GP Out-of-Hours - Dr. I. Cameron - Transcript - 29 September 2006

Social Affairs Scrutiny Panel

GP Out of Hours Review FRIDAY, 29th SEPTEMBER 2006

Panel:

Deputy F.J. Hill, B.E.M., of St. Martin (Chairman) Deputy D.W. Mezbourian of St. Lawrence

Deputy A.E. Pryke of Trinity

Witness:

Dr. I. Cameron (GP)

Present

Mr. W. Millow (Scrutiny Officer)

(Please note: All witnesses and Panel Members were given the opportunity to comment upon the accuracy of the transcript. Whilst the transcript remains a verbatim account of proceedings, suggested points of clarification may have been included as footnotes to the main text.)

The Deputy of St. Martin :

Yes. Well, can I formally say good morning to you and thank you for coming. I am Deputy Bob Hill, the Chairman of the Social Affairs Scrutiny Panel. I think you know my 2 colleagues but they will introduce themselves for record purposes.

Deputy D.W. Mezbourian :

Deputy Deidre Mezbourian of St. Lawrence .

The Deputy of Trinity :

Anne Pryke, Deputy of Trinity .

Mr. W. Millow :

William Millow , Scrutiny Officer.

The Deputy of St. Martin :

The lady in the corner is the lady who is taking all the recordings and I would ask that you keep your voice up because everything is transcribed. Also, you were sent a letter informing you of the privileges, et cetera, the protocol that goes here?

Dr. I. Cameron (General Practitioner from Cleveland Clinic): Yes.

The Deputy of St. Martin :

So, with that, I now thank you for coming and also, for the record purposes, could I just ask you to give your full name and your details, please?

Dr. I. Cameron:

Doctor Innes Cameron, General Practitioner at Cleveland Road.

The Deputy of St. Martin :

Okay, fine. As I said, we thank you for coming. Just to clarify the situation, could I ask what capacity you are going to come here this morning? Because, as I understand it, the Cleveland practice have made an application now to join the JDOC.

Dr. I. Cameron: Yes.

The Deputy of St. Martin :

But you have views which may be your own which may not be compatible with that of the Cleveland practice.  Maybe if we just deal with that little area first before we go through the line of questioning.

Dr. I. Cameron:

Yes, of course. Yes, I think I represent not Cleveland Clinic this morning; I represent just myself and probably a few other general practitioners with similar views. I am not sure of the number of those.

The Deputy of St. Martin :

Yes, okay. Could I just ask what your reasons for dissenting from what may now appear to be almost -- you have got your list, well done.

Dr. I. Cameron:

Well, I had a little think about, you know, what the setup of the co-op might mean for the on-call arrangements in the Island and I guess it has got lots of potential ramifications. I suppose the first thing really is costs. I am aware that Cleveland Clinic have made an application, for instance, to join the co- op within the next month or so, as a consequence of which our night-visiting fees will automatically go up. They are going to go up by about 15 per cent because the co-op have a set rate, and it is significantly higher than it is at Cleveland. So, just for the sort of day-to-day basic basis, that is going to raise the costs for our patients. I imagine that is not limited to Cleveland Road because although we were not one of the higher charging practices in the Island, we certainly were not one of the cheapest;

we were somewhere in the middle. So, if it has that implication for our patients, it must have that implication for others.

The Deputy of St. Martin :

Could I ask you on that question about fees: is there a charter or a list anywhere of what practices charge? Because you are telling me that Cleveland are somewhere in the middle but --

Dr. I. Cameron:

Yes, there used to be every year in the JEP a list of the fee rates for practices and a spread was given; top, bottom and some sort of average was written. That used to be an annual thing that came out in the JEP and I think it was done last year, as would be expected. That is sort of how we know, really.

The Deputy of St. Martin :

But when you talk about costs, are there any other particular reasons that you think is a disadvantage of going into --

Dr. I. Cameron:

Oh, going into the co-op? Oh, many, many disadvantages. At the moment you have, I do not know, half a dozen general practitioners on call for the Island. When the co-op is running, there will be one, maybe 2. Now, clearly, the workload and your ability to cover the geographical area is going to be reduced. Whilst you have got 6-8 general practitioners attending to however many practices they do, you have a, you know, bigger capacity. That is going to be reduced significantly. I guess it is pretty much a fait accompli now that all practices are going to join the co-op. The pressure to do so from a number of places is significant and that is one of the reasons we brought our decision forward to join the co-op. We were not due to review this until October of this year but we brought that decision forward because there were other pressures. Home visiting is a really important part of general practice. It is where you find out what goes on in people's houses, it is where you find out what makes families tick, it is sometimes often where you find out why people are presenting with illnesses. To some extent, it is difficult to find out what goes on inside a family without visiting their home and see where they live and how they live. If I am on call for the co-op, I will be going out to see patients who I would probably never see again. What ultimate value is that for family practice? I also will not be going out to see my own patients who I would otherwise have been going out to see.

The Deputy of St. Martin :

I just make it quite clear, I am a member of the Cleveland practice. Fortunately, I do not see my doctor very frequently because I am in good health, but if indeed I wanted a doctor tonight, there is no guarantee that I would get the doctor that normally sees me.

No, that is true but if I go and see somebody in the middle of the night, the chances are I would know them or have met them. I have been at the practice for 17 years, I know an awful lot of the patients there, particularly the ones that are calling at night. So, the chances are that you might see somebody whom you have met, whom you have a relationship with, whereas, clearly, if there are 120 general practitioners in the Island join the co-op, or however many there are - I do not know how many there, 110, 100 - your chances of doing that are much smaller. I will be moving from a system where I am on call 3 nights a month to a system where I am on call 3 nights a year. That then comes to the question of experience and exposure for general practitioners as it does for every other doctor. This is a significant issue in the UK for training purposes. Junior doctors are not doing the kind of hours that we were doing when we were younger. You cannot get the mileage under your belt that you need to do unless you go out and do it. How are you going to have experience with dealing with people at home if you do not go? How do you keep up your skills of visiting people at night? Well, if you are not doing them, you do not.

