GENERAL PRACTITIONERS (DEPUTISING SERVICES) (Hansard, 19 January 1977)

§ Mr. William Small (Glasgow, Garscadden)

I have chosen to raise on the Adjournment the subject of general practitioners' deputising services, because they need examination. We should take a look at what is going on in most of these services. I have chosen to use copious notes for my speech in order that I may describe the picture as clearly, as pragmatically and as emotionlessly as possible.

I have discovered from my researches that there is no official deputising service 598 provided in Scotland or anywhere else in Britain by the National Health Service. Doctors are required to take reasonable steps to ensure continuity of treatment and they may delegate treatment to a partner, assistant or deputy.

The deputising services grew up in the 1960s, first in the major conurbations in England. Some of the services were professional while others were non-profit making services organised by the British Medical Association. The services provided deputies for general practitioners at times that are out of normal working hours. These services were not and are no part of any contract with the National Health Service. Consequently, the medical services Committee procedure can be invoked only in the event of a complaint against a patient's own doctor. It cannot be invoked against the deputising or against the deputy that it has provided.

The situation is further complicated by the fact that a doctor has no responsibility for his deputising service. It is not legally possible to impose any such vicarious responsibility on a general practitioner. That would be beyond the Secretary of State's powers. A medical services committee can investigate a complaint against a deputy only if he is already on the medical health board's list.

The agitation on 23rd February by Mrs. Still of Scotstoun aroused much Press comment in Scotland. All the Press took up the matter and continued to feature articles about the distress occasioned to Mrs. Still when she used the service. I shall give full details because this case was behind my decision to raise the matter on the Adjournment.

In February 1976, Mrs. Still's 20-year-old daughter died in distressing circumstances. She became ill during the night of 21st February and her condition worsened rapidly. On the evening of Sunday 22nd February Mrs. Still was so worried that she telephoned her family doctor and she was referred to another doctor as a deputy. She rang the telephone number of that doctor but he was not available, so Mrs. Still left details with the person who answered the telephone. A short time later the deputy doctor rang back, but, on hearing of Miss Still's complaint and her symptoms, was unwilling to come out. He said that they were 599 influenza symptoms and he arranged for a prescription to be collected from a Springburn chemist.

That is probably three miles away. Mrs. Still had to arrange for someone to collect the prescription and it was a further three hours before she was able to get the prescribed medicine for her daughter, whose condition was still deteriorating. She got her first capsule three hours after the prescription had been obtained.

In the morning, the daughter's condition had worsened further. Mrs. Still rang the doctor again and he came out quickly. As soon as he saw Miss Still's condition, he arranged for her immediate removal to hospital by ambulance. She was so ill that she was transferred on the same day to the intensive care unit of the Western General Infirmary where she died, despite all the efforts of the staff.

Subsequently, the cause of death was established as acute viral pneumonia and viral encephalitis. Mrs. Still wrote to me and alerted the Sunday Mail, which published an article protesting at the doctor's diagnosing by telephone. That is part of the reason for a deeper examination of the technique.

The newspaper quoted the chairman and secretary of the Greater Glasgow Health Board as saying that his advice to Mrs. Still was that she should make an official complaint to the board which would be fully examined.

I wrote to the Secretary of State enclosing a copy of the Sunday Mail article. He said that since a formal complaint had been made to the health board, it would be improper for him to comment upon the outcome. The procedure is private, but both parties have the right of appeal to the Secretary of State.

Following this distress and frustration, Mrs. Still was told by the board that it was too late to complain—that it was time barred. Eventually it was decided that her failure to lodge a complaint within six weeks was reasonable and it was referred to the chairman of the medical services committee.

In April. Mrs. Still received a letter from the board advising her that the chairman was not satisfied that the complaint disclosed a cause for complaint against the doctor, whose terms of refer- 600 ence did not preclude him from engaging a suitably-qualified deputy. That deputy had no contract with the board unless he was a GP on the board's list.

The terms of service did not prevent the GP from prescribing by telephone. I could go on in this vein, but suffice it to say that the Minister replied to my letter and said that there was no cause for action under the complaints procedure. The deputy was not on the board's list and the deputising service was not part of the NHS and so could not be investigated by the board's medical committee.

