111 Telephone Service: 5th June 2013

Miss McIntosh
I believe a local solution should be found. A question I will come to is whether there is a difference in the roll-out of the service in rural and urban areas—in my hon. Friend’s case, an island. Local solutions must be found. To me, the best solution will always be for someone to see their own GP on the day they are ill.

I hope that my hon. Friend the Minister will put our minds at rest and say that the story in the newspapers about rationing our visits to GPs is a myth. We cannot dictate how often we will be ill. If an elderly person has a chronic condition, they cannot limit the number of times they might have to call on a medical service in one year.
 
Barbara Keeley (Worsley and Eccles South) (Lab)
rose—
 
The Parliamentary Under-Secretary of State for Health (Anna Soubry)
Will my hon. Friend give way?

Miss McIntosh
If I may, I will give way first to the hon. Member for Worsley and Eccles South (Barbara Keeley).
 
Barbara Keeley
I thank the hon. Lady; she is being very generous with her time. Dr Clare Gerada of the Royal College of General Practitioners told the Health Committee yesterday that many GPs’ books are now full at 8.30 in the morning, and that if they have open slots there are often queues down the street, which she said she had not seen for years. I agree with the hon. Lady that we need more GPs, because that is what most patients want.

Miss McIntosh
I know what I am going to say is controversial but perhaps I, as a woman, can say it. Some 70% of medical students are women and they are well educated and well qualified, but when they go into practice, many marry and have children—it is the normal course of events—and they then often want to work part time. Training what effectively might be two GPs ​working part time obviously puts a tremendous burden on the health service. I will now give way to my hon. Friend the Minister.
 
Anna Soubry
On the point my hon. Friend made about any rationing of or charging for GP appointments, let me assure her that that was an idea floated on a website and is not Government policy. It is reasonable for people who have an interest in such issues to be able to debate whatever they wish to debate, but it is certainly not Government policy, and I know of no good reason why it ever should be. She makes a very important point when talks about, rightly, the good number of women who are training to be doctors, but the unintended consequences.

The Parliamentary Under-Secretary of State for Health (Anna Soubry)
It is a pleasure to serve under your chairmanship, Mr Robertson, for what I believe is the first time.

My hon. Friend the Member for Thirsk and Malton (Miss McIntosh) made an admirable speech, raising many points and asking many questions—some of which, I will say bluntly, I will not be able to answer in my speech. I assure her that she will receive an answer to those by way of a letter. Before I discuss her speech, I want to deal with the points raised by the hon. Member for Copeland (Mr Reed). It does neither him nor his party any credit to use the serious problem in A and E as a political device to attack the coalition Government. It is not as simple as that. To suggest that the problem has been caused by the Government is plain, simple rubbish. It is accepted that there are many complex reasons for the situation, although I am reliably informed that the number of people being seen within the four-hour target is improving and that many accident and emergency departments are achieving the target, and have been doing so for some weeks. Some, indeed, are exceeding it.

There is much evidence emerging that a firm grip is being taken on the situation, but things are complex. There is no magic bullet. It does not matter which party is in power, the Government would face the problem that we have, because there are many causes. One of them, which people on all sides of the argument have identified, is the fact that we do not have the out-of-hours service we want.

Barbara Keeley
The Minister says that the issue is complex and accuses the shadow Health Minister of making political points. It is about time that Health ​Ministers stopped making excuses. They have been in office three years and it is time they started to take responsibility for what they are doing.

I have gathered evidence, and the causes of what has happened clearly include insufficient call handlers, which is not complex—it is just a shortage of staff. Another factor is the replacement of trained nurses and trained clinician input for phone triage with computer-led or non-clinician advice. Those things are not complex. They are just wrong.

Anna Soubry
I am not for a moment saying that there are not difficulties and problems in 111. We know there are, but if only the issue were as simple as solving the 111 problems. The out-of-hours service is just one of many factors. [Interruption.] I want to make some progress on this point: 111 is one factor among the failings in relation to the sort of out-of-hours service that people want. We have also had the difficulty of a long, cold winter, which has added pressures—that is something that often happens. Also, there are 1 million more people attending A and E. That is not the fault of the Government. We have not suddenly caused it. It is because of changes—

Andrew Percy
rose—

Anna Soubry
I will take interventions, but I want to make these points first.