The Deputy of St. Martin : So, are you saying that --

Dr. I. Cameron:

You become more apprehensive about it, you withdraw from it. I mean, that applies to all aspects of medicine, you know, whether it be surgery or whatever: if you are not doing it, you get less good at it so you withdraw from it. That causes me some concern as a practitioner because I do not want to lose my skills.

The Deputy of St. Martin :

So, costs, knowledge.  I do not know if you have got any other questions before we ...?

The Deputy of Trinity :

Just going back to your first point there, Innes, about the cost of visiting patients at night, are your costs different to kind of when a surgery closes?  It is what time?  7.00 p.m.?

Dr. I. Cameron:

Well, Cleveland Clinic, I think, is probably a little bit peculiar: we are open until 8.00 p.m. and have been as long as I have been a member of the practice. I do not know what is going to happen because it is not something that we have discussed yet, but I can see that the discussion is coming. If we were working for the co-op from 6.00 p.m. until 10.00 p.m. in that clinic, which one of us will have to do on 4 nights a month, why are we also opening Cleveland Road from 6.00 p.m. through 8.00 p.m.? So, this discussion is going to come within the practice. So, are we then going to narrow our service down to the patients? Bearing in mind that to go to the co-op between 6.00 p.m. and 10.00 p.m. costs £40 and to come to Cleveland Clinic between 6.00 p.m. and 8.00 p.m. costs £26. It may not happen. I do not know

how that discussion would go within the practice but I can see that it might be coming.

The Deputy of Trinity :

Right.  So, your costs are different from, say, when the practice closes at 8.00 p.m.?

Dr. I. Cameron:

Our charges at 8.00 p.m., yes, because we --

The Deputy of Trinity :

8.00 p.m. until --

Dr. I. Cameron:

Yes, 8.00 p.m. until 8.00 a.m.  We would be closed from 8.00 in the evening until 8.00 in the morning.

The Deputy of Trinity :

Right. So, do you have different charges --

Dr. I. Cameron: For night-visit rates?

The Deputy of Trinity : Yes, after 8.00 p.m.?

Dr. I. Cameron:

Yes, we have an early evening visiting rate, which is less than our top rate, and our top rate is still significantly less than the rate that the co-op charges.

The Deputy of Trinity :

Have your fees increased this year?

Dr. I. Cameron:

Our fees increase every year and have just done so and they increase at the cost of living.

The Deputy of Trinity : Just at the cost of living?

The Deputy of St. Martin :

How do you rate the cost of living?

Dr. I. Cameron:

The cost of living comes from, you know, whoever does it in Jersey. Somebody produces that at Cyril Le Marquand House, do they not? The tax office produce a figure.

The Deputy of St. Martin :

Just as a matter of interest, how many patients does the Cleveland Clinic have?

Dr. I. Cameron:

Well, that is a very difficult thing to gauge in Jersey. There is no registration process, no patient is bound to any -- one of the beauties of general practice in Jersey. We would think we have probably got about 16,000-18,000 active patients, if you call an active patient somebody who has been seen within the last 3 years. As far as you can judge it, there is probably - I do not know - 4 or 5 per cent of patients who they go to see different practices all over the place and I am sure that happens elsewhere too. It is just easier to do it here.

The Deputy of Trinity :

You talked about some patients that you see regularly, getting to know their home situation, their home circumstances; do you get a group of patients that tend to call you out at night time?

Dr. I. Cameron:

Inevitably, that is so. I do not think that was quite what I was getting at, though. You know, when families have crises, and I am not talking about the sort of group of patients that you are talking about who maybe call you out and who see you in surgery lots and lots of times - I have a few concerns about them too - but I am talking about when families have crises or people have crises, often it is at night time. To understand their crises, you may need to visit them at home. You know, if they come into surgery, it is difficult to gauge somebody's crisis when they are sitting next to you because they present a completely different face to what is going on at home. Crises often occur at night, in the dark, in the small hours of the morning.

The Deputy of St. Martin :

Can I just ask, are there any arrangements within JDOC that if indeed Cleveland do become members of it and, say, I want you to come to me now you are in JDOC, will the arrangement still be that I can still call up my GP or will it be just the fact of JDOC? That only JDOC people can come and see me once you are -- do you know how strict the rules are?

Dr. I. Cameron:

I guess the answer to that is that there are not any rules about it. If you ask me how do I think it will work in practice - and it is only my view - I suspect that what would happen is they would say: "I am sorry, your own GP is not available", unless you have a sort of private and personal arrangement that you can pick up the phone and speak to your own doctor. Because otherwise there would be no point in being part of the co-op because you would be on call every night. So, I think that is pretty likely to end up being a fait accompli but, you know, I do not know that. I suspect there is nothing been written about that. You know, for instance, on Sunday a patient of mine phoned up my practice and called and said they wanted to speak to me, so my partner then rang me at home and said: "Look, is it okay?" so then I rang the patient back. Now, in the confines of JDOC, I imagine they will just deal with the call, I think, but I do not know that.

The Deputy of St. Martin :

You would lose the personal touch.

