NHS Funding (York and North Yorkshire)

Baroness McIntosh of Pickering Excerpts

Wednesday 7th January 2015 Westminster Hall

[Julian Sturdy (York Outer) (Con)]

It is a privilege to serve under your chairmanship, Mrs Riordan. I am delighted once again to have secured an opportunity to address the important issue of health care funding in York and North Yorkshire and, ultimately, the formula used to calculate the per patient funding from which clinical commissioning groups—and, before them, the primary care trusts—derive their money. Other North Yorkshire and York MPs and I have been campaigning on this issue since 2010, and I am delighted that my hon. Friends the Members for Skipton and Ripon (Julian Smith) and for Harrogate and Knaresborough (Andrew Jones) are here to support me this afternoon. I strongly believe that the nettle has to be grasped on what I accept is a difficult issue, albeit one that cannot continue to be ignored.

The quality of local health care is of the utmost importance to many, if not all, people because, ultimately, it is something upon which we all come to rely at some point in our life. Health care provision is a measure of the local community’s economic well-being and happiness, and it is in our moral and economic interest to ensure the widest availability of health services, the shortest waiting lists and that the most impressive health outcomes are available to all, which I stress. Ensuring such health care standards for all is truly one of the Government’s most essential roles. Indeed, I am sure that all hon. Members from North Yorkshire, both those who are here and those who are not, will agree that health-related concerns crop up frequently in our constituency mail. That is certainly the case in my constituency, as I am sure it is in yours, Mrs Riordan. As such, I welcome the £2 billion of health care spending promised by the Government for this financial year in the autumn statement. That injection of cash has led to every area’s budget increasing ahead of inflation in the recently released allocations. It is for such reasons that I believe the Government can stand proudly on their NHS funding record.

I have called this debate, however, to address the fair allocation of funding and the impact on health care delivery due to a funding formula that works to my CCG’s disadvantage. In a previous debate on this issue I outlined my concern that the now-abolished primary care trusts would pass on their historical debts to the new CCGs. Vale of York CCG inherited a deficit of some £7 million in April 2013 due to the current funding formula. NHS England has acknowledged that the previous York and North Yorkshire PCT received approximately £17 million less than the allocation should have provided for the local population demographic because the funding is phased in over time. Although I am pleased to say that Vale of York CCG has cleared the deficit it inherited, it is still struggling to offer many services that constituents have a right to expect. Allocations made for the newly formed CCG in 2013-14 were a straight uplift of the historical allocations, which resulted in a postcode lottery for certain health care services in my area.

Why does Vale of York CCG, in particular, receive such a poor allocation? The Government decide how much money should be allocated to each CCG. Officials begin by dividing the total budget by the number of people living in each respective area. Money is then added or taken away to account for local characteristics, including the proportion of people claiming benefits, the teenage pregnancy rate and the number of people who leave education early. That is where the problem lies. Of the 10 characteristics, nine reduce the amount of money allocated to our area. That disparity in the allocation is due to the funding formula failing to take account of both the rural nature of the region and, most importantly, age. Instead, the current formula provides a significant weighting that awards additional funds to areas with high levels of social deprivation. The allocations for 2015-16 have now been announced and, once again, Vale of York CCG has received, by a substantial margin, the lowest per capita funding of all the CCGs in the area. Although I recognise that health needs are generally greater in more deprived areas, the current formula provides far too much weighting for deprivation and insufficient weightings for age and rurality.

Age and rurality are even greater problems in my constituency and in other North Yorkshire constituencies because York and North Yorkshire have the highest proportion of over-85s in the north, but Vale of York still receives among the lowest funding per head of any northern CCG. The area also has a high number of people in care homes, with a typical GP practice informing me that up to 50% of home visits are taken up by care home residents, who account for only 2% of patients on the practice’s roll. The distribution of health care costs is strongly age dependent, and it is difficult to argue against that. On average, it costs approximately eight times more for the NHS to care for a patient over 85 than for a patient in their 40s, which, of course, is due to elderly people being more likely to have additional health problems. We are all living longer, which is obviously a good thing, but we are living longer with more complicated conditions. Age is increasingly becoming a defining factor in health care funding.