The population is also living considerably longer. That is good and welcome, but there are many frail elderly people with complex illnesses and diseases, so they attend A and E in a way they did not previously. In addition, we suffered under the previous Government from a lack of integration between health and social care. That was one of the things that the Health and Social Care Act 2012 addressed, and will solve. It is about better integration. The hon. Member for Copeland sneers at that.

Mr Jamie Reed
I do not sneer; I laugh.

Anna Soubry
He laughs at it, Hansard will record. It is not a laughing matter at all. What I was describing is one of the achievements of the Act. I am confident it will deliver.

Andrew Percy
The Minister is making sensible points. As to manufactured indignation, if that is what it is, mine comes from the fact that I spend 30 to 40 hours a week volunteering in the NHS as a first responder, and I spent 30 hours doing so last weekend.

A big issue that creates pressure in the NHS is the lack of integration between social care and health services, and a lack of proper intermediate care facilities. We do not have the step-up, step-down facilities that we need to deal with the ageing population. That is one of the biggest problems in my area and a reason for increased pressure.

Anna Soubry
I, too, know that it does no one any favours to make out that someone forcefully and passionately giving a view based on their experience is ​manufacturing it. I know that that is not true of my hon. Friend, and I thank him for his valuable contribution. He is right.
 
Mr Jamie Reed
I think casual outside observers will struggle with the concept that politicians from different political parties should seek to have different political opinions about the services and Department for which the Minister is responsible. She makes an almost Kafkaesque defence of the Government’s NHS record, but will she accept that the awful implementation of the 111 scheme, the collapse of adult social care, the closure of walk-in centres and the huge pressures on the NHS elsewhere in the system have resulted in the crisis in A and E?
 
Anna Soubry
I will not accept any of what the hon. Gentleman says, because he does his cause no service when he makes cheap political points. The matter is hugely complex, but it is wrong to say that the Government caused the problems in A and E. He is wrong in that. It is difficult and complex.

Barbara Keeley
Will the Minister give way?
 
Anna Soubry
No, I will not. The responsibility, if we are honest—would not it be refreshing if we could for once have an honest debate about the national health service?—probably goes back 10 or 20 years, a period encompassing Governments of different political colours. I am happy to say that—by which I do not mean I am happy that those Governments have failed, but people may think the honesty is refreshing.

I want to deal now with the excellent speech of my hon. Friend the Member for Thirsk and Malton. I pay tribute to her and her work in this place, but also to the considerable efforts and work of her late father. I am sure that if he could have heard his daughter’s speech he would have been very proud. I remember my own father saying that out of all evil comes some good, and perhaps some good may come from her late father’s terrible experience of 111 and the fact that he died shortly thereafter.

I pay tribute to all GPs. There are huge difficulties with the GP contract, which was introduced in, I think, 2004. The consequences have included the loss of the out-of-hours service that I enjoyed as a child, teenager and young woman. With few exceptions, we have wonderful general practitioners, and many whom I know, including my own, and others who are friends of mine, work long, difficult hours. It is important to make that point.

As you know, Mr Robertson, during the recess, far from enjoying holidays, as the popular press makes out, we go back to our constituencies and use the time to make or renew contact with, for example, our local clinical commissioning group or ambulance trust. Alternatively we just go out and about, as I have done, knocking on doors and talking to people. One of the things I did during my recess was meet the head of the A and E department of the Queen’s medical centre, which is the local hospital in my constituency of Broxtowe in Nottingham. The head happens to be one of my constituents, and they tell me that there is much improvement at the Queen’s medical centre, as I know from the stats and so on. I also talked to GPs, and the ​CCG in my constituency now opens its doors for Saturday morning surgeries, which do not replace any other surgeries; they are extra facilities. The CCG has done that for two simple reasons: first, to improve the service it gives to its patients, and, secondly, in recognition of the need to reduce the pressure on the A and E department of the Queen’s medical centre.