Dr. I. Cameron:

That is speculation on my part. Coming back to the group of patients you were talking about, the ones that might be calling you up lots of times at night - and, yes, there are some patients who call us out lots of times in the night - you know, these are people with, you know, big ... or inability to cope with all sorts of things in their lives. They attend and use the facilities and services frequently during the daytime and also at night. I know that new income support is coming in. I cannot say I am familiar with how that is going to work exactly. I would sooner be concerned that HIE (Health Insurance Exception) patients, many of who are going to be getting income support, will be given on an average sort of basis. Now, we all know that those with the least wealth are the most needy and they are going to be the least able to cope with that system and the very people you want to try and avoid ending up in that quagmire are probably going to end up in it. At the moment, the accident department provides a great sponge for minor things that, okay, maybe should not be seen in the accident department but it is where patients go. I know that already patients are being sent from the accident department around to the co-op and it is happening now. So, what is happening to these HIE patients who cannot afford, for whatever reason, to pay for a doctor's visit or to see a doctor? Because, you know, what is going to happen to them then? I do not know and it worries me. Now, if they phone me up at 3.00 a.m. and I know them and I saw them at 3.00 p.m., I could say: "Mr. Smith, it is okay, you can wait until the morning" or whatever, or: "I need to come." Because we all know these families. Within our practice, we know them all because we have all seen them lots of times.

The Deputy of St. Martin :

Okay, just whilst we are talking about fees, please, Sir, is it possible for us to have a copy of the fee structures for Cleveland?

Dr. I. Cameron: Yes, I am sure.

The Deputy of St. Martin :

I am interested. You are saying at the moment if someone wanted to come to Cleveland practice between 8.00 a.m. and 8.00 p.m., it would be £26?

Dr. I. Cameron:

8.00 a.m. to 8.00 p.m., in the surgery.  £26.  That is a flat fee.

The Deputy of St. Martin :

If indeed a patient - it could be me, anyone else here - wants to come and see a doctor after 8.00 p.m. but before midnight, what would the arrangement be?

Dr. I. Cameron:

We would make arrangements to see them at home.

The Deputy of St. Martin : So, the fee would go up?

Dr. I. Cameron:

The fee would be up, yes.

The Deputy of St. Martin :

Yes. So, it could be argued one of the advantages of having the surgery between the current hours --

Dr. I. Cameron:

You could argue that. Do you know what the current callout rate is between 8.00 p.m. and 8.00 a.m.? 1.1 callouts per night.

The Deputy of St. Martin : Sorry, what time is that?

Dr. I. Cameron:

At Cleveland Road, our night visit rate between 6.00 p.m. and 8.00 a.m. is 1.1 visits.

The Deputy of Trinity : For 18,000 patients?

Dr. I. Cameron:

Yes, as best as I can gauge it. Some nights you get 3, some nights you get none. So, it is not a huge --

yes, that 1.1 visit would cost you probably about £45 more than a surgery visit would.

The Deputy of St. Martin : So, about £85 to go --

Dr. I. Cameron:

It is about £75, so £26-£75 for an early evening visit.

Deputy D.W. Mezbourian :

What discretion, if any, do you have in the fees that you charge?

Dr. I. Cameron:

Total, really. As an individual practitioner, yes, we set fees. If I take the surgery situation, for instance, we have a fee structure there where we have 5 different ranges of fees from £26, which is our standard rate of fee, under 5s are charged approximately a half, but we have discretion within that to reduce it further if we choose, or to charge nothing, of course. I mean, you can just charge a signature, a refund. Or you could waive the refund if you felt it was appropriate. I guess we sometimes have visitors, people from abroad, who are, you know, working in difficult conditions and you might waive a fee completely for them.

Deputy D.W. Mezbourian :

If you were to join JDOC, are you aware of whether or not you would still be able to use that discretion when passing charges to the patient?

Dr. I. Cameron:

My understanding is that we do not have that discretion but I really do not know.

Deputy D.W. Mezbourian : If your practice joins

Dr. I. Cameron:

Can I tell you that the vote to join the co-op was not unanimous; it was a majority vote and we run a very democratic practice and so, you know, we have to go along with that as a practice. We have decided -- we have voted to join for one year and to review the situation after 12 months.

The Deputy of St. Martin :

How many doctors have you got? I asked how many patients; how many --

We have, for the purposes of this exercise, 12 doctors.

The Deputy of Trinity :

When JDOC first came to be talked about and discussed, you did a patient survey of your patients?

Dr. I. Cameron:

Yes, yes.  It was not a very extensive patient study.

The Deputy of Trinity :

But you were the only practice --

Dr. I. Cameron:

We did.  Well, we had replies from about 200 patients in the end.

The Deputy of Trinity :

Right. So, with this new decision that your practice has made, have you been back and discussed with the patients?

Dr. I. Cameron: No.

The Deputy of Trinity : No?  Are you going to?

Dr. I. Cameron:

No, there is no intention to.

The Deputy of Trinity :

Right, okay.  What pressures are being put on your practice to join?

Dr. I. Cameron:

The pressures are principally internal. Well, what influences people's thinking, you know? There is a problem with recruitment of general practitioners nationwide and that affects Jersey. I think it is perceived that the absence of a co-op is a negative feature in attracting new doctors to come to the practice, or to come to Jersey, full stop. So, that is quite a topical issue because we have got a partner that we are trying to replace and it has been very difficult; we have been looking for 2 years to get somebody to come and replace the partner. So, that is, I think, quite an acute point for us as an individual practice. It is not the only pressure, I think, and I think focussing on the co-op side of things and the on-call side of things is probably a little bit limited from our point of view, but that is quite

important. But there was pressure put on originally from JDOC. They had sort of made some sort of punitive measure that if you did not join on the date that they started the co-op that you would be penalised. They have subsequently dropped that - I am aware of that - but I think the fact that they took that line in the first place probably left a bitter taste in some people's mouths. It was not a very nice tactic. So, that sort of pressure from individuals within the practice is there, you know, for whatever reasons that they may want to join the co-op, and they are mixed.

Deputy D.W. Mezbourian :

Why did your practice reconsider?

