The Out of Hours Care Report

The last week has been very busy, both politically at a national level and locally in my surgery, but most of my time has however been focused on the issue of the performers‘ list and Out of Hours provision, following the inquest into the tragic case of Mr Gray. The Coroner was very clear in delivering a verdict of unlawful killing on the Out of Hours doctor Daniel Ubani. This whole case has upset me greatly, and clearly this was an appalling tragedy. I do feel for Mr Gray’s family, and I admire how Stuart Gray, his son and West Midlands GP, has handled himself throughout what must be a really difficult time.

The independent review that I carried out with the Primary Care Tsar Dr David Colin Thomé was published immediately after the inquest. The Minister, Mike O’Brien, David and I were immersed in news and television interviews for most of the day. Most went reasonably well but Jeremy Vine, and then Edwina Currie had a go at me – ‘the good professor’. They seemed to think that we should go back to pre-2004 – complete nonsense. They don’t understand.

It seemed like they were putting all the blame on GPs – you and me – or the GP contract. I tried very hard to say that the contract was needed and how I had spent five or six years working every other night and every other weekend, being exhausted and having to go out and visit people – many of whom didn’t need visiting – children with runny noses and sore ears in the middle of the night. I can even remember visiting an old woman with a chest infection one Christmas to find a GP from another practice in the same bedroom visiting her husband who also had a chest infection!

I tried to point out that the awful case in Cambridgeshire has nothing to do with the contract and that the whole point of moving commissioning to PCTs was that better quality care could be provided across a locality by GPs who are alert and not exhausted both in and out of hours. They completely missed the point, but most of the other media thankfully took a more sensible view.

We conclude in our report that the quality of OOH provision varies across the UK, and made twenty-four recommendations, which include:

• PCTs should review the performance management arrangements in place for their out-of-hours services and ensure they are robust and fit for purpose;
• The Department of Health should issue guidance to PCTs to assist them in making decisions about whether or not a doctor has the necessary knowledge of English;
• The Department of Health should develop and introduce an improvement programme for PCTs to support their commissioning and performance management of out-of-hours services;
• Out-of-hours providers should consider the recruitment and selection processes in place for clinical staff to ensure they are robust and that they are following best practice;
• Strategic Health Authorities should consider how they monitor action taken by PCTs in response to this report and in carrying out appropriate performance management of out-of-hours providers; and
• Providers should co-operate with other local and regional providers (both in and out-of-hours) to share any concerns over staff working excessive hours for their respective services.

The report can be found here

I hope you will have a chance to read the report in full and would be very interested in your feedback – especially as I have to give evidence on the issue to a Parliamentary Select Committee in early March, which is a stressful experience in itself.

I know that all of us GPs want to provide the best quality care for our patients. It’s a real shame that people feel that because of this case we’ve all let our patients down. I hope that some good can come out of this and that we can improve the system to ensure that patients get the care they deserve, night and day, regardless of where they live.

Thanks as always for your support. I value your opinions and feedback enormously, and I urge you to get in touch if you have any comments or questions for me.

The end of January

One of the joys of being Chairman of the college is that I am privileged to see how general practice is delivered across the length and breadth of the country (and pinch some of the good ideas for my own practice). There is lots of good work going on, and in particular this week, I was energized by my visit to Tower Hamlets PCT. I met with the directors of the PCT and was impressed by the collaborative work taking place, particularly between their Chief Executive Alwen Williams, Medical Director Doug Russell and their colleagues. Dr Victoria Tzortziou Brown, a member of our council and a local GP, had invited me over. At a time where we hear that the London SHA are coming up with silly ideas of reducing consultation times to eight minutes, it was reassuring that in this PCT they want to support GPs and recognise that spending longer with patients who are complex and have a number of co morbidities is the way forward. It was impressive to see their managers and doctors working together to provide excellent and innovative care for their patients 24 hours a day.

There is a certain irony in the fact that the view from the Chief Executive’s office window is dominated by the behemoth that is Bart’s Hospital. The provision of care is often dominated – both physically and professionally – by the specialists and the specialties, but there is a growing and strong feeling that GPs need to get more involved in commissioning care, so that we can get more high quality care into the community. It seems that this is happening in Tower Hamlets.

On the same theme – I went back to Croydon last week to meet with Dr Agnelo Fernandes, our RCGP Clinical Champion in Urgent Care and was inspired by the excellent work that is taking place. The individual GPs in Croydon and their GP Federation are doing great things, including their award-winning work improving access to diagnostics. The Croydon GP Federation just demonstrates how collaborative work – even across many practices – gives excellent benefits both for individual patients and the population as a whole.

I’ve been doing a number of surgeries this week and I was delighted that a woman we resuscitated at Bellevue managed to get out of hospital and came back to see me. She couldn’t remember any of the drama that unfolded, but she certainly looks better. Her case gave me a real sense of the excellent work that can be achieved when the practice team work together for the benefit of our patients.

Having a relationship with the media has its benefits, and its inevitable pitfalls, and this week I’ve been misquoted a few times in the medical press. It’s unfortunate sometimes that in supporting an idea, you can be misinterpreted. I firmly support the Cancer Reform Strategy, and Mike Richards’ work. But I think that if you look at the statistics – and by that I mean the Cancer Outcomes of one year and 5 years – we can do better. This isn’t an issue about bashing GPs around the head which is how it came across in the press, it’s about everybody doing as much as we possibly can to get patients to approach us when they have relevant symptoms and then either refer or investigate as appropriate and as quickly as possible. One of the things I think is a good idea is the Critical Events Analysis – sometimes called Significant Event – when someone is diagnosed with a cancer. It’s important to ask: Is there anything we could have done better? Could the hospital have worked more efficiently?