Alongside age, the formula does not account for the additional cost of providing health care services in sparsely populated rural areas. Those additional costs are reflected, among other things, in longer average journey times for ambulances and community health staff, such as health visitors. There is also a need to provide additional smaller hospitals in rural areas in order to retain accessible and essential services for those communities.

The distortion in the funding formula has led to certain areas being awash with money, which in the past has sadly led to well publicised vanity health care projects, whereas York and North Yorkshire have consistently struggled to balance the books, resulting in their continuing to take difficult decisions on health care provision. Those decisions have had a massive impact on the quality of life of many of my constituents, hampering their ability to work and affecting their careers.

To my mind, Vale of York CCG does not provide some procedures due to the funding formula. I have been contacted by many constituents over the past few years regarding their inability to receive pain-relief injections free on the NHS. I have been actively campaigning for the removal of those charges for all who require such injections. I am sorry to say that the charges are symptomatic of the postcode lottery due to the current funding formula. The CCG reviewed its position on pain-relief injections and concluded that the injections are not clinically beneficial, which is why it decided to retain the charge, but I would argue that the injections can dramatically improve people’s quality of life and should be offered free of charge. Pain-relief injections are offered free of charge by many other CCGs across the country and across our region.

Alongside pain-relief injections, another procedure that has not been available through the Vale of York CCG is IVF treatment. In fact, for a long time the Vale of York was the only health authority in the country not to offer any free IVF treatment. I know from many constituents who have contacted me about the issue that infertility has an awful effect on people’s lives, causing stress and depression, and with the potential to tear otherwise healthy relationships apart. It must be extremely frustrating for someone to know that treatments are available just a few miles away but are inaccessible to them; nevertheless, that has been the reality in many parts of my constituency for a number of years.

I was pleased to hear the CCG announce in late December that it will now offer at least one cycle of IVF. Although that falls well short of the three cycles recommended by NICE, it is a welcome step in the right direction.

[Miss Anne McIntosh (Thirsk and Malton) (Con)]

I apologise to my hon. Friend for missing the start of his speech and congratulate him on securing this debate. This may tempt him toward a conclusion, but does he agree that spending more on primary care in the Vale of York and other North Yorkshire CCGs would keep people out of hospital, which would obviously be to the greater good of the health service and those living in North Yorkshire?

[Julian Sturdy]

I entirely agree with my hon. Friend. Given the rurality of the whole of North Yorkshire, which I mentioned at the start of my speech, we know that providing health care services is difficult and expensive. That is part of the argument for why the funding formula must be adjusted. At the same time, it must be more cost-effective to deliver services in people’s homes and offer more accessibility. Nevertheless, as my hon. Friend will know from the situation in her constituency, it is important that we also keep small hospitals open and accessible. I know that that is an important issue in the constituency of my hon. Friend the Member for Skipton and Ripon. This debate is all about ensuring that we have a fair formula so that we can deliver those services.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health (George Freeman)]

Thank you, Mrs Riordan, for calling me to speak. It is a pleasure to serve under your chairmanship this afternoon.

I start by congratulating my hon. Friend the Member for York Outer (Julian Sturdy) on securing this debate, with the support of our hon. Friends the Members for Skipton and Ripon (Julian Smith), and for Malton (Miss McIntosh), and I congratulate them all on their contributions to the debate. I am very aware of the personal interest of my hon. Friend the Member for York Outer in health matters affecting his constituents, and of course his interest in NHS allocations, including this question of fairness for rural areas.

I will also take this opportunity to pay tribute to all the North Yorkshire MPs who have worked so hard together on this issue since 2010: my hon. Friends the Members for Selby and Ainsty (Nigel Adams), for Skipton and Ripon, for Thirsk and Malton, and for Harrogate and Knaresborough (Andrew Jones), the hon. Member for York Central (Sir Hugh Bayley), my right hon. Friend the Member for Richmond (Yorks) (Mr Hague), and my hon. Friend the Member for Scarborough and Whitby (Mr Goodwill). I know they have had one meeting, if not more, with the Secretary of State for Health, and as a group they have been an effective and forceful lobby on this important issue, which we in the Department of Health all take seriously.

