GP Co-Operative Out-of-Hours Service SR6/2007.

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A decision made (25/07/2007) regarding: GP Co-Operative Out-of-Hours Service SR6/2007.

Subject:	GP Co-operative Out of Hours Service SR6/2007
Decision Reference:	MD-H SS-2007-0048		Exempt clause(s):
Type of Report: (oral or written)	Written		Person Giving Report (if oral):
Telephone or e-mail Meeting?			Report File ref:
Written report – Title	GP Co-operative Out of Hours Service, Response of the Minister
Written report – Author (name and job title)	Senator Stuart Syvret, Minister for Health and Social Services
Decision(s): The Minister reported his formal response to the findings of the Scrutiny Panel.
Reason(s) for decision: The Minister approved the response to the findings of the Scrutiny Panel and agreed that it should be presented to the States.
Action required: The States Greffier is requested to present the Ministers response to the States.
Signature: (Minister/ Assistant Minister)		Date of Decision: 25 July 2007

GP Co-Operative Out-of-Hours Service SR6/2007.

EDUCATION AND HOME AFFAIRS SCRUTINY PANEL

THE GP Co-OPERATIVE OUT – OF – HOURS SERVICE (S.R.6/2007)

RESPONSE OF THE MINISTER FOR HEALTH AND SOCIAL SERVICES

This report is tabled in response to the Education and Home Affairs Scrutiny Sub-Panel report ‘The GP Co-Operative Out – Of – Hours Service’ and is a formal re-statement of the comments previously provided to the Panel on 5th March 2007.

RESPONSE TO THE SUB-PANEL’S RECOMMENDATIONS

The Panel recommends that the annual report should be made public in order to ensure transparency in the use of public funds. If, however, the inclusion of commercially sensitive information precludes this, then a summary of the main parts should be made public. (9.9.9)

The annual report is currently in development. When completed consideration will be given to the extent to which the report may be made public. At the very least a summary of the main parts of the report will be made public.

The Panel recommends that the Department should review its payment arrangement and consider whether the subsidy would be better spent on patient care.(10.1.4)

At the Public Hearing on 13th November 2006 , the Minister for Health and Social Services advised the Panel that he was satisfied that the use of public funds represented good value for money and a good investment. This money is, in fact, being spent on patient care.

This view is further strengthened by the events that followed which:-

· resulted in all but four of the Island’s GPs deciding to join the GP Co-OP;

· have demonstrated that the public value and use the opportunity to gain cheaper access to GPs outside of normal working hours via the GP Co-OP Surgery located at the General Hospital;

· have demonstrated the success and quality of the service with only two complaints received by patients during the early formative months of the service. These two complaints have been formally assessed and followed up to minimise their reoccurrence. Furthermore, formal on going patient feedback via questionnaires conclusively demonstrate that the public value the service being provided.

As a consequence of the above, the subsidy is indisputably being used to enhance patient care and the Department sees no reason not to continue to support this initiative.

Given that it is not possible for the service to be fully audited at present, the Panel recommends that, at the beginning of 2008, the Minister provides the Health, Social Security and Housing Scrutiny Panel with an update on the co-operative service. (10.2.6)

In line with normal practice in such matters, the Department is more than happy to oblige with this request.

RESPONSE TO THE SUB-PANEL’S KEY FINDINGS

1. The Panel believes that, from the outset, the development of a GP co-operative seemed, to some GPs, to have some merit. The idea had been discussed several times by GPs during the last ten years but this was the second time that the Department had become involved (7.3.5)

Whilst this statement is factually correct, it should be noted that a GP delegation approached Health and Social Services with a proposal to enter into a partnership with GPs to develop a GP Co Op, not the other way round. At the outset a significant majority of GPs had joined the GP Co OP, which is a more accurate reflection of the situation than that stated by the Panel that some GPs thought the development of a GP Co OP had some merit.

The Panel notes the perception that the introduction of JDOC was driven by a minority of GPs. The Panel found no evidence that GPs were coerced to join the co-operative. However, it believes that circumstantial pressures arose once a significant number of GPs had joined. As a result, there were few viable alternatives for practices which chose to remain outside and they were therefore compelled to join. (7.4.17)

The Department believes that the panel should give due and greater credence to fact rather than perception in its reports. The fact was that in line with normal practice for such matters, the views of many of the GPs were articulated through a representative group. This resulted in a significant majority of GPs of their own free will to agree to join the GP Co OP from its inception.

The Department and members of the Joint Working Party gain no comfort from the fact that the Panel could find no evidence that GPs were coerced to join the co-operative.