It is right and fair to say that many GPs look with concern at what is happening in many of our A and Es, and with 111, which is commissioned in some areas by CCGs and in other parts of England by clusters of GPs. They are by no means fools. What motivates anyone to enter the medical profession, in my experience, is a real desire to serve people. They want to help and treat people. They are motivated by the very best of motives, so of course our GPs are concerned about the situation.

There is much work to be done with the GP contract to improve out-of-hours service, but we also have to be honest in this debate. There are often urban myths and anecdotes, but it is a fact that many GPs have already said that, far too often, people who come to see them in their surgeries, who attend A and E or who dial 999 or 111, are calling when they do not need to make that call or that appointment. They might be better off making their pharmacist their first port of call.
 
Miss McIntosh
I thank my hon. Friend for allowing me to intervene and for recognising not only the work my father did, but the work that all GPs do in very trying circumstances. May I bring her back to the Government’s framework, to which I referred, and the very real issues that GPs have raised in North Yorkshire about different GP out-of-hours providers suddenly working with one 111 provider? How will those issues be resolved?

Anna Soubry
Indeed. I will answer as many of my hon. Friend’s questions as I can. There are some questions I will not be able to answer, but I will certainly write to her.

One of the reasons we introduced pilot schemes was to learn from them, and I can tell my hon. Friend a few things as a result. The university of Sheffield did an evaluation report, which said that there was “no statistically significant” impact on services in most of the pilot areas. Importantly, NHS England is collecting data on 111 and its impact on other services, especially, as one would imagine, on A and E. NHS England is in a position to monitor that, and it will report in due course. I am told that the April data will be published this Friday.

I am reliably informed that the A and E performance of York Teaching Hospital NHS Foundation Trust, which serves my hon. Friend’s constituency, is that in 2013-14 so far, 96.1% of people have been seen within the four-hour target. That is above target. I think the average across England for people being seen in A and E is some 55 minutes.
 
Mr Jamie Reed
This question is not a trap in any way, shape or form. The Minister just said that NHS England is assessing data on the performance of 111 thus far, which will be made available in due course. This is an empirical question: will the system be rolled ​out across the country without the data on the effect of the 111 service on the rest of the system being fully understood?

Anna Soubry
I do not know the answer, and I will not start speculating because it invariably gets one into terrible trouble.

Mr Reed
Will the Minister write to me?

Anna Soubry
I am more than happy to write to the hon. Gentleman with some sort of answer from either NHS England or the Department.

I should say, of course, that we know that 111 has not been successful in the way it should have been in many parts of the country, and we know that there were particular problems over the bank holiday and Easter periods, but we also know that it has now been rolled out to 90% of England. NHS England is monitoring, overseeing and collecting the data, as we would all hope.

I will do my very best to respond to the content of today’s debate and the questions that have been raised, with apologies for those questions that I do not answer.

The ratio of call handlers to professionals, about which my hon. Friend the Member for Thirsk and Malton asked, is 4:1. That ratio is not specified, however. There is no prescription that it must be 4:1. As 111 is locally commissioned in the way that I have explained, it is for local commissioners to decide whether to change that ratio, depending on the particular needs of the people in their area. One of the great benefits of the 2012 Act is that we have enabled local commissioners, either as a CCG or as a cluster, to commission services to meet the specific needs of their patients. I hope that will mean that a cluster or CCG in a rural area, obviously knowing that its patients live in a rural area, will ensure that its service is tailor-made to suit the needs of those patients, which may be different from the needs of patients in, say, a city and its surrounding suburbs. That is one of the joys of local commissioning.

My hon. Friend asked whether the three to three-and-a-half hours—in truth, I think it was really four hours—before her father was seen is normal, and the unequivocal answer is no. Is it acceptable? In my view, it is certainly not acceptable.

My hon. Friend then asked who pays. She is concerned about whether the debt in which her primary care trust found itself will have an impact. The 111 service is paid for by CCGs, which is one reason why CCGs are involved in the local commissioning of the service.