Of course, the whole House will agree that good-quality patient care is something we all expect, regardless of which part of the country, or indeed which county, we live in. As my hon. Friend the Member for York Outer has signalled, the question is how we work within the overall NHS budget—I welcome his acknowledgement of the Government’s increasing that budget—to determine how funding for each area should be assessed and decided. He made the key point: that it must be done in a way that is fair to all citizens and patients, wherever and whoever they are, and that where someone lives should not in any way unreasonably distort their access to health care. It is the NHS—the national health service—and those initials should mean something.

My hon. Friend will be aware that I, too, come from a very rural constituency—Mid Norfolk—where many of the issues he has identified chime, including ambulance response times and the extra time that clinical staff and patients take to travel around. Of course, there are other issues and problems, which he has highlighted: hidden deprivation, ageing and elderly populations, and isolation and loneliness compounding conditions such as dementia, making it harder to set up initiatives such as dementia cafés.

Health funding is an issue I have taken an interest in for a long time. Years ago, I did some work in County Durham to unpack the index of local conditions and the standard assessments in local government spending. When we unpack those formulae, we discover that those used to allocate funding for deprivation are all inner-city indicators: they are all about high-rise blocks, the percentage of black and minority ethnic people, and density. They are all urban indicators, as if only urban areas really experience deprivation. So my hon. Friend is raising an important point, which goes to the heart of much of the way that Whitehall allocates funding.

I will say something about how allocations within the NHS are made under the arrangements we have put in place. As my hon. Friend is aware, NHS England is the independent organisation responsible for managing the budget and the day-to-day workings of the NHS. It supports clinical commissioning groups—the local groups of GPs and other health professionals who commission NHS services on behalf of their patients. To make sure that the taxpayer has a say in how that money is spent, the Government provide direction and strategic ambitions for the NHS through a document called “the mandate”. The current 2014-15 mandate was reviewed and updated in December. There are eight key areas, which are about making general improvements; the Government deliberately leave the NHS free to make decisions about how these objectives should be met. They are: helping people to live well for longer; managing ongoing physical and mental health conditions; helping people to recover from episodes of ill health or injury; making sure that people experience better care, and integrated care; providing safer care, with a greater emphasis on patient safety; promoting NHS innovation; supporting the NHS to play a broader role in society; and making better use of our health resources.

NHS England has been given £98.7 billion this year, rising to £101 billion in 2015-16, to achieve the objectives in the mandate. I welcome my hon. Friend’s support for the extra £2 billion that the Secretary of State recently announced. NHS England has the responsibility to ensure that that money is well spent.

The first thing to say on the financial aspect of the mandate is that we have protected NHS funding in this Parliament, as my hon. Friend acknowledged. In 2014-15, all CCGs received a funding increase matching inflation. Furthermore, like all CCGs in England, North Yorkshire CCGs will benefit from the £2 billion of additional funding announced in the autumn statement. As I say, those CCG allocations and the formula used to decide what they should be are the responsibility of NHS England. NHS England itself commissions some services directly, including all primary care, as well as making allocations to individual CCGs. So these allocations to CCGs, although they are crucial, are only one part of a broader picture. In making those allocations, NHS England relies on advice from the Advisory Committee on Resource Allocation. As my hon. Friend will be aware, ACRA provides advice on the share of available resources provided to each CCG, in order to support equal access for equal need, as specified in the mandate.

NHS England does not set income on an equal “cost per head” basis across the whole country. Instead, allocations follow an assessment of the expected need for health services in an area, and funds are distributed in line with that, which means that areas with a high health need, including rural areas, should receive more money per head. There have sometimes been suggestions that a single per capita payment should be made across all CCGs, but I am not sure that that would not in fact lead to further discrepancies. As my hon. Friend will be fully aware, the key question is what overall weighting should be given to a range of factors, including age, disability, rurality and disease prevalence. As he himself acknowledged, there is no simple answer that would please everyone; this process requires the making of difficult judgments.