Contrary to the view presented by the Panel, there were alternatives for GPs to consider; they could have remained within one or more clusters that existed prior to the formation of the GP Co OP. Given the benefits to patients and their own members it is little wonder that GPs wanted to join the GP as the GP CO OP offered the main sustainable way forward for GPs, rather than the negative slant put forward by the Panel that GPs felt compelled to join rather than the fact that this was what the majority wanted from the outset.

Bearing in mind that these proposals could potentially affect every Islander, the Panel feels that there was a lack of public meetings held by the Joint Working Party. (7.5.14)

The Department understands such a statement but believes it had sufficient supportive information and took appropriate care to ensure that the decision to implement a GP Co OP was the right decision to make. Subsequent events and the success of the GP Co OP has validated this view.

A belief was expressed that the lack of public response to the consultation indicated the public was not apposed to the scheme. The Panel can only conclude that a lack of response is evidence that the public did not respond and not evidence of whether the public either supported or opposed the scheme. (7.5.22)

In the Department’s view sufficient care was taken to ensure that the public knew of the proposed creation of the GP Co OP and were afforded the opportunity to voice their concerns should they wish. As a consequence, a decision to implement or halt/amend the project had to be made on the balance of all the available information to the Joint Working Party/Department. The lack of any significant concern from the public when viewed in conjunction with the benefits that might accrue from the creation of the GP Co OP allowed the decision to proceed to be made with some confidence.

The Panel believes that it was unsatisfactory for the service to be implemented on the same day as the consultation period ended. The Panel questions whether this left sufficient time for consultation (potentially) to be assessed. (7.5.23)

On the face of it, the concern of the Panel appears have some legitimacy. However, the reality was that the Joint Working Party was receiving feedback from GPs and members of the public very soon after the initiation of the consultation process. This feedback continued throughout the formal three month consultation process. As a consequence this information was regularly assessed by the Joint Working Party and therefore it knew that subject to political approval it was appropriate to proceed to implement the GP Co Op at the end of the consultation period without delay.

The Panel welcomes the ease which people can access the co-operative service and agrees that people should only need to make one telephone call. (9.2.9)

The Department is pleased that the Panel has recognised this advantage (one of many) of the GP Co Op.

The Panel acknowledges that the initial telephone call to the service acts as a form of triage and therefore recognises that the skills of the receptionist are essential and that relevant training should be provided for this role. (9.3.5)

The fact that appropriate training should be given to all GP Co Op staff (not just receptionists) commensurate with their role is standard Health and Social Services Policy.

The Panel notes that provision has been made for patients who may not speak English as a first language. (9.4.5)

The Department notes that the Panel has recognised this particular provision.

The Panel notes that the appropriate ICT is not yet available to allow the co-operative service to be fully audited. (9.5.12)

The Department notes that the Panel has appreciated this fact.

The Panel notes that, whilst some arrangements have been made, no protocols have been drawn up to address the third Jersey Quality Standard but acknowledges the close working relationship that has been established with Jersey Hospice care. (9.6.13)

It is incorrect to state that there are no arrangements to address the third Jersey Quality Standard as it is clear from paragraph 9.6.11 of the Panel’s report that there is a system in place albeit a manual system. In large part, Standard 3 relates to the implementation of an appropriate IT system.

The Panel notes that the statements made in October 2006 by the JCRA regarding additions to the co-operative do not refer to the competition clause that was present in its initial decision of 24th August 2006. (9.7.19)

Whilst the views of the Panel are a matter of fact, it should be stated that the JCRA was fully satisfied that the additional GPs to the GP Co OP was justified under the criteria supporting JDOC’s exemption under the Competitions Law.

The Panel notes that GPs will continue to be able to exercise discretion over fees charged. However, it remains concerned that the level of discretion available to GPs may have been reduced and questions whether the billing process will ultimately be as discretionary as in the past. (9.8.7)

Notwithstanding that the Panel were informed by Dr B Perchard (as set out in paragraph 9.8.2 of the Panel’s report) that GPs had not lost the freedom to exercise discretion to waive fees (or amend fees for that matter) for individual patients, the key question is whether the fees are appropriate. In this regard both the Department and the JCRA have deemed the fees to be appropriate from the inception of the GP Co OP and have the means to ensure that the fees remain appropriate in future years.

As most practices employ their own secretarial and administrative staff which are paid by those practices, the Panel questions whether, in the case of the co-operative, public money should be used to fund these overheads. (9.9.2)

It should be noted that the GP Co OP receptionist/reconciliation clerk does not handle funds. The GP Co OP receptionist/reconciliation clerk will send confirmation of consultations (either at the GP Co Op clinic or home visit by the visiting GP of the GP Co Op) to the patient’s GP practice. All the billing arrangements (and reconciliation between the patient’s GP practice and the GP practice of the GP carrying out the consultation) are performed by the patient’s practice. As a consequence, it is the GPs’ practice that bills patients and reconciles income between the patient and the GP who undertook the consultation, not the GP Co OP and therefore there is very little duplication of work.