This feature is worth further study because of the reply from the Greater Glasgow Health Board: As you will be aware, a statutory procedure exists governing complaints against general practitioners and the Health Board will be continuing to carry out these procedures as set out in Form SCP1 sent to you on 23 April 1976. The letter is signed by J. Laing, the Administrator Primary Care.

The matter could be pursued by a civil action, but the medical profession is unlikely to lose.

The legal, theological and commercial meaning of the term "vicarious liability" is most complex. Where previous advocates have failed, how does one pursue a shadow who is apparently above the law? If lawyers could not do it, how could Mrs. Still pursue the case successfully? She is looking not for compensation but for justice and for some assurance that this kind of thing cannot happen again.

Diagnosis by telephone is growing. Someone in distress, faced with illness in the home, is in physical, emotional and environmental difficulty. We all act from instinct and impulse when trying to describe a condition to a doctor in an effort to get guidance. In those conditions, a telephone call must be treated as a shadow line between safety and danger.

Since doctors seem to be forsaking conventional treatment for prescription by telephone, the practice could develop systematically over the years and might not be just an emergency procedure. "Dial-a-diagnosis" is a distinct possibility. Emotional and other elements are necessarily ignored. A phone cannot read a thermometer or take a pulse. Like any other tool, it can be laid aside once 601 it has been used. There should be an immediate personal visit to make a deeper diagnosis.

Is this technique a process of rationalising the patient into scientific detachment? Is diagnosis being depersonalised, and are we moving from ethical to technical considerations in this area? If so, could the use of the phone be validated by some such contraption as the "black box" which is used in aircraft, by which data could be recorded as an aide memoire to safeguard the patient who might eventually want to take action to get the best treatment?

If we are to accept this new element, the acid test for the 6,000 doctors in Scotland is whether they would use it for members of their own family instead of consulting a colleague. The Department should analyse the use of the telephone and the inability to pursue cases successfully under the doctrine of vicarious liability, the prescribing doctor under the deputising service having immunity in his own right. One is pursuing a shadow.

I ask my hon. Friend to urge the Government to seek an early agreement with the profession about the control of deputising services, or, failing any agreement, to impose restrictions on them for the benefit of the citizen in need of treatment.

§ The Under-Secretary of State for Scotland (Mr. Harry Ewing)

First. I should like to associate myself with my hon. Friend the Member for Glasgow, Garscadden (Mr. Small) in expressing sympathy with Mrs. Still, of whose tragic loss of her daughter he has spoken. It is a feature of the House that some of the very important matters affecting people personally are raised in Adjournment debates—often at a similar hour.

I assure my hon. Friend that I and my ministerial colleagues, including my right hon. Friend the Secretary of State, share his concern about the difficulties involved in the use by general practitioners of deputies who are not on the health boards' lists, particularly where these are provided by deputising services. In fairness to the British Medical Association, I should make it clear that the 602 deputy in this case was not provided by the BMA.

Over the years there have been a number of complaints to Ministers from hon. Members about the use by doctors of deputising services which, under the present provision, the National Health Service authorities have no locus to investigate. That was the point made by my hon. Friend when he talked about vicarious responsibility, which is difficult to define, but which perhaps could best be described as relating to employees. As general practitioners are not employees but are contracted to the NHS, there are certain difficulties in imposing what is loosely described as vicarious responsibility.

There is a difference between England and Wales and Scotland in this respect. A general practitioner in England and Wales has written into his contract that he or she is responsible for the actions of anyone he or she engages in fulfilling his or her contract.

The complaints to which I have referred arise in a variety of circumstances. In some instances the problem stems from difficulties in communication, either because the patient does not know what steps to take to secure medical help in the absence of his or her own doctor, or because it can be hard to convey to a strange doctor, unfamiliar with the patient, the precise nature of the medical emergency. Complaints have also been received about delay, sometimes extensive, in the response to an emergency summons, and about the adequacy of the service to cope with the work involved. A further source of concern is the lack of any means of investigation or redress in respect of particular complaints. My hon. Friend highlighted the feeling that Mrs. Still must have in respect of her inability to gain redress in respect of her complaint and the grievances that she feels she has.

