 million people. If the hon. Lady has been told that that is not an option in her area, she should take the matter up with her PCT and suggest that it obtain guidance from the exemplar sites to determine what might be achieved.

Additional resources of £110 million over three years from 2003–04 have been announced to help fund the PCT with the provision of out-of-hours services. A further £28 million was announced in November last year, to be focused on those PCTs facing the biggest challenge in developing their out-of-hours services.

PCTs in Hampshire have been working collaboratively with stakeholders, including the local medical committees, to develop out-of-hours services and to ensure that patients continue to gain access to health services whenever and wherever required. I understand that four PCTs in west Hampshire, a cluster that covers the hon. Lady's constituency, have joined together to develop effective out-of-hours arrangements for their population. I also understand that that project is being co-ordinated by a steering group with clinical representation from the four organisations, together with further representation from the local medical committee and NHS Direct. If she thinks that that group has not consulted her on the matter in some way, she may wish to contact her PCT and insist on a discussion with it.

From July 2004, the four PCTs in west Hampshire will contract with Primecare for out-of-hours services for one year. That will involve the provision of call handling and triage for local providers. In addition, locally trained staff will assist with priority calls, triaging calls from a central position in Hampshire. Decisions will be taken laterally about how out-of-hours services are provided, depending on the development of local services. I am confident that that will build on the current out-of-hours service for the residents of Hampshire.

I am aware that there have been some challenges and problems associate d with the out-of-hours service provided for the west Hampshire population by Primecare. The hon. Lady expressed those concerns eloquently. The concerns and challenges have, in the main, related to the quality of the call-handling service and the delays encountered by patients attended by on-call doctors. The majority of those complaints relate not to clinical performance but to delays in response times.

PCTs must ensure that the out-of-hours services that they commission or provide meet the national quality standards set out in regulations, to which all significant professional bodies are signed up. All organised out-of-hours providers must meet those standards in the transitional period between 1 April and 31 December and all providers will have to meet the revised quality standards, which are under review by an expert group.

It is important that the momentum for improvement is not lost. I understand, for example, that the PCTs are in continuous dialogue with Primecare to explore concerns and to identify opportunities for improvement, which to date include improving Primecare call handlers' local knowledge, enabling them to manage calls quickly and safely, and establishing a group dedicated to the assessment of performance and to ensuring service quality for out-of-hours services.

I understand that work is also under way to integrate primary care out-of-hours services with out-of-hours arrangements in mental health services, social services and transportation I am assured that the Hampshire and Isle of Wight strategic health authority is taking a strong role to ensure that out-of-hours services are developed and delivered appropriately for their area. As well as having a performance role, I understand that the SHA is securing the support of national advisers as well as facilitating joint work across the county on issues such as the work force, education and training. There is significant evidence to suggest that the Hampshire and Isle of Wight health system has identified the matter as their priority for development. I understand that the health community has invested an additional £3 million.

Mr. Deputy Speaker (Mr. Frank Cook)

In anticipation of the Division, that is about to be called, and to avoid unnecessary disruption of the opening comments of the next speaker, I suspend the sitting for 15 minutes.

4 pm

Sitting suspended for a Division in the House.