Dr. I. Cameron:

For those reasons, I think. Yes, for those reasons, yes. There are some vociferous voices; with a 12- man practice you get all sorts of personalities and, you know, it is a normal tactic within any committee. We run, basically, a committee that if you want something to happen, you bring it up at the next committee meeting and then the one after that and then the one after that until everybody gets tired of hearing about it. You do, so you say: "All right, then, let us ..." You know, it sways a few people one way or the other.

Deputy D.W. Mezbourian :

What do you think the overriding decision was for the joining? Would it be correct to say it was for the benefit of the patient?

Dr. I. Cameron:

I am struggling to find a benefit for the patient. I can see lots of benefits for me, really. Well, they appear beneficial anyway in that I will not have to be on call very often. Whoopee. But from what I have said already, that is a double-edged sword. I am not sure what benefit there would be for the patient. They get to see a different doctor; that is not a bad idea. You know, sometimes your familiarity breeds contempt. Well, maybe not contempt but, you know, so having a fresh face and a new look at things is quite good, so there can be some benefit there.

Deputy D.W. Mezbourian :

Going back to what you said earlier about certain skills being acquired or necessary for home visits, are those skills that cannot be learned or acquired in other situations?

Dr. I. Cameron:

I do not think that if you sit in your ivory tower that you can really understand what is going on in people's homes.  Yes, I do not think you can.

I would agree with you on that.

The Deputy of St. Martin :

Okay, were you going to look at number 3, were you?

Deputy D.W. Mezbourian :

I do not think we have touched on this. We have been asking you rather a few questions in quick succession, but when did Cleveland as a practice first become aware of plans to introduce the JDOC system?

Dr. I. Cameron:

Well, I guess it would probably be I mean, a co-op was talked about probably 4 years ago, 5 years ago, and did not take off. This current arrangement, I guess, various people of the practice were involved in, I guess, probably a year or so before it took off. I would think 12 months plus before it -- because, you know, feelers were put out, you know, would you be in it, you know, all that sort of thing was going on in the background all the time. So, yes, we had all been aware of that well in advance of when it started.

The Deputy of St. Martin :

Has there been, really, any resistance because of the people involved in setting it up or was it just a general feeling that a co-op was not really necessary?

Dr. I. Cameron:

I do not think it is a personalities thing, no. See, because we are a 12-man practice, we sort of run our own co-op anyway, really, and the necessity for us to do it was slightly different, probably, from, say, smaller practices. You can see that for a smaller practice who might be on a couple of nights a week, you know, it is a good thing because I do not think I would want to be on more than 3 nights. I would not want to be on call more than 3 nights a month, that is plenty. I think less than that you are probably, you know, not exposed enough.

The Deputy of St. Martin :

Are there many other practices with a number of 12 or more or are you --

Dr. I. Cameron:

No, there are no others. There are 1 or 2 getting close to 10 now. Practices have expanded their size greatly in the last 5 years. There has been a couple of amalgamations and so there are now sort of 4 or 5 bigger practices, but I still think we are still numerically a little bit larger than the others.

If your practice was to join, what compulsion is there for you --

Dr. I. Cameron: As an individual?

Deputy D.W. Mezbourian :

-- as an individual who is not in favour of the system to take part in the service?

Dr. I. Cameron:

I think the same as there would have been within the service we currently run. I am responsible for my 3 nights a month. I can sell them to one of my partners or I can buy a 4th or 5th or 6th night from one of our partners and the same applies to the co-op. I do not really think there is any difference in that respect. I suppose when it comes to individual people, they have to make up their own mind about how they want to go about that. We made a democratic decision to join. I think you just have to get on with it and go along and serve your patients - or the patients - as best as you feel you can when it comes to your turn. Again, I am aware that some people have some longer nights and other doctors or partners or practices are doing them for them and think that is -- you know, as far as individual choice for practitioners is concerned, that was largely the purpose of the co-op. Some people do not want to do on call; other people want to do more.

Deputy D.W. Mezbourian :

So, by implication, I believe you are saying that you possibly would continue to work the out of hours?

Dr. I. Cameron:

Oh, I will continue to at least look after my responsibility that I am party to, yes, without -- I might do a little bit more than that. It depends. I do not really know how it is going to pan out until you have, you know, taken part in it. But for the next year, until we make some other decision, I certainly intend to, you know, take part in the co-op as I am not duty bound to do but -- yes, it is important for me, of course. It is a valuable part of my job.

Deputy D.W. Mezbourian :

What do you think your reaction would be if you were to visit a patient and you thought that their home circumstances were perhaps questionable or should be referred to their own GP for consideration?

Dr. I. Cameron:

You would hope that the communication systems, you know, are going to work properly and send the information. I mean, clearly that is more complicated with 20 practices than it is within our practice where that sort of thing goes on on a daily basis. I come in in the morning, we put it in the computer now or you stick it on a bit of paper and you pass it on to the relevant doctor. You know: "I went out to

see this patient last night and, you know, X, Y and Z; can you do something about it?" You know, that is clearly a really important issue. If I go and see somebody's patient in the middle of the night for whom I have ultimately no responsibility, am I really going to look after them as well as I might have to meet them in surgery a week later and they say: "Oi, why did you not do what you said you would do?" Or meet their own doctor and have to say to them: "Oh, I forgot", you know, or for whatever reason you might -- that sort of communication is not -- again, I am long enough in the tooth to realise that not every consultation you go out on is going to go swimmingly. Supposing it does not go swimmingly, how are you going to, you know, mend that situation? Mostly, I think people just will not even know about it.

The Deputy of St. Martin :

Sorry, we are just coming on to that, I will let you finish, but surely if you go to a patient at night and you give whatever treatment you are going to, but then you will then send a form on or something, there will be some notification to a doctor there?  So, that must happen already at Cleveland?

