I attended Cambridgeshire NHS Primary Care Trust’s board meeting on the 26th of August 2009. One of the major items of business was to approve a specification for the provision of out of hours GP (and emergency dental) services in the county. The PCT currently buys this service from private companies including Take Care Now Ltd.. In February 2008 problems with the current system were highlighted when a German doctor killed a Cambridgeshire patient by accidentally giving them a tenfold overdose of painkillers. The doctor blamed the mistake on tiredness as he had only flown into the UK the night before and had had just three hours rest. There have been many other reports of foreign doctors commuting hundreds of miles from other countries to provide out of hours services in the UK.
I used the opportunity for members of the public to address the meeting. The public speaking section of the meeting was taken at the end, after the “formal business” had concluded, so by the time I made my points the board had already unanimously approved the draft specification in front of them without amending it. There is nothing in the draft specification precluding new service providers from using doctors who are commuting from other countries and working while they are tired and jet-lagged.
I welcomed elements of the draft specification which referred to a requirement for a service: “embedded within the local community” and said I supported a point which had been brought up by a number of board members – it would be desirable to have local GPs from the area providing the out of hours service. I asked what could be done to ensure those aims were met, and if it was possible to insist that the service was not provided by doctors who were commuting from other countries, hundreds of miles away. I asked what constraints employment law, and European law, was putting on the PCT’s ability to obtain the service its members, on behalf of the people of Cambridgeshire, clearly desire. The board’s chair, Maureen Donnelly, responded saying:
We’re doing what we can do within the constraints of company law and the EU
I then turned to openness. Two other public speakers had already called for more openness and public engagement in the process of commissioning the out of hours service, I echoed those calls and asked for the whole process to be as transparent as possible. The board chair said that this would happen “as much as possible”, but noted publication of bids would be constrained by commercial confidentiality. Personally I cannot see why the bids cannot be placed into the public domain, and all the information needed to assess them made available. I commented on the fact that the PCT board had just established an “advisory committee” to work on the process which is to come – of assessing those tendering to provide the service. I asked if that advisory committee (a sub-committee of the board) would be meeting in public and have its papers and agenda made public, I expressed a concern that this key item of business had been taken out of the public domain. The board chair’s response was: “It’s only an advisory committee”.
I also asked that the specification document itsself be put online. The board’s chair responded to say: “The specification document is part of the papers for today’s meeting, and is online”. The document, while available on paper to the public at the meeting, had not however been published online. The board’s chair had lied to the board, and the members of the public present. I mentioned this to the board’s secretary after the meeting, and showed her the committee’s webpage on my laptop. I demonstrated there was no link to the specification document, and drew attention to fact the report entitled: “OOHs Procurement Update.pdf” was only 84kb in size, only 5 pages long, and clearly did not include an appended specification. The board secretary then admitted she had been told on Saturday by someone-else that this key document, which was clearly by far the most important committee paper, had not been published. I think that the secretary, who was sitting next to the board’s chair during the meeting, ought to have interrupted and corrected her. The board secretary said she had asked for the specification to be placed online; I felt that in itself indicated a problem as surely the board secretary ought be able to publish documents online themselves rather than require someone else to do it. That latter kind of problem is endemic in the public sector.
Lastly, with respect to the specification itself, I said there were two points where I felt it was aiming rather low. The minimum competencies of a provider are listed as including an; “ability to manage common medical, surgical and psychiatric emergencies in the out of hours setting”. People unfortunate enough to have less common problems might find themselves out of luck. The specification also incorporated “National Quality Requirements”, which include a requirement that no more than 5% of calls are abandoned (which I think means they hang up on you, or you abandon waiting for them to answer). I think Cambridgeshire ought be looking for an out of hours service provider who does significantly better than one in twenty callers having their calls abandoned!
Other Public Speakers
There were two other public speakers, out of the twenty or so members of the public observing. One person made the point that if there was no public confidence in the service then its aims would not be fulfilled as people would go to Accident and Emergency rather than use it. They suggested the tendering process be used to improve public confidence, and spoke in favour of openness and public involvement in the stages of the process to come.
Liberal Democrat County Councillor Geoffrey Heathcock spoke as a member of the public. He said that he was the chair of the county council’s health scrutiny committee (at the county council the opposition members chair scrutiny committees). He asked for the tendering process to be conducted in an open and transparent manner.
After the meeting I made Cllr Heathcock aware that the specification paper had not been posted online as claimed, and that the NHS PCT had not begun the process very openly. He said: “we will watch them”.