Without knowing that background, it can sometimes be hard for people to understand what are misleadingly presented as huge anomalies in allocations to CCGs. In the Vale of York, the funding is £1,067 per head; in my constituency of Mid Norfolk, it is £1,050; and in central Manchester, an urban area with an urban CCG, it is £1,085. I appreciate that those small differences add up over large populations, but they are not huge variations. The objective is to ensure a consistent supply of health services across the country, with health funding following —as best the system can map it—health need. That is one of the reasons why the data steps that we are putting in place are so important to allow us to monitor disease and health need.

NHS England has reviewed the funding formula and made welcome changes that take into account three important factors in driving health care need: population growth, deprivation and the impact of an ageing population. That should go some way towards helping to address the points my hon. Friend made.

NHS England now believes, and tells us, that it has a funding formula that sets recurrent allocations to CCGs more accurately and fairly, which is what the formula is supposed to do. However, I welcome the scrutiny that my hon. Friend and other colleagues from North Yorkshire are rightly insisting that it be put under.

By reflecting changes in population around the country and better targeting of pockets of deprivation, the NHS should be able to offer the best services to patients where they need them. I know there is a perception in North Yorkshire that the area is relatively underfunded. However, the NHS in North Yorkshire has benefited from increased funding, and when the Vale of York CCG’s funding is compared to that of other CCGs across the country, it is evident that it is not a significant outlier in terms of either funding per head of population or the level of funding relative to the formula. I appreciate that those are average figures; my hon. Friend will know better than I do the specific details of his own constituency.

At a time of continued pressure on the public finances, the additional funding we have provided for the NHS underlines the priority that this Government place on it. It means that the NHS will continue to benefit from stable, real-terms increases in funding, which will allow us and NHS England to get those formulae more and more accurate. Next year, the recurrent allocations of all CCGs in North Yorkshire will grow by 1.94%, an increase of almost £17 million. I am delighted that these increases will ensure that CCGs, including those in North Yorkshire, can continue to meet ever-growing demands for services, while investing in new services.

As time is short, with my hon. Friend’s permission perhaps I could write to him on the specific points he raised about back pain and IVF.

[Miss McIntosh]

I have a very simple question. Obviously, we as Back Benchers scrutinise the Department of Health, but who scrutinises and monitors NHS England?

[George Freeman]

As Ministers, we are responsible and ultimately accountable to Parliament for that. However, I am conscious of the time, so perhaps I could pick that point up in a letter to my hon. Friend.

As I said, I welcome the attention my hon. Friend the Member for York Outer and other North Yorkshire MPs are bringing to this issue, and I hope I have signalled that I consider it a substantive concern. Citizens in this country, rural or urban, demand and expect a national health service—rightly so, because they have contributed to it—and they expect national access on a fair basis. The structure we have put in place is really about giving NHS England the clinical freedom to ensure that funding decisions are made on the right basis. No system will be perfect, but as Ministers we are absolutely committed to ensuring that the system we have is as accountable and transparent as possible, and to providing the security of funding to allow that process to be pursued.

I know from my own experience in County Durham and in my Norfolk constituency that these are important issues. It is about ensuring that our citizens in rural areas get equal access to health services. My hon. Friend the Member for York Outer and other colleagues are doing exactly the right thing in raising this issue. I will happily address in writing the points I have not had time to address this afternoon. I look forward to writing to colleagues with more detailed answers to the specific points they have raised.

Question put and agreed to.

Oral Answers to Questions

Baroness McIntosh of Pickering Excerpts

Tuesday 15th July 2014 Commons Chamber

[Jane Ellison]

I congratulate the right hon. Gentleman on the creativity with which he has introduced sugar into this question. He is right to highlight the fact that sugar is an important factor in considering how we get the nation healthier, which we see in the overall context of trying to encourage people to consume fewer calories. A lot of work has been done. He will be aware that we have just had a very detailed scientific report on sugar and carbohydrates more generally. We are considering that but he will be pleased to know that Public Health England has already started to roll out that advice at both a local and national level to consumers and families. We will of course consider what more we might do.

[Miss Anne McIntosh (Thirsk and Malton) (Con)]

Does my hon. Friend share our concern on the Select Committee that not enough regular food analysis is being done by local authorities? Will her Department press for this to prevent any further adulteration or food scares in the future?