Dr. I. Cameron:

Yes, absolutely, yes.  Yes.

The Deputy of St. Martin : Is it working fairly ...?

Dr. I. Cameron:

It works pretty well, yes. You know --

The Deputy of St. Martin : Because you have regular contact?

Dr. I. Cameron:

Yes. Well, that too. At 3.00 a.m. when you are writing up your notes, do you always write up the notes that you should be passing on to the next doctor? You might not do, you might do it the next day, you might see the doctor the next day. The chances of you doing that are better, I think.

The Deputy of St. Martin :

You say that would be one of the weaknesses of the co-op system?

Dr. I. Cameron:

I would imagine it might be. Not just the passing on of clinical information but also if things do not go swimmingly. You know: "I will just ring up that Dr. Cameron and I will just tell him that he made a right mess of last night." Are they always going to do that or are they just going to say: "Oh, he is always doing that; we will not bother telling him", you know? So, whereas within our practice these sort of things, we discuss them, they are open to discussion for all of us, we have a meeting once a month and that sort of thing goes on, we have processes in place for that; JDOC are not going to meet once a month and discuss clinical situations.

The Deputy of Trinity :

Just to pick up that point even more, if with JDOC - and I know it is difficult for you to surmise - but if you felt that a night time consultation did not go very well for whatever reason, would there be any way that you, the next day, could retrieve it in some way?

Dr. I. Cameron:

I would think so. I mean, I guess that is up to the sort of skill and ability of individual practitioners, you know, to recognise those sort of things. We do not always. We have them thrust in our faces by our partners who are good enough to tell us: "That patient you thought had indigestion had a heart attack. You should have done X, Y, Z differently" or: "Maybe you should have done X, Y, Z differently." Now, if the patient belongs to a different practice and all the material from the hospital admission goes back to the different practice, I am never going to hear about it. I have not even got a chance to stumble over it, for instance. So, you know, that is sort of -- and in the day-to-day running of a system, are you going to send on all those bits of paper to all the different practices wherever they might -- because, first of all, you have got to find out who visited the patient, who sent them in, where the information went. I am not sure if that is going to happen but I might be wrong and, you are right, I cannot surmise about that but I know that it happens within our practice.

The Deputy of St. Martin :

Did you pass these concerns on to anyone at all from JCRA?

Dr. I. Cameron:

I had a very long chat with Charles about 6 months ago when I discussed all of our concerns with him and they are, you know, pretty much what we have discussed today. So, yes, I had a long chat with him about that.

Deputy D.W. Mezbourian :

Do you believe that your concerns were taken into consideration?

Dr. I. Cameron:

Yes, that is why I am here, is it not?

Deputy D.W. Mezbourian :

No, I mean, when you spoke to the JCRA?

.

Dr. I. Cameron:

Charles seemed to listen very carefully to what I said.

Deputy D.W. Mezbourian : Have you read their report?

Dr. I. Cameron:

I do not think so. No, in fact, I do not know I was aware that they had made a report. JCRA? No, I do not think so. No, I was not aware of a report from JCRA.

The Deputy of Trinity : Would you like a copy?

Deputy D.W. Mezbourian : We can supply you with a copy.

Dr. I. Cameron:

I would be interested to look at it, yes. Yes. Currently, the JCRA are just, I think -- you know, they are looking into our application and that is the only sort of contact that I have had recently with the JCRA. They had mooted that they were going to do a survey within our practice, you know, of patient desires about the on-call service after I visited them originally and then nothing happened; it all went quiet.

Deputy D.W. Mezbourian :

That may be something that they will give consideration to now that your practice has applied to join and perhaps - you seem fairly proactive, from my first meeting with you - it is something that you should remind them of.

Dr. I. Cameron: Maybe, yes, yes.

The Deputy of Trinity :

In that JCRA report, there are quite a few conditions about the review process and that if any other GPs wish to join the practice then they have to, like you are doing now --

Dr. I. Cameron:

Joining JDOC, you mean, or --

Dr. I. Cameron: Yes, yes.

The Deputy of Trinity :

Then they have to go through the JCRA. But there are a number of conditions but the exemption is through until the end of March anyhow.

Dr. I. Cameron:

I see, through to March? Okay, so, yes, right, okay, sure. Yes, we had sort of decided at our practice to review it after a year but it looks as though we will be reviewing after 6 months by the sounds of things, which is fine.

The Deputy of Trinity :

With this current application that you have got in with the JCRA, are you going to make a personal submission to them about --

Dr. I. Cameron: To JCRA?

The Deputy of Trinity : Yes.

Dr. I. Cameron:

I do not think so. I mean, I think I have said -- you know, I have said my piece to you guys and I think they are aware of my views. You can only say it so often. You know, once -- I do not know.

The Deputy of St. Martin :

Some of the positives and the negatives, one would hope, would go in with the reports or the application that has been made on behalf of Cleveland.

Dr. I. Cameron:

You know, you are really talking about --

The Deputy of St. Martin :

Because really, what you are doing, you are saying if Cleveland come in, they are going to profit out of it because the fees will be much higher?

Dr. I. Cameron:

See, there is another good question.  Who is going to profit out of that?  I do not know.

The Deputy of St. Martin : Well, the patient will not.

Dr. I. Cameron:

I do not think so. I do not think the taxpayer is going to profit out of it, which is something I do not understand, I have to say. As I understand it, the setting up of the co-op has been subsidised by public money. Why? That money could have been spent on healthcare. It has been spent -- I do not know what it has been spent on, health administration, I suppose, I do not know. Somebody has done something with it.

The Deputy of St. Martin :

We will be seeing the Minister --

Dr. I. Cameron: Is it value for --

The Deputy of St. Martin :

That will be a question we will be addressing with the Minister of Health, Sir.