How are the concerns of GPs being addressed? The NHS is having a review in the way that I described. My hon. Friend the Member for Brigg and Goole (Andrew Percy), who must be a member of the Select Committee on Health—that shows my profound ignorance, and I apologise to him—has helpfully reminded me that Dr Gerada, who is the chair of the Royal College of General Practitioners, said in her evidence yesterday that she has not seen such queues since the flu epidemic of two to three years ago. She said that the reasons for the high demand are mixed and complex, including the nasty flu virus that went around earlier this year and at the end of last year. I reiterate my point: if only it were so simple to cure the problems in A and E.

Barbara Keeley
The Minister talked earlier about the issue being about out-of-hours service. The NHS 111 problems in Greater Manchester put greater pressure on our out-of-hours service. She said there was a long winter, but 111 was rolled out at the end of March. Does she think that was a sensible time? It was not even the end of a very hard and long winter. Finally, she said that we have had more A and E attendances, but the problems have caused further pressure on A and E. The point many hon. Members have made, which I hope she accepts, is that the chaotic launch of NHS 111 in the end part of winter caused more problems than it solved.

Anna Soubry
Again, I do not think it is as simple as that. Of course we have not been happy with the roll-out of 111, which is accepted. The service has not been the success that we had hoped. We agree on that.

Barbara Keeley
Will the Minister give way?

Anna Soubry
No; forgive me. The most important thing, though, is that things are improving.

Andrew Percy
We on the Health Committee were provided with figures yesterday showing that referrals to A and E from NHS 111 were about half the amount of those from NHS Direct, but that there had been an increase in referrals to out-of-hours and GP services. The link between NHS 111 and pressures on A and E is perhaps not proven.

Anna Soubry
I am grateful for that intervention. I know that the university of Sheffield specifically examined the pilot and found that in most pilot areas, there was no impact. However, we also know that NHS England is monitoring the situation, reviewing the data and analysing all the different, complex problems causing pressure on A and E to ensure that we make the improvements that we want.

My right hon. Friend the Member for Thirsk and Malton—[Interruption.] Well, I am going to make her right hon. for the moment. It will not be put into Hansard, so no one will know; it is just between us. She made an important point about providing for people receiving palliative care, catheter treatment and so on. She said that perhaps they needed a different script. There is much merit in that. Again, I would hope that the commissioning services would put that aspect in the script. She asked specifically about the script. I am reliably informed that it has been written by clinicians at the highest levels, but I also know that there is ​concern at a senior level about the fact that it takes an average of 20 minutes to go through a prescriptive script.

There is a wider problem here. We live in an age in which it is increasingly difficult to rely on common sense. When somebody rings up and says, “My father is a retired GP. We’ve been here before, and he has all the symptoms of a urinary tract infection,” they should not be asked whether he is still breathing. A large dose of common sense would mean that that question would not be asked, nor would “Is he bleeding?” and so forth. That is the stuff of nonsense.
 
Margot James (Stourbridge) (Con)
I apologise for not being here at the beginning of this excellent debate, and I congratulate my hon. Friend the Member for Thirsk and Malton (Miss McIntosh) on securing it. I have been in regular correspondence with the 111 service in the west midlands region, and with the other related services. I am satisfied that some of the teething problems will be resolved, but my local hospital asked me to raise one question with the Minister. Will she look into the treatment algorithms used by 111? There is a belief in the hospital that they are more likely to result in a referral to A and E than those used by the previous service.

Anna Soubry
I am grateful for that intervention, because I have heard that anecdotally as well. It is an important question. I cannot give my hon. Friend a full answer, but I will do all that I can to provide it in a letter if she will allow me. That concern has been raised with me on a constituency basis.

As I said from the outset, 111, which is a good service in theory and should be of considerable benefit to health professionals and, most importantly, to patients and all others concerned in the national health service, has not gone as smoothly as we had hoped. That is conceded, and one should not make party political points from it. However, the service has improved, it continues to improve and it is being monitored. I am grateful to my hon. Friend the Member for Thirsk and Malton for bringing this matter to the attention of the House, and I apologise to her for any questions that remain unanswered. I will reply to her and will address all the other points raised by hon. Members in this debate.