The Out of Hours debate continues, and I am hoping that the Report, produced by myself and David Colin-Thomé for the Minister will be published in the next couple of weeks. What has been heartening throughout this debate is how the three leading UK political parties have praised the role of GPs, in and out of hours. There has, however, been a bit of a setback with regard to 5-year GP Training, and there is still some work to do to convince out specialist colleagues that we need longer training to prepare GPs for the numerous extra responsibilities they now take on as more care moves into primary care. The College’s curriculum ensures that good GPs enter practise, but many tell us that they’re not confident in their work and not gaining crucial experience in key areas, for example in the treatment of acutely ill children. But we will soldier on in the knowledge that all of the international evidence agrees that by having the right number of GPs in the right place at the right time, patient care is better and less expensive than secondary- or tertiary-dominated care. These are points that I also raised to the NHS Chief Executive David Nicholson and Jim Easton Director General Jim Easton, who has the remit for finding savings, while improving quality and productivity.

Well, it’s the end of a busy week, I’ve finished this afternoon’s surgery a bit late, but I’m looking forward to a restful weekend, and a win for the Baggies.

As always, I value your opinions and feedback enormously, and I urge you to get in touch if you have any comments or questions for me.

RCGP Conference and Beyond

It’s been an exhilarating, if exhausting, week. Our Conference last week in Glasgow was an enormous success, and as ever it was a brilliant opportunity to meet many of you there. I was particularly impressed to see how many associates-in-training had attended the Conference this year and to see the excellent small group work taking place.

I would like to take this opportunity to offer my enormous thanks to Clare Gerada, who has worked tirelessly with her team over the past year to organise what was a fantastic, inspirational conference. Clare’s vision, creativity and hard work ensured that the Conference was such an enormous success, and without her continued commitment and enthusiasm it would not have been possible.

I would also like to thank the in-house staff at the RCGP for their efforts in ensuring the Conference went without a hitch, and Profile Productions, our organisers, for their invaluable assistance.

Of course, the Conference is not céilidhs and coffee mornings – I also found time to attend some excellent speeches and presentations. I felt that one of the big successes of the Conference were the variety of Revalidation themed sessions.

The headline Revalidation workshop – Revalidation Ready? – was a particular highlight, and demonstrated an encouraging shift in attitudes toward Revalidation as it edges ever closer. There seemed to be a general feeling of confidence and positivity among the attendees, where previously there was anxiety and fear. This is a fantastic development, and one which I support wholeheartedly.

There was a good response to the CPD credit scheme, and any remaining concerns are now in the hands of others. With this now in place, the RCGP is ready to lead the way in ensuring that we have an appropriate appraisal scheme and systems of CPD. I believe very firmly that Revalidation is actually about professional development and not about finding another Harold Shipman.

It’s difficult to single out any particular presentations, but I must mention Gordon Moore’s. His views on the US healthcare system offered invaluable insight and were enormously thought provoking.

Of course, discussions on the issue of Practice Boundaries dominated the Conference. I’ve commented widely on this issue to the media, and it was a key feature of my keynote speech. There are a small number of patients who want the continuity of care provided by GPs but can’t get it because technically their home is not where they spend most of their time. There are patients who wish to choose a high quality practice but currently are having difficulty in doing so because of how boundaries are drawn. We said we’d work with the DH to look at solutions, and I know that the GPC has also indicated its willingness to discuss the issues with them. Providing excellent patient care should, and must always remain our priority, and continuity of care is vital in achieving this – isn’t it fantastic that people are calling for more opportunities to have the high quality and continuity of care provided by GPs.

I’ve returned from the Conference to a flurry of media interest, and have given a number of interviews over the last week to discuss issues raised at the Conference. On Wednesday I was interviewed by CBS to discuss the UK’s swine flu vaccination programme. The CBS interview aired late last week, and in it I talk about the contrast between the UK and US response to swine flu, and our comparative vaccination programmes.

In my keynote speech, I commended the current UK programme and its ability to target those most at need, in comparison to the US programme, which I said was "the survival of the fittest and the richest".

It’s a contentious issue, and one which is very close to the heart of a particularly angry American woman who got in touch with me this week in order to respond to my comments. She wrote:

“You and the rest of the world can go jump in a lake. Any idiot that opens his mouth - publicly criticizing hard-working Americans - should do just a little more research into what has really been happening in my country. And.....here's a BIG clue for you! You are NOT going to see it on CNN or any of the mainstream media. I never thought I would live to see the day when our media was as corrupt as Russia's was when I was growing up. You will need to do a little seeking to find the real stories - basically, they will be the OPPOSITE of what you are apparently basing your uninformed opinions on.”

I suppose this just highlights the old cliché that you can’t please all of the people all of the time…

I believe that we are very fortunate to have a national health service with general practice at its heart. It made me very proud to see you all at the Conference and to hear about the brilliant work you’re doing day to day to raise standards of care for our patients ever higher. I look forward to seeing you all again at the Conference next year.

As always, both I and the College value your opinions and feedback enormously, and I urge you to get in touch if you have any comments or questions for me.