Dr. I. Cameron:

Ultimately, do I object or, you know, I might not think a co-op is a good idea for Cleveland Clinic. I can see that it is a good idea for some general practitioners in the Island but, of course, we work in a competitive, open market. Patients can go and see who they like, you know, and choose what value for money they get.

The Deputy of St. Martin :

If I lead on to number 5, and I think we touched on that one, really, and ask --

The Deputy of Trinity :

Yes, we have asked quite a lot of questions or Innes has ...

The Deputy of St. Martin :

Yes, I think we have covered 4, really. But really, we are looking at since the introduction of the service, has there been any impact at all on patient numbers that you are aware of? Because one of the arguments has been that if it could be cheaper going to the co-op, those doctors who were charging more

would lose their patients.  That was an argument.

Dr. I. Cameron: Sure, sure.

The Deputy of St. Martin :

Have you noticed any impact at all?

Dr. I. Cameron:

On our day-to-day patients, you mean, the ones that come to see us during daylight hours?

The Deputy of St. Martin : Or any time, for that matter.

Dr. I. Cameron:

No. We have not seen a difference. I do not think so. I do not think so. I mean, I would say about night visits, you know, that night visiting has been in decline over the last 15 years in Jersey anyhow.

The Deputy of St. Martin : Any particular reason?  Costs?

Dr. I. Cameron:

No, I cannot say that I have got a very good answer for that really. I do not know why that is so, but I can tell you that night visiting rates have gone down over the 15 plus years that I have been there. What I used to do on a night on call is very different now than it was then. Like I said, 1.1 is the average visit number per night for Cleveland Road and it did not used to be.

The Deputy of Trinity :

Would you say that as you have got 12 GPs in your practice and 18,000 patients, have you got the highest number of patients in a practice? Because you have got --

Dr. I. Cameron:

I do not know but I suspect so. I mean, yes, I guess just in terms of doctor mass you must have, and we are open 8.00 a.m. until 8.00 p.m., we are open Saturday mornings at 3 separate sites. So, yes, you know, that is all part of the service provision, is it not? That is what makes you different from other practices. That is why they come to see you.

The Deputy of St. Martin :

You have a cost implication as well because you are running 3 surgeries; those 3 surgeries have to be

costed.

Dr. I. Cameron:

We have that but, of course, if your surgery is full, it makes sense but if all of a sudden, you know, you join the co-op and you find, you know, St. Brelade is empty, well, we had better close it because we cannot afford to run a place that is empty in any event. That is part of what I am saying about, you know, if you have got a practitioner -- and we have our responsibility for the evenings for JDOC between 6.00 p.m. and 10.00 p.m. when they are in a clinic, you know, we will have our responsibilities for that, but we also run 3 sites. I do not know how it is going to work yet. That is a discussion that we have not had.

The Deputy of St. Martin :

You may well have to reduce your service because of the cost?

Dr. I. Cameron:

Well, I guess ultimately that would be part of the mix. It is not a view we have taken yet because we, you know, run 3 surgery sites on a Saturday morning and we feel it is part of the service arrangement that we have with our patients. I mean, it is not ultimately; it is just something that we feel reasonably strongly about. Saturday mornings are not always busy but we still operate 3 sites with 4 doctors.

The Deputy of Trinity :

Then in the evening, between 6.00 p.m. and 8.00 p.m., when you are open, it would be cheaper to come to you than it would be to go to the JDOC, will it not?

Dr. I. Cameron:

Oh, yes. For 1.1 patients per night between the hours of 8.00 p.m. and 10.00 p.m., it will be cheaper to go to JDOC and then it will become more expensive again.

The Deputy of St. Martin :

Are you likely to keep your surgeries open until 8.00 p.m.?

Dr. I. Cameron:

That is exactly what I am saying; I do not know.

The Deputy of St. Martin : One of the questions.

Dr. I. Cameron:

We have not had that discussion yet.  What will our view be a year down the line?  I do not know.

The Deputy of Trinity :

Yes. Talking about some of the funding from Health and Social Services, and I understand they have put in the region of £84,000 to £100,000, have you --

Dr. I. Cameron:

Is that per annum or just a single figure or ...?

The Deputy of Trinity :

I understand a lot of it is staffing, so I presume per annum. Have you received any extra funding from Health and Social Services to compensate that they have given?

Dr. I. Cameron:

We are a private business and would not expect that.

The Deputy of Trinity : Right.

Dr. I. Cameron:

I had thought that all general practitioners were private businesses. If you wanted to set up a co-op, fine. Why is the public paying for it?

The Deputy of St. Martin :

Those are questions we will be asking the Minister.

Dr. I. Cameron:

You know, that is why I say, you know, effectively, we have a co-op and have done, you know, for many years and it works great. Why do you need -- well, £100,000 then, we will call it, the conservative per annum of public money?

The Deputy of Trinity :

One of the other reasons for being in a co-op was that -- sorry?

Dr. I. Cameron:

But if you were offering to pay us £100,000, we might not join the co-op. [Laughter] I am sorry, go on.

That is all right. One of the reasons said about being part of the co-op was the clinical governance to be put in. I mean, how would you see that coming into place? Like, if you were going to join the co-op, how would you and your practice feel about clinical governance?

Dr. I. Cameron:

Sorry, just say that question again?  If we were going to join or we were not?

The Deputy of Trinity : Yes, or both ways.

Dr. I. Cameron:

Yes, I mean, if we are going to join the co-op, that is fine. That is absolutely okay. You have got to get on with that. It is part of normal practice nowadays, is it not, to have some sort of governance over what you are doing and some level of supervision and standard setting. I mean, those are sort of, to some extent, expected. As we are, within our practice, we certainly have a sort of informal arrangement, we have a process for dealing with complaints which goes through, you know, our multi-practice meeting and practitioners have to reply and justify their actions in circumstances where they are, you know, perceived by somebody not to be acceptable. So, we have that sort of, you know, probably what might be described as a light-touch supervision in what we do. Of course, because we work at a practice together, you know, if something raises an eyebrow with one of us, you know, we discuss it. We have a monthly meeting, we discuss clinical matters, and we discuss business matters at that monthly meeting.

