111 Telephone Service

Barbara Keeley Excerpts

Wednesday 5th June 2013 Westminster Hall

[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.

--- Later in debate ---

[Barbara Keeley (Worsley and Eccles South) (Lab)]

It is a pleasure to speak under your chairmanship, Mr Robertson. I congratulate the hon. Member for Thirsk and Malton (Miss McIntosh) on securing this debate and on the way that she has opened it, which has been really helpful.

The British Medical Association has consistently expressed serious concerns about the transition from NHS Direct to NHS 111. I understand that the BMA wrote to the then Health Secretary—the Leader of the House of Commons, the right hon. Member for South Cambridgeshire (Mr Lansley)—in February and April 2012, to warn

“of the dangers of rushing implementation of NHS 111.”

It also wrote to Earl Howe, the Health Minister, and to the chief executive of NHS England, David Nicholson, urging them

“to delay the launch of NHS 111 beyond April 2013, due to concerns that many areas were not ready for the transition.”

Those concerns were borne out when the service was launched in Greater Manchester on 21 March, prior to the national launch one week later. I have collected information on the launch in Greater Manchester from the chief executive of Salford Royal NHS Foundation Trust. He told me:

“Significant operational problems were experienced when 111 first launched at the end of March and these problems persisted for the first two weeks of operation. 111 did not equip their call centre with the required levels of trained staff and were therefore unable to deal with the volume of calls received; some patients were left waiting up to an hour to get through on the phone lines and as a result patients just turned up at A&E/GP Out Of Hours Service causing significant capacity and demand issues.”

That is just the point that the hon. Member for Thirsk and Malton made about what people would do if they could not get through to 111.

Senior staff of the Salford clinical commissioning group told me that NHS Direct had given assurances that it had the capacity to handle calls, but after the failures that we experienced in Greater Manchester, NHS Direct admitted that it had insufficient call handlers in place. Apparently, when these problems occurred, 111 asked all GP out-of-hours providers to return to their pre-launch call-handling service. However, that was not an option for us in Salford, as our previous call handlers had transferred all their staff over to 111 under TUPE arrangements. So the problems with NHS 111 continued. Salford CCG staff also told me that the out-of-hours service in Salford came under pressure owing to this NHS 111 failure, and that pressure had to be met with increased staff capacity.

Salford Royal NHS Foundation Trust has commented that further improvement to the service is still required. It feels that

“the care pathways still need further modification to reflect local services”

and that

“there are currently gaps in alternative routes of care”,

which the 111 service is showing up. If there are issues with social care, the community team, the district nurse or self-care, that becomes apparent. The trust also said—this is important for our debate this morning—that

“there are also concerns that what we have done with this service is to replace clinician triage in Out of Hours service with computer or non-clinician advice.”

To give an example of the problems that this change has caused in Salford, I will quote the trust again:

“This has led to patients being brought to the emergency department when they are actually on end-of-life pathways”

and should have “community input”. That is just the problem that the hon. Lady talked about—that situation has happened in Salford. It is distressing to think of people who are in their last few days of life being dragged into hospital, when they should really receive care in their own community and in their own home, which is the care that they probably desire.

Salford CCG has reported that feedback forms on NHS 111 have been received from clinicians and that two “significant events” were recorded, which are under formal investigation. The feedback tends to relate to delays in treatment. The CCG also says that its

“immediate priority has been to stabilise the service after a disappointing start. Some positive improvement has occurred but long term there are serious doubts, with NHS Direct identifying the need for extra investment about the contract level to make the service effective.”

I was also told by staff at Salford Royal NHS Foundation Trust that they felt that expectations were set too high about the outcomes that 111 would deliver. They commented that NHS 111 was operating at a level and in a role that an “experienced grandmother” might historically have achieved. That is an important point; my local NHS trust thinks that is what it is getting from the service. That advice—that of an “experienced grandmother”—could be seen as helpful, but staff told me that their preference was for

“an alternative service which had at its core clinically trained primary care staff available over an extended working day, 7 days per week.”

They also believe

“that this service would be better if it was included within a single integrated urgent care service, incorporating responsibility for GP out-of-hours triage.”

[Guy Opperman]

I am listening to the hon. Lady’s contribution, and given her background, it is clear that she is a specialist in this area. Like her, I met staff from my local CCG and local ambulance service last week to discuss the development of this system. I note that she talks about integration. Does she agree that the integration of those various parts of the NHS system is the absolutely crucial thing going forward?