Public Consultation After Key Decision
While the board approved the new out of hours service specification on the 26th of August, a public consultation on the subject is due to start on the 25th of September. Stephen Heard, Director of Contracts & Performance at NHS Cambridgeshire, who is the director responsible said that incorporating the results of the consultation into the new specification and contract would be tricky, given the timetable. Mr Heard also pointed out that a report by the Care Quality Commission into an Serious Untoward Incident (perhaps this one) involving Take Care Now would report in November 2009, and that, as well as the public consultation, might result in the specification being altered despite the tendering process being well underway by then – and companies presumably having submitted tenders based on the specification approved on the 26th of August.
Other Points from the Discussion
- Mr Heard, as the director leading the procurement project, reported he had met with current service providers in Cambridgeshire, and had also been to see how out of hours services were provided elsewhere in the country. He said he had appointed a project manager, and someone else had been identified as the “owner” of the procurement project.
- Dr Dennis Cox, Director of Clinical Strategy at NHS Cambridgeshire said that he would like to co-ordinate the views of GPs rather than be the sole voice of GPs influencing the tendering process. The board discussed the importance of having people with relevant clinical experience involved in assessing the bids.
- Stephen Heard made a big thing of saying this would be an “electronic process”, he said this meant that more work could be done “at desks” and it would be possible to send the tenders for comments to a wider group of people. A board member asked for clarification on if the “electronic process” meant interviews would not be held for those companies tendering. Mr Heard said interviews would be held.
- As the whole item was dispatched in ten minutes or so it would be wrong to suggest any aspect was discussed in depth, but one topic which did provoke discussion was that of if there ought be financial rewards or penalties for the company depending on their performance. Some were in favour of this, and others not. Some cautioned that it would invite criticism that decisions made by out of hours doctors were motivated by money.
- Dr Dennis Cox said that there had to be a system of encouraging appropriate medical risk taking. He pointed out that the safest course of action was generally to call an ambulance and get someone into hospital, but said that often that wasn’t what the patient or the PCT wanted. (One of the main aims of the out of hours service, as detailed in the specification document, is to reduce admissions to accident and emergency).
- The out of hours service consultation will be approved at a board meeting on the 23rd of September and if approved will run between the 25th of September and the 18th of December.
- Board member Robert Kynnersley stated that the “worst case would be a split North / South system”, but when asked to explain why he withdrew his remark. He spoke in favor of “ways to ensure our own GPs become involved in the provision of the service”. Mr Heard said he had had discussions with those considering tendering and hoped that bids would include this. Mr Kynnersley said he wanted to see the same standard of care offered across the county.
- Some board members called for a focus on “quality not targets”, and there appeared to be broad agreement that they were not looking to award the contract simply on the basis of price. Mr Heard stated that quality, innovation and price would all be key factors. He talked about harnessing the innovative minds present in region to improve the service, but did not explain how he intended to do this.
- Board members discussed the level of expertise that would be need to evaluate bids, and check they were “underpinned by reality”.
- The board were being asked to consider if PDoc (which covers Peterborough) ought be included in the tender. It appeared no board members had anything to say on this, no opinions either way or any information to share – so the board delegated the decision to Mr Heard.
- The old contracts are to be extended for three months, while the new one is put in place. The new contract will run from April 2010
The specification passed by the board does not appear to enable consideration of linking up with NHS Direct. We’re currently, as taxpayers, incurring costs by duplicating a service. About half of all calls to the out of hours service are dealt with on the phone, and it appears that NHS direct does offer a service to out of hours providers in other regions, but the Cambridgeshire specification does not appear to me to have been written to encourage NHS Direct to submit a tender. The potential for splitting the service geographically is mentioned, but the potential for NHS Direct to deal with the call answering and clinical assessment for patients is not. A commercial provider could act as an intermediate between the PCT and NHS direct and take a cut for doing so – that would be absurd – but very “new labour”.
Notable Points from other Agenda Items
Mr Winn of Cambridgeshire Community Services (CCS) presented a report to the meeting.
His formal written report stated:
CCS with partner organisations has tendered (via Anglia Support Partnership) hotel and cleaning services across the service portfolio. The new cleaning contract provides a significantly improved cleaning specification, which complies with the 2007 cleaning standards. The CCS yearly contract value is £1.36m which subsumes two separate contracts and one in house team.