Deputy D.W. Mezbourian :

You touched on recruitment difficulties earlier. How do you think being part of the co-operative would impact upon recruitment?

Dr. I. Cameron:

Sure. I do not know; it is a difficult thing. I think it is perceived as being very important. It is perceived to be very important. But I was looking at some adverts in the British Medical Journal this week and last week, not because I am going to move but because I was aware that this was an issue. You know, one of the adverts I looked at was from an island elsewhere in the British Isles and I looked at their salary and their holidays and their study leave and their working week and their on-call commitments, and all of those things are very, very different from how things are here. You could see that in that circumstance recruitment in Jersey might be difficult but, you know, Jersey has its own merits that make it different from that other little island and, you know, maybe they are having difficulty recruiting people too. There is a big problem with recruitment.

The Deputy of St. Martin :

Is it because of lack of doctors being trained, basically?

Dr. I. Cameron:

Yes, yes.  There is a huge crisis in doctor training in the UK.

The Deputy of St. Martin :

Would you say it is a bit of a myth then, the issue about the co-op?  It would be helpful but ...?

Dr. I. Cameron:

Sure. I think it is one of the factors in deciding whether to go somewhere. I mean, interestingly, I think in the UK more and more you see a reversal of the trend for co-operatives. You see places popping up now and you can see that they are starting to do their own on call and there is some private practice going on. The sort of system that was clambered for 10 years ago is sort of running into crisis because they are staffed with people from Nigeria and Poland and Czechoslovakia, all perfectly good practitioners but the general practitioners, you know, the people who look after these families during the day are not doing the calls, they are not visiting. Recruitment is a problem.

The Deputy of St. Martin : Yes, okay.

Deputy D.W. Mezbourian :

Can you say what the other island is?

Dr. I. Cameron:

Oh, the Isle of Bute, it was.

Deputy D.W. Mezbourian : Okay.

Dr. I. Cameron:

The Isle of Bute.  Yes, very nice.  I looked at the advert, they have 14 weeks' annual leave.

Deputy D.W. Mezbourian : Fourteen?

Dr. I. Cameron:

Fourteen weeks' annual leave, paid study leave, a 4-day working week.

The Deputy of St. Martin :

Is that to get people to work up there, is it?  [Laughter]

Dr. I. Cameron:

Well, but they have -- that is exactly what I am saying. Jersey has, you know, other attractions, does it not? You know, it is a beautiful -- I am sure the Isle of Bute is a beautiful place to live too, but ... yes. Yes.

Deputy D.W. Mezbourian :

How do you compete with an advert like that for recruitment?

Dr. I. Cameron:

You have to use your imagination and produce something which looks attractive, I think, you know. Try and --

Deputy D.W. Mezbourian :

So, if you were to show in the recruitment advertisement that you belonged to a co-op, do you think that would be an attraction?

Dr. I. Cameron:

I think it is a perceived attraction by people applying. It is difficult. Obviously, it is difficult for me to say; I have not applied for a job for nearly 20 years now, I think it is. So, yes, my perception is that that is important to people, that you are part of -- that they are not doing on call, you know. People want to work from 9.00 a.m. until 5.00 p.m. and have a one-hour lunch break. You know, and one of the things that got mentioned is that people's illnesses do not occur between 9.00 a.m. and 5.00 p.m.. That is what I was saying about crises. Crises happen in the night; that is when people get ill. Really, if I was having a crisis in the night, I would like to have an experienced general practitioner and maybe one who knew something about my circumstances and my family and who had an investment which was not purely in how I got better, that they would see me tomorrow or next week or next year or my grandfather or my father or my children.

Deputy D.W. Mezbourian :

I wonder if I might refer to the joint working party that produced some information on the proposed GP out of hours service. They looked at benefits of the proposal. One that we have not mentioned as being of benefit to GPs is the provision of a driver to aid the safety of the GP. What would be your comments to that?

Dr. I. Cameron:

I have never been threatened, felt threatened, within Jersey when visiting. I have been to see a few

patients wielding large knives and I never felt threatened by them and, if I had done, I would have called the police. So, is that real or perceived? We live in a very fearful society. Our children are not allowed to cycle to school on their bikes because it is too dangerous, you know, they cannot walk in the streets at night because it is too dangerous, they cannot play outside because it is too dangerous, and now general practitioners cannot drive to their patients' houses because it is too dangerous. How many general practitioners have been threatened or injured in any way?

The Deputy of St. Martin :

Are you aware of any others? You have had no personal experience but have --

Dr. I. Cameron:

I have once been threatened but that was by a patient in the surgery, and I called the police. They came along and they took him away and it was fine. When he calmed down, he came back to see me but I felt, you know, vulnerable stuck behind my desk where I could not run away.

The Deputy of St. Martin :

But the 2 questions would be that you have no personal --

Dr. I. Cameron: No.

The Deputy of St. Martin :

The other one would be have any of your colleagues that you are aware of?

Dr. I. Cameron:

Within my practice, and bear in mind that there have been at least 8 other practitioners left the practice since I have been there, so that is about 20 plus practitioners that I --

The Deputy of St. Martin : Have come and gone?

Dr. I. Cameron:

On a day-to-day basis, none of them have ever been threatened or felt threatened.

The Deputy of St. Martin :

I think really most have been asked. Maybe a few other things on number 9 now, just to tidy up, a few supplementaries.

I think you have said about Cleveland Clinic's decision to make an application in JDOC.