[Jane Ellison]

We have discussed this with the FSA and we will respond in more detail when we have the final Elliott review. But it is worth noting that the FSA is supporting local authorities financially and with expertise, but is also very much encouraging people to work smarter so that a lot of inspection is based far more on risk. That is right, as we do not want businesses with excellent records of compliance being subjected to the same regime of testing and inspection as those who give rise to greater risk. I hope my hon. Friend would agree that an intelligence-led approach is the right thing to do.

Oral Answers to Questions

Baroness McIntosh of Pickering Excerpts

Tuesday 10th June 2014 Commons Chamber

[Dr Poulter]

I do not believe that that is the case. In looking at the changes, we need to factor in the point that the minimum practice income guarantee, which was a historical payment and not based on patient need or patient demand, is being phased out in order to achieve a more equitable solution. As a result, we can see that the global sum payments to GPs have risen from £66.25 per patient in 2013-14 to £73.56 per patient in 2014-15. Clearly, the global sum payment to GPs per patient has increased, which is a good thing for patients and the equitability of services.

[Miss Anne McIntosh (Thirsk and Malton) (Con)]

Historically, there used to be a payment for the distance GPs or their patients travelled. The removal of minimum practice income guarantee funding may make certain rural practices unviable. Will the Government address that issue, and will the Minister look particularly at rurality and sparsity in order to address what is a very real issue for rural GPs?

[Dr Poulter]

My hon. Friend makes a very good point, and we know that rural practices have unique challenges. The point is that because the money from the minimum practice income guarantee is going to be reinvested in a global sum payment, and because the global sum payment per practice is increasing, one of the key determinants of that payment is, in fact, rurality, so that should be of benefit to many rural practices.

Oral Answers to Questions

Baroness McIntosh of Pickering Excerpts

Tuesday 14th January 2014 Commons Chamber

[Dr Poulter]

The important point the hon. Lady has to remember is that it takes six years to train an A and E consultant, so it would be much better to put the question about advanced work force planning to the former Secretary of State, the right hon. Member for Leigh (Andy Burnham), rather than to members of this Government. Since we have taken charge of medical education and training, the number of those entering acute common training—those who may go on to become A and E consultants—has increased. We are now seeing a complete fill rate for those entering that training—something that the previous Government were not able to achieve.

[Miss Anne McIntosh (Thirsk and Malton) (Con)]

How much of this difficulty might be caused by excellent staff working part time in accident and emergency? On a recent visit to the emergency department at York hospital trust, I was struck by the excellent work done by doctors, many of whom, by choice, worked long shifts three days a week. Will my hon. Friend look into this matter?

[Dr Poulter]

I will certainly do that and write to my hon. Friend to reassure her, although members of staff who work part time often put tremendous effort into their work, and we often get well rewarded by the broader experience they bring as a result of being part time, so there are benefits to having part-time staff in the NHS.

Oral Answers to Questions

Baroness McIntosh of Pickering Excerpts

Tuesday 26th November 2013 Commons Chamber

[Mr Hunt]

Will the hon. Gentleman think about what he has said? He said he was against a reorganisation that got rid of 8,000 managers and put 6,600 doctors on to the front line. That is why we are doing nearly a million more operations every year and why waiting times for longer waits are shorter than they were under Labour. We are recruiting more doctors because we are putting money into the front line.

[Miss Anne McIntosh (Thirsk and Malton) (Con)]

It takes seven years to train a doctor, but, for whatever reason, the new GP contract is looking to end seniority pay in six years. Is my right hon. Friend not concerned that that will lead to a mass retirement of doctors at the end of that six-year period in 2020?

[Mr Hunt]

We have to make the GP profession attractive to younger GPs as well. The money we save from getting rid of seniority pay will go back into practices, but it should not be given to people just for length of service; it should be related to quality of service too, which will make the GP profession much more attractive.

Oral Answers to Questions

Baroness McIntosh of Pickering Excerpts

Tuesday 22nd October 2013 Commons Chamber

[Jane Ellison]

On the Government Benches, we are interested in all measures that might stop children smoking. I do not recognise at all the time scales that the hon. Gentleman mentions. We are looking now at what is emerging in Australia and around the world so that we have more information on which to base an informed decision.