It should also be noted that GP practices do not operate (to any significant extent) surgeries outside of normal working hours. The Department believes that it is appropriate that it supports the creation of this new service to the benefit of the public.

14. The Panel questions whether the process for billing patients that involves the employment of a reconciliation clerk may lead to duplication of work carried out by GP practices’ own staff. (9.9.3)

Please see answer to key finding 13 above.

15. The Panel questions why the tax-payer is being asked to subsidise the co-operative scheme. (10.1.4)

Given the increasing governance agenda, the need to recruit and retain GPs, the Panel seems to miss the fundamental point that the creation of the GP Co Op, is an appropriate and sustainable organisational response to providing an enhanced out of hours service to the public of the island. As a consequence, it is appropriate that the Health and Social Services should enter into a partnership with the Islands ’ GP to the overall benefit of the public.

The Panel notes that the Gwyneth Huelin Wing is being used at a time when otherwise it would be closed. (10.1.6)

The Department notes that the Panel have recognised the advantage gained by the increased utilisation of an existing building for the GP Co Op.

The panel questions why, under the JDOC system, it was necessary for a daytime driver to be provided on Saturdays, Sundays and Bank Holidays as GPs would previously have driven themselves when undertaking daytime visits. (10.1.8)

In answer to this question it should be noted that the volume of work for the visiting GP during these peak times are too much for a single GP to safely handle. A driver allows the GP to attend to and co ordinate his/her response to other incoming telephone calls whilst still travelling to attend to a home visit.

The Panel notes that the GP Co Op Management Board receives £14,400 for payment to Board members which represents approximately 17% of the public investment. The Panel acknowledges the work undertaken by Board members but questions whether the tax-payer should be responsible for paying Board members. (10.1.10)

Whilst the Panel appear to appreciate the necessity of the GP Co OP Management Board (which is fundamental to the functioning of the GP Co Op) it appears not to realise the connection between the GP Co OP Management Board which meets outside of normal working hours and the delivery of a service that delivers genuine benefit to the public. As a consequence the Department believes it appropriate to support the maintenance of this Management Board which it should be noted does not cover the full commitment provided by its members.

The Panel notes that one of the perceived benefits of the co-operative scheme is the Service Level Agreement made by the Department and JDOC and the possibility that this allows for the introduction of clinical governance. (10.1.13)

Whilst, the Department is pleased that the Panel has recognised this advantage (one of many) of the GP Co Op, it believes that genuine benefit will accrue from the Service Level Agreement and attached Governance framework rather than the perceived benefit stated by the Panel.

The Panel found that the introduction of the co-operative service had had no impact on the Accident and Emergency Department. (10.3.9)

The Department notes the comment of the Panel in this regard and can confirm that the factual accuracy of this statement holds true to date.

The Panel believes that the ambulance staff expressed reasonable concerns regarding the potential use of the Ambulance Service for JDOC. It agrees that the Service should not be used for this purpose. (10.4.8)

The Ambulance Service has not been used for transport purposes in connexion with the GP Co OP since its inception and there are no plans to do so. As a consequence this fact brings into question the relevance of this key finding.

It is possible that this statement or view of the Panel was formed before the implementation of the GP Co Op (when the Department was exploring the potential use of the ambulance service in transport duties) but failed to update its subsequent report.

The Panel notes the concerns expressed to it that working as part of the co-operative system would not allow GPs to gain the necessary skills and experience required for dealing with people at home. The Panel believes it is the responsibility of individual GPs to ensure that any reduction of out-of-hour duties does not impact negatively on their skills. (11.3.12)

Whilst the Department appreciates the concerns expressed in relation to this issue by one or more GPs, it is a fact that such misgivings must have been reconciled as the GP Co OP contains all but four of the Islands ’ GPs. Factors which may have featured in such deliberations include the need to have sustainable out of hour’s rotas, and more formal and consistent governance arrangements etc. Notwithstanding this, it is a matter of fact that GPs /Doctors and other professionals are obligated to ensure that they maintain their professional competence in all the duties they may perform. This would include the maintenance of appropriate skills in carrying out their visiting GP duties.

The Panel notes the perception that the presence of a GP co-operative would make Jersey a more attractive employment destination for GPs. (11.5.7)

The Department is pleased that the Panel has recognised this advantage (one of many) of the GP Co Op.

The Department can confirm that at least one new GP to the Island has confirmed the importance of the GP Co Op in their decision to apply for the vacant post.