[Barbara Keeley]

Indeed. We talk a lot about integration, but the feedback that I have received from both my local CCG and my local NHS trust is that we have just taken a backward step. We had a nurse-led service that was working fairly well, although it was not as integrated with other services as it should have been. We now have a system that is led by computer scripts and non-clinicians, in which the patients calling the service—if they get through to it—do not have confidence, and as a result, they are falling back on visiting their GPs or going straight to A and E. My point was that that single, integrated urgent care service—the single service that the hon. Gentleman just talked about—should include responsibility for GP out-of-hours triage, and at the moment it does not. The system could have been set up that way, but it was not. Does the Minister believe that the alternative that I have just put forward is the right direction for an improved NHS 111?

Beyond our experience in Greater Manchester, there have been many criticisms of the NHS 111 service and the shambolic transition to it from NHS Direct. Dr John Hughes, a GP from Manchester, said the service had been withdrawn in his area hours before the launch, owing to problems. He told the BBC that it was “an omnishambles” and

“a waste of public money.”

Dr Hughes has called for a full public inquiry into the procurement of that service, because he feels that it was

“forced forward to meet a political objective.”

Janet Davies of the Royal College of Nursing has argued that nurses from NHS Direct have been running NHS 111. She told the BBC for a report:

“Staff from NHS Direct, the service being abandoned, are supplementing the work of 111—staff that were being made redundant and still are at the end of this month… Specialist nurses that can talk to patients have not left and they are propping up that service.”

She felt that, unlike the nationally run NHS Direct, NHS 111 was a

“fragmented service with local contracts”,

which in her view was “very, very chaotic”. She also said that NHS 111 was an attempt to cut the cost per call, by using non-clinical staff to handle the majority of call time, and that it was

“not using qualified nurses, people with the skills to talk to people and make a sensible decision”.

She felt that the Government had thought about costs but not value. As we have seen, NHS 111 is offering poor value if patients turn away from that service, because it is far more expensive to go to A and E or a GP than to have a conversation with a trained nurse.

In Salford, patients were left waiting on phone lines for up to an hour and then turned to the more expensive options of a GP visit or A and E. Our out-of-hours service came under pressure and extra staff capacity had to be brought in. The opinion of staff at Salford Royal NHS Trust is that NHS 111 operates at a level and in a role that an “experienced grandmother” might achieve. Surely, we can and should do better.

--- Later in debate ---

[Mr Reed]

I am going to make some progress, because I want to get on to the substantive issues in play.

When Labour first suggested a new NHS 111 service, we were clear—the hon. Gentleman should listen—that it would not replace NHS Direct. Our manifesto in 2010 said:

“A new national 111 telephone number will make nonemergency services far easier for people to access and book.”

The 111 service was planned to help people find an emergency dentist, a late-night pharmacy or an out-of-hours primary care GP. This Government scrapped that and instead pressed ahead with the botched implementation of a system that just could not cope with what it was expected to do. They were warned, but, as usual, they did not listen.

There is no doubt that the 111 service is not fit for purpose. The statistics show it, the examples given by Members today show it and, most importantly, patient testimonies show it. Indeed, the Minister herself acknowledged it in response to the right hon. Member for Mid Sussex (Nicholas Soames) in late May, when she stated:

“We recognise that the service has not been good enough and we are working closely with NHS England to ensure improvement in performance. NHS England have put a number of measures in place already.”—[Official Report, 21 May 2013; Vol. 563, c. 740W.]

I hope the Minister will outline what those measures are and what their effects have been, because the contributions we have heard today suggest they are having a negligible effect.

The implementation of the system has undoubtedly caused serious problems; indeed, in my area, NHS Direct is having to be maintained alongside the 111 service to cope with demand. The Minister must explain in detail how a botched, fragmented implementation was allowed to happen despite there being a significant pilot scheme.

[Barbara Keeley]

On the issue of propping up NHS 111, I wonder whether this is the point at which to give credit to the NHS Direct nurses whom Janet Davies of the Royal College of Nursing cited. Even though some of them are being made redundant, they were prepared to prop up the service during its few weeks in places such as Greater Manchester. We really should give those nurses credit. What a dreadful experience, just before they were made redundant, to have to prop up the service that was replacing them.

--- Later in debate ---

[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—

--- Later in debate ---

[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.

--- Later in debate ---

[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.