[Miss Anne McIntosh (Thirsk and Malton) (Con)]

When the Secretary of State meets the chairman of NHS England to discuss future priorities for NHS spending, will he ensure a fair deal for rural areas by ensuring that they reflect rurality, sparsity and the number of elderly patients and that we keep the minimum income guarantee for rural GP practices?

[Mr Hunt]

I can reassure my hon. Friend, as I am meeting some Yorkshire GPs later this week who have concerns about that very issue. The most important thing about the difficult issue of the funding formula is that it should be fair. That is why under the new legislation we have given the decision to an independent body so that it is taken at arm’s length from Ministers and so that it strikes the right balance between the issues of rurality, age and social deprivation.

Oral Answers to Questions

Baroness McIntosh of Pickering Excerpts

Tuesday 16th July 2013 Commons Chamber

[Mr Hunt]

The hon. Lady makes a very important point and I do not want to defend that service in the instance she cited at all. It is completely unacceptable if that kind of thing has to happen. The principle of 111—which is for people to have an easy-to-remember number and to be able to be connected to a clinician directly if they need to be, which did not happen with NHS Direct—is a good one, but it is not happening in practice as much as it needs to be. We are broadly meeting our operational standards, but it is not good enough and she has given a very good example as to why.

[Miss Anne McIntosh (Thirsk and Malton) (Con)]

First, may I thank the Under-Secretary of State, my hon. Friend the Member for Broxtowe (Anna Soubry), for responding to the recent debate we held on this issue? When it was my own father in those circumstances, I did not say that I was an MP, as I felt that would be an abuse of the system. I am delighted that North Yorkshire has reported no problems since 111 was introduced, but there is the issue of the deficit for clinical commissioning groups, which we hope will not detract from the 111 service. Can the Secretary of State assure us that the review of funding will be brought forward at the earliest possible moment?

[Mr Hunt]

I am pleased the 111 service worked more satisfactorily in my hon. Friend’s case. NHS England is working on the funding formula and it hopes to make any necessary changes in time for the next funding round, which starts in April 2014.

111 Telephone Service

Baroness McIntosh of Pickering Excerpts

Wednesday 5th June 2013 Westminster Hall

[Miss Anne McIntosh (Thirsk and Malton) (Con)]

May I welcome you to the Chair, Mr Robertson, and say what a pleasure it is to serve under your chairmanship? I also welcome the Minister and her shadow, the hon. Member for Copeland (Mr Reed), to their places, as well as other colleagues. I am delighted to have secured this debate on the operation of the 111 telephone service and its effects on emergency services. The service is still in its early days of operation. It has yet to be introduced in my own area of North Yorkshire, although the roll-out is expected to commence in early July.

My starting point is that I believe that the 111 telephone service could be a useful tool for out-of-hours services and patient treatment, but that some alarm bells have already been set ringing in areas where it has been rolled out. It is not my intention to go through all aspects of the general practitioner contract and out-of-hours services; I want to look at the narrower point of the potential impact where the 111 telephone service is not working.

In my view, the service might offload problems on to accident and emergency and, indeed, the ambulance service. A lot depends on the content of the script that is used and who sets the script, because the time taken should be as short as possible to allow the swiftest access to nurses and medical advice for those in palliative care, terminal care and other regular patient care, such as catheter patients. The length of time before a patient, or someone acting on their behalf, is passed to a medically qualified adviser—a nurse or doctor—is absolutely crucial.

I want to refer to my family history to illustrate the very real problems being experienced. It relates to one of the pilot areas, County Durham, where my father was a GP, but had long been retired. The carers looking after him in his home, or occasionally me, had had consistent recourse to the 111 service. The last occasion when we used the service in relation to my father was on Sunday 4 November last year. I had reason to call the number, and I explained that my father showed worrying signs of a urinary tract infection. Being a doctor’s daughter, I was well qualified to talk about such infections, which my father had had, on and off, for some two or three years.