He verbally added that the new contract includes cleaning below shoulder level, whereas the old one left all areas over shoulder height uncleaned. A meeting of the CCS Board in Ely on the 22nd of September was mentioned.
- Prior to the discussion on out of hours care Robert Kynnersley raised the point about tightening up who is on the PCT’s “performers list” – the list of medical staff allowed to work. He pointed out it also applied to out of hours care. The board chair, and the chief executive, stated it was impractical for the PCT to set its own standards and that ensuring staff were properly qualified and competent to work was something which had to be addressed nationally. The chair said “it is a concern” and it was reported that despite Cambridgeshire only standards being considered impractical, in the absence of progress nationally, there were attempts to work with other relevant groups to create some East of England standards.
- A report on complaints revealed that 2/3 of complaints to the PCT were upheld, one member suggested this statistic revealed lower level complaint handling procedures were not working as they should be.
- The Chief Executive said that a target response time of 15 days led to complaint investigations being rushed.
- The Chief Executive reported that an extra P had been added to the NHS acronym QUIPP (Quest for Quality and Improved Performance) by a minister. The extra P being for prevention. The board discussed funding cuts, describing what they expected to have to deal with in the near future as reductions of funding “like nothing we’ve ever seen”. Board members said they would “try not to cut” but preferred the wording of: “do things better”. The point of adding the extra P was to ensure that in light of cuts (or “doing things better” resulting in savings) care needed to be taken to avoid stopping doing preventative work. As while stopping preventative work would provide short term savings it would result in higher costs over the longer term.
- A board member referred to an aim to reduce to zero the number of avoidable cases of MRSA. Avoidable cases being defined as those arising as a result of healthcare interventions.
- A board member expressed concern about the frequency with which the PCT accepted the results of “self-assessments” conducted by those they had commissioned to provide services. The chair dismissed this concern stating the PCT had “relationship management teams”. Mr Heard responded saying the PCT had begun a scheme to internally rate suppliers – he said these ratings could not be made public as they were opinion on the suppliers. Another board member suggested that the PCT wasn’t responsible for monitoring the performance of all the services it contracted, saying “we’re not the regulator in all cases, sometimes it’s the Care Quality Commission and sometimes there are national standards”.
- The board discussed the fact it was still proving difficult to make staff aware of the importance of infection control / handwashing etc. A board member reported seeing empty containers of handwash. The board agreed there was a need to “check what people say is being done is being done”. Board members mused on the subject of what staff they would need to perform that role effectively.
- A report on the NHS Constitution was taken to the board, it was reported that this will go through Parliament in October and the PCT will legally have to comply with it. A table, available on paper, but not in the online version of the meeting papers, highlighted areas where the PCT was compliant in green and where it was not in red. The only item discussed was vaccination, which it was reported was mis-coloured red, as while the PCT doesn’t meet targets for childhood vaccination, it does offer all the vaccinations required by the constitution.
- Two health indicators for which Cambridgeshire is significantly worse than the England average were brought to the board’s attention: Road Safety and Alcohol related health problems.
- Road Safety was discussed, and while the county has a poor record for injuries on the roads, it was felt this was due to geography and nothing could be done. It was pointed out the county council does try to improve road safety. It was suggested that the board ought receive information on Cambridgeshire’s statistics compared with other geographically similar counties. It was pointed out that there is a Local Area agreement with respect to road safety, and that LAA is being met (despite the injuries still occurring). Engineering, Enforcement, and Education were mentioned as actions which needed to be taking, with the PCT noting it really only had a role in the latter; members wondered inconclusively if they ought be dong more.
- Alcohol related health problems were discussed, and the fact these were spreading from just being focused on Cambridge City Centre to other towns in the county was reported. Again the PCT board discussed the point without deciding if there was anything more they could do about it. The report to the board meeting pointed to a current public consultation on a specification for “community alcohol services”.
Once the public section of the meeting was over, the board members went for lunch in another room. They were to re-convene for a secret meeting in the afternoon.
Members sat on red velvet covered chairs, each emblazoned with a gold square and compass symbol. The meeting was held in a wood paneled room lit by gold chandeliers and the board’s chair sat under a large portrait of the Queen which was flanked by portraits of men in masonic regalia. There were no signs from the road pointing to the meeting, a gardener pointed me in the right direction.
No elected councillors or MPs or similar are on the PCT Board. The majority of members of the board are the Executive Directors, who are members of NHS staff, non executive members are appointed by the appointments commission. I don’t think elected individuals mindful of their constituents would have passed the proposed specification document unamended.