Opinions differ as to whether deputising services are a desirable or undesirable development. Their protagonists argue that since general practitioners are independent contractors, they must have the right to arrange for the treatment of their patients and the organisation of their practices as they see fit. They contend that in an emergency a patient—or his relatives—does not necessarily want his 603 own doctor, provided that a doctor is available.

Be that as it may, it cannot be satisfactory that patients may not know, or have any means of knowing, whether their doctor hands over all or any of his out-of-hours calls. In the stress of explaining an emergency to an unfamiliar and, to judge by some of the complaints received, unsympathetic voice, they may fail to transmit the important features of the emergency.

In many ways this deals with the point my hon. Friend was making about diagnosis by telephone. I find it difficult at times to understand how any doctor could give a diagnosis by telephone if he or she is not in possession of the background knowledge of the patient. My hon. Friend made telling points which I hope will be taken note of in the right quarters.

My hon. Friend will be glad to know, however, that negotiations on the central issue which he raises are in train between my Department and the representatives of the profession, and accordingly I do not wish to take up too rigid a stance on this occasion. I should, however, make it clear that in the Government's view patients register with doctors on the understanding that the doctor has contracted with the health board to provide the services stipulated in the National Health Service regulations. The doctors cannot, with any moral justification, claim an unfettered right to sub-contract the provision of these servives to others with whom the health board has no contractual link and for whose treatment the doctor, in the event of a complaint, cannot be called to account by the board.

We recognise, of course, that doctors require time off for study and for recreation and that in some cases this can be achieved only by the use of deputising services. But we are concerned that this should be done in a responsible way and within defined limits, which we hope can be agreed with the profession during the course of discussions and negotiations in which we are involved.

In that context I should say that we have had every co-operation from the British Medical Association in the setting of acceptable standards, and indeed we know it is as anxious as we are to see 604 regulations introduced governing that aspect of the matter. There remains to be settled, however, the question of the use which doctors may reasonably make of the deputising services. Negotiations about this are continuing. In the particular case to which my hon. Friend referred, the family's own doctor was reported as saying that, had he received the phone call, he would probably have acted similarly and prescribed by telephone.

But at least he would have had the benefit of some knowledge of his patient and her family, whereas the deputy had none. Whether, had she been seen earlier, Miss Still's life could have been saved is a question to which we can never know the answer, but her bereaved family would not have been left with the distressing thought that earlier attention might have resulted in a different outcome.

With all these considerations in mind I share the concern which has been expressed that the use of deputising services should be brought under the control of the National Health Service, and that such use be sanctioned only where the health board is satisfied that the standards observed by the particular agency are acceptable to the board.

Perhaps one further point I should make, to avoid confusion, is that what is popularly known as the "emergency doctor service" is not an emergency service provided by the National Health Service, but a privately organised service providing out-of-hours deputies to doctors on payment of a fee. Therefore, patients requiring a doctor out of hours should contact their own doctor. The onus is on him to have these patients referred to any other doctor acting for him. In the event of difficulty in securing the attendance of a doctor, any doctor practising in the area and who is available can be called upon in an emergency to a patient whose own doctor is not available.

The relationship between a doctor and his or her patient is very sensitive. I am sure that my hon. Friend will share with me the wish that nothing that we say—myself as Minister and my hon. Friend as instigating the debate—should disturb that sensitive relationship. By far the vast majority of patients throughout the country place great stress on their faith 605 in their doctors and the relationship to which I have referred.

The general practitioner's job is not particularly attractive. It does not have the attractiveness of the acute specialities to which many consultants are attracted. Often the general practitioner's work is mundane, but he does it well.

General practitioners do not need any tribute from me, but it is right and proper in this debate to place on record our appreciation of the invaluable work that they carry out. They are held in the highest regard by the overwhelming majority of their patients. That is a much better testimony to the regard in which they are held than any tribute that I can pay to them. 606 This has been a very important debate, because it has given the Government an opportunity to air their concern about the deputising service. It has also given me the opportunity to inform my hon. Friend and other hon. Members present of the negotiations which are proceeding to seek to resolve the problems surrounding the service.

For those reasons. I thank my hon. Friend for raising this important issue tonight. I hope that what I have said has helped to clarify the issues and will assist towards the resolution of a long outstanding problem.