When I called 111, I got the ritual reply of sticking very closely to a script, which I found completely inappropriate at times. I explained my father’s condition, but the responder insisted on sticking religiously to the script—asking whether the patient was breathing, whether they were bleeding—and I kept saying that I was not reporting an accident but a regular condition, the symptoms of which were extremely plain, and asking whether I could, please, just be passed to a nurse or doctor. I said that we probably needed a doctor to attend to confirm that there was an infection and to administer the relevant antibiotics.

I have to say that in the end I hung up in sheer frustration, 10 or 15 minutes into the call, because I could tell that I was not getting anywhere quickly. I had previous experience of using the 111 service, and I like to think that I am not prone to flap unnecessarily, but I found that the system failed. I then called 999, and an ambulance was dispatched immediately and attended to my father within half an hour. The paramedics confirmed my suspicion that the condition was an infection, and said that the patient was too ill and frail to travel some 25 miles on country roads in an ambulance, so that was not an option. They used their direct line to call a doctor, but even then, it took three hours for one to attend. In that case, from first calling 111 to the doctor’s arrival, about three and a half to four hours had passed.

My father subsequently died on the Thursday of that week, 8 November, and I believe that the infection had obviously taken such a grip that his death would have been very difficult to prevent. He had lived to a very grand age, and we were just grateful for the treatment he did receive. However, that example shows the pressure points that need to be addressed and which, I regret to say, have not been addressed, even though I have raised the issue, in relation to my family experience, on two or three occasions.

For the 111 service to work effectively a degree of flexibility has to be built into the system and the script. It would be helpful if the Minister told us who is responsible for setting the script. I would argue that doctors, working with community or district nurses—those medically qualified—must work out the script, so that it diverts regular patients who can be taken off it at the earliest possible stage.

What is particularly poignant for me and my family is that my father had been a local GP in that area for some 30 years. He retired as a senior partner, ironically through ill health. He attended patients in all weathers and at all hours. My father was from a generation of GPs who worked all hours: he worked every other night on call and every other weekend on duty, and he always put his patients first. It is obviously a source of some regret that he did not have similar access to a GP in his own hour of need.

The 111 service was piloted in several areas, and I am drawing on my experience of the one in County Durham before the service was rolled out nationally. I want to make some suggestions and pose some questions. It would clearly make sense for regular patients—such as those in palliative care, terminal care and catheter care—to be diverted to nursing or other medically qualified staff as early as possible in the process. In North Yorkshire, the intention is that that will happen when the service is rolled out, but I want confirmation that, now the problem has been identified, it is being addressed in all areas, including pilot areas and ones opting for early roll-out. That would save more time for those who were in urgent need of care, short of the 999 service.

We must all be aware that if a patient or someone on behalf of a loved one phones, they tend to be quite distressed and distraught, and they do not want an automatic responder to stick blindly to some script that does not fit their or their loved one’s condition. If calls are not responded to quickly, those calling will simply divert to other emergency services, such as the ambulance service and accident and emergency—I am the first to admit that that is what I did in those circumstances—because people are just desperate to get medical care.

The key to the success of the 111 service is the speed and efficiency with which one’s calls are responded to and with which access is given to medical advice from doctors or nurses, so I want to take this opportunity to ask some questions. What is the average ratio of call responders—those reading out the script—to GPs and nurses on duty? It would be helpful to know that average ratio in each area where the 111 service is in use. What is the average response time to the initial call? What is the worst response time and what is the best? What is the average time before a caller is transferred to a medically qualified person? Is it normal to expect a delay of up to two hours before a medically qualified person or even the initial responder returns the call? Is it normal to face a delay of three and a half to four hours, which is what we experienced, before a doctor is dispatched, even if it truly is an emergency?

What has been the knock-on effect on the ambulance and the accident and emergency services in those areas where 111 is operating? Is my reaction typical of those who feel they are being let down by 111? If someone dials 111 in North Yorkshire, they get through to the out-of-hours service, so it would be helpful to know how, in areas where 111 is being introduced, the roll-out will be operated smoothly.

In areas where 111 has not been seen to work effectively, what have been the implications for the local hospital, ambulance service and GP practices?

