Dr. Howard Stoate (Dartford) (Lab):  Thank you, Mr. Deputy Speaker. I shall endeavour to keep my remarks within your eight-minute time scale.

This has been an interesting debate that has raised important issues about the quality and delivery of out-of-hours services in general practice. The hon. Member for Boston and Skegness (Mark Simmonds) highlighted the problem well when he said that the present system was patchy. In many parts of the country, it is unacceptable. We need to do something radical to change that, to ensure that patients in every part of the country have access to good-quality out-of-hours services from whomever is delivering them.

The problem is that I do not agree with the hon. Gentleman's analysis of what needs to be done. He seemed to imply that a return to the old GP commissioning system would somehow improve the situation and put things right. It could well do that in some parts of the country, but it is a rose-tinted view of the situation. This takes us to the nub of the problems that we had before 2004. Some GP commissioners are undoubtedly of extremely high quality and extremely highly skilled, and undoubtedly take a great interest in the service and do a first-class job, but the fact is that most GPs do not want directly to commission. A recent publication by David Colin-Thomé, the national director for primary care, acknowledged that many GPs were not skilled or interested in direct commissioning, and simply did not want to do it themselves. My worry is that compulsorily bringing GPs back into the commissioning role would work in some places but not in others. In other words, we might have a different patchwork, but we would still have a patchwork.

We need to consider why GPs were so keen to divest themselves of their responsibility for out-of-hours care in 2004. They voted overwhelmingly to end the situation in which they were legally responsible for what happened out of hours. I personally know GPs who had been on holiday and who received a complaint when they got back because of the actions of a deputy who had been doing the out-of-hours care for them. The GP, who might have been sunning himself in Spain at the time, was legally liable for the deputy's actions. That was nonsense. It would not occur in any other situation; why should it occur in general practice? Let us also bear in mind the fact that, before 2004, most GPs did not deliver their own out-of-hours services. They contracted them out to deputising services, to co-operatives or perhaps to an in-town rota. Nevertheless, they were legally responsible for the services provided.

It is hardly surprising, therefore, that GPs decided that the situation was unsustainable. If we did the work ourselves, we were worn out the next day and not able to provide the top-quality service that our patients deserved. However, if we divested ourselves of the service and gave it to, say, a commercial service, we remained legally responsible. We were never able to sleep soundly in the knowledge that someone else was truly responsible for our patients. The situation clearly could not continue. It was affecting recruitment and retention, and GPs were retiring early because they simply could not keep it up any longer. The situation was untenable and could not continue indefinitely.

The Government therefore, quite rightly, renegotiated the contract in 2004, and made primary care trusts responsible for the delivery of these services. In most cases, the PCTs simply continued to contract with the same bodies that had already been providing the out-of-hours care. In my area, for example, an organisation called Grabadoc, which covers Greenwich and Bexley doctors on call, was almost entirely staffed by GPs before the 2004 contract, and it got the contract to continue to provide the same service, so almost nothing changed. The only thing that changed was that the responsibility was taken away from the individual practices. That is how it should be.

If anything needs to be learned from this afternoon, it is that we should be much tougher in regulations-I agree with the Minister-to ensure that primary care trusts can be held accountable to deliver the service that they contract. They are legally responsible to provide the service, so it is up to them to monitor it. It is then up to the CQC, perhaps, to monitor whether the PCTs are doing their jobs. If not, they need to be held to account in whatever way is deemed appropriate. That is not a matter for this afternoon, but it needs to be done properly.

In the limited time available, I also want to say that the situation is not all bad. It is easy to concentrate on situations in which something has gone wrong, a patient has suffered harm, or a patient's family has waited an unnecessarily long time for a service, and to assume that the service is generally not very good, but that is not the case. We must differentiate carefully in-hours care, when a GP, who is generally known to the patient, will provide a service with a wide range of back-up, practice nurses, diagnostic equipment, access to colleagues within the hospital or community services, and the full armamentarium of interventions. Out-of-hours provision has never been like that. It has always involved an individual practitioner, generally on their own, making an assessment of a patient they probably do not know, and trying, with the limited resources, interventions, diagnostics and treatments available to them, to provide an emergency service for that patient. It has worked well over the years, and some of the evidence is quite interesting.

I have done some reading of The British Journal of General Practice, as Members would expect, and it clearly draws a distinction. A paper a year ago said:

"When dealing with acutely ill patients in usual in-hours clinic circumstances, the support provided by a competent team in familiar surroundings cannot be underestimated. Not only is the patient likely to be known to the practice, but triage, emergency equipment and diagnostic assessment can also be arranged most effectively".

"In the out-of-hours situation, however, particularly if a home visit...is involved, the GP must deal with many of these aspects alone...clinical decision making is inherently more difficult because patients are much less likely to be known, and options for adequate diagnosis and subsequent patient care are more limited".

It goes on to make the point that GPs vary considerably in their attitude to risk taking. Many GPs can handle far higher levels of uncertainty of risk than others, and therefore perhaps are better placed to make out-of-hours decisions. It is wrong to assume that all GPs are similarly skilled and competent and that all GPs will provide the same decision making in different situations. Certain types of GPs might be much better placed to make such decisions-that is the direction we are going in-and those GPs often become sessional doctors for co-operatives or out-of-hours services because that is their particular skill and interest. They can provide a better service. The situation is very complex, and one size does not fit all. There are different types of doctor in different parts of the country.

Another study carried out in south Wales, and published in the Emergency Medicine Journal in 2008, made a similar point. It found that 80 per cent. of patients were satisfied with the service they received from the out-of-hours service involved. Only a fifth of patients were dissatisfied with the service. The authors examined why those patients were dissatisfied, and concluded that it was due to "a mismatch between patients' expectations of the service and what the service actually provides to some specific user groups."

They concluded that, generally, the service was adequate, but the communication between the patient and service provider was often poor. That point has wide relevance. Quite a few of the worries about out-of-hours care concern a failure to arrive at a clear definition of what an out-of-hours service should provide to patients. Better communication is essential if we are to address that and ensure that patients get the best of the deal.

Previously, most patients were reluctant to call their own doctor out to make a home visit at night, knowing that that doctor would have to carry on their normal surgery the next day. On the few occasions they did call the doctor out, expectations were generally modest. They were so grateful that their own doctor had come to see them that they were reluctant to put abnormal demands on that doctor.