The Deputy of St. Martin :

Yes, we were looking at the cost. It is going to cost the clinic but there will be other costs as well, you think, not necessarily by you. You think the cost will be for the patient?

Dr. I. Cameron:

Yes, I think that. I mean, ultimately, I do not think it is going to cost Cleveland Clinic. I mean, we have got to pay an annual fee, about £600 or £700 per doctor.

The Deputy of Trinity :

Has that increased? If you had gone in initially -- have I asked that question? Has that increased?

Dr. I. Cameron:

As I understand it, that was the initial suggestion but that, I think, has been waived. But I have not been deeply involved with it personally because I have left it up to those in the practice who are concerned with it, which is fine. You know, you have to split what you are doing, so I think that is no longer an issue. But nevertheless, it is going to cost us £700 per practitioner, per annum. Well, that is £8,000. Who is going to pay for that? I suspect that is going to land in the patients' lap.

The Deputy of St. Martin :

Do you know what you are paying for?

Dr. I. Cameron:

A driver, I think, is it? A telephonist, of course; somebody to answer the phone, I think. Is that what I am paying for? I am not sure. Again, communication is an issue. You know, if I go back to when I first started in practice here, we used to -- the Guardian Medical Services provided a marvellous service where somebody at the end of the phone would or would not pass on the message from the patient. It depended; sometimes they did, sometimes they did not. It depended how good their English was but it was a lot better than having it through to everybody's house, which is what it used to be back in the 1960s. A patient would phone the doctor's house and the whole of the doctor's family would be up all through the night if they were on call. Then it changed to that Guardian would take a message and they would bleep the doctor on call and so he might be out on a call and he could take the bleep. The public telephones disappeared and we all have mobile phones now; a system that is absolutely fantastic. The patient rings up the surgery, a phone message says: "Press 2 if you want the doctor", they press 2 and it comes directly through to my phone.

The Deputy of St. Martin :

We have moved on now from the old days, yes?

Dr. I. Cameron:

It comes directly to my phone and I can speak directly to the patient, no intermediary, they do not have to leave a message and they do not have to go through a second telephone call. It is fantastic. Now, within our clinic not everybody uses that system but it is what I do and a number of the other partners do something slightly different. But the possibility for communication is so much better now than it was even 6 years ago.

The Deputy of St. Martin :

Would you see joining the co-op, really, basically, the only advantage there is to you would be really the fact you are not going to be called out so many evenings during the course of the year? But you are paying for the privilege of that?

Dr. I. Cameron:

Yes, I am going to be on for 3 nights a year. That will ultimately be what it is. I think we are responsible for 12 nights a quarter.

The Deputy of St. Martin :

But you have to pay for that privilege?

Dr. I. Cameron:

Yes, of course, yes. That is right, yes. Quality of life. I think we have got great quality of life here, you know? We have got wonderful beaches and, you know, just a great environment to live in for ourselves and our children. We want a better quality of life. You should not record this but if you want a better quality of life and you do not think it is good enough here, go somewhere else.  [Laughter]

The Deputy of St. Martin :

Okay. I do not know if there is anything else we particularly want to ask but I always ask the witnesses if there is anything we have not asked you that you wish we had or if you would like us to, we will do so. Is there anything you can think of that you would like to say that you have not had an opportunity to say or ask, maybe?

Dr. I. Cameron:

Not really. You know, I think, sort of, intention and will is -- you know, I think with the best will in the world, the co-op want to provide a, you know, reasonable service to the patient; I think that is their intention. Ultimately, delivery of that service comes down to individual people and what they do on the ground. Will that be improved by the co-op? I do not know.

The Deputy of St. Martin :

It could be perceived that what you are setting up is a faceless co-operative rather than --

Dr. I. Cameron:

Yes, yes. I think that is the problem of having, you know, somebody from another practice going out and seeing a patient for whom they have really got no interest in the outcome, except to keep themselves out of court, you know, and not to, you know, make a real mess of things.

The Deputy of St. Martin :

Okay, all right. I think, Deidre, it would be in order, if William has a spare copy, I think it would be useful for you to have --

Dr. I. Cameron: The JCRA report?

The Deputy of St. Martin :

Yes, because, you know, we have been delayed along the way.

Dr. I. Cameron: Sure, sure.

The Deputy of St. Martin :

We were hoping that we could come through because it is not for us to say at the end of the day whether you can carry on or we have got to do a report. At the end of the day, we will make our findings and suggestions; it is not us who say whether you can come in or not. That is for someone else. We also have got to see a couple more people as well, so we will not be finished yet until possibly a few weeks.

Dr. I. Cameron: Yes, sure.

The Deputy of Trinity : Yes, another one.

The Deputy of St. Martin :

You know, we have been delayed  a lot --

Dr. I. Cameron: Sure.

The Deputy of St. Martin :

-- not through our doing, but I think it would be helpful if we gave you a copy, if you want to pass on your comments to your colleagues as well.

Dr. I. Cameron: Yes, that is great.

The Deputy of St. Martin :

But if you, as a result of reading that, have anything, any comments to make, I think we would be quite interested to hear from you.

The Deputy of Trinity :

The back page is the recommendations, which --

Dr. I. Cameron:

Yes, I am just having a quick look at it to see if -- you know, I see a lot of documents and: "Have you read this one?" No, I have not seen this one, so I just wanted to make sure I have not, but I have not seen that document. When was that produced? August?

The Deputy of Trinity : Fairly recently, yes.

The Deputy of St. Martin :

It says 6th August on the back.

Dr. I. Cameron:

Right. So, I mean, it is not -- August of this year? So, it is not surprising I have not seen it then; it has only just come out really.

The Deputy of St. Martin :

This is one of the reasons we were held up. Could I just thank you, then? We can close the proceedings now.