[Alison McGovern (Wirral South) (Lab)]

We are often at our best when we are sharing personal experiences, and I pay tribute to the hon. Lady’s father for his many years of service. The questions she is asking seem to be the right ones. I know from the clinical commissioning group in my area that GPs themselves have expressed frustration at the operation of this service. Does she therefore agree that, from each locality, we need to get their input and listen to their answers to those questions?

[Miss McIntosh]

I entirely agree, and I welcome the hon. Lady’s intervention. One reason why the 111 service has not yet been rolled out in North Yorkshire is that GPs have expressed their concerns, which leads me to my next question, on the involvement of GPs in areas where the service is being rolled out. How are the legitimate concerns of GPs, such as those in her area and in mine, being addressed and met?

Concerns have been raised in North Yorkshire about the governance framework. How are those are being addressed? A key issue in my area is funding, and I would like to know how 111 is being funded and from whose budget the funding has come. The service is replacing NHS Direct, which caused similar concerns when it was rolled out, so this is not unknown territory for us as parliamentarians or for the Department. It is a little depressing that we are seeing the same problems being played out now, because they were clearly not addressed when NHS Direct was rolled out.

Let me express a very personal view—it is not a view I have picked up locally. As a GP’s daughter, a GP’s sister and the niece of a late surgeon, I believe that people just want to see their GP. They want to walk in to the surgery or phone up and speak to their own GP. Sometimes 111 can be seen as a barrier, as NHS Direct was, to seeing one’s own GP.

We have an historic debt of £12 million built up by North Yorkshire’s primary care trust. There is real concern locally that that debt will affect the funding of GP practices, and especially of the new 111 service. The funding issues are absolutely the key to 111 going forward.

[Mr Andrew Turner (Isle of Wight) (Con)]

Does my hon. Friend agree that one of the questions is at what level the 111 service should be sorted out? Is it something, for example, for Hampshire and Isle of Wight or for the south-east, or should it be sorted out nationally? There has been very little concern over this matter on my island, but that is perhaps because it is dealt with more locally.

[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.

[Miss McIntosh]

The problem is similar in other professions, such as my original profession of law. The Chamber will welcome the Minister’s confirmation that it is not Government policy to ration or to charge for GP appointments, as we have heard under successive Governments. We are very reassured to hear that it is not their policy to ration GP visits.

How is the interface with GP out-of-hours providers being addressed? In the rural area of North Yorkshire, three and a half clinical commissioning groups cover one constituency, which poses some real practical problems. Where there are multiple GP out-of-hours providers, what regard has the Department had to the potential difficulties of rolling out the 111 service? Furthermore, are there any issues relating to delivery in rural as opposed to urban areas? I am talking in particular about the distances that GPs or nurses might have to travel to respond to calls under the 111 system.

Most worryingly, there seems to be a political vacuum here. Will my hon. Friend the Minister reassure us that there will be political accountability? Where does the political responsibility and accountability lie for any potential failings or successes of the 111 service? Does the Department plan to review the system further? I ask that because my own experience in the pilot area of County Durham has not convinced me that the review has borne any fruit. Does the Department plan to review the system after three or six months?

[Guy Opperman (Hexham) (Con)]

I congratulate my hon. Friend on securing what is a very important debate and thank her for sharing with us her genuine and very sad experiences. Does she agree that, while everybody would accept that 111 is the way ahead in reducing the burden on A and E, it is all about integration—be it urban areas or deeply rural areas such as those that she and I represent—and that there will be future improvements in GP, 111, A and E, and other services?

[Miss McIntosh]

The 111 service is a tool and should never be a substitute for the ability visit a GP. I accept that we cannot expect GPs and their families to put up with the antisocial hours of GPs of my father’s generation, who were leaving the profession in droves. I see 111 as a useful tool—an appendage, not a substitute. There are issues that must be addressed in that regard.

Will the system be reviewed, and if so will it be within three or six months? I repeat: is 111 really geared up to deal with sparsely populated rural areas such as those that a number of us here today represent? North Yorkshire has a sparsely populated rural area—one of the largest in the country—and a high number of older patients with complex medical needs, which the GPs are very cognisant of.

I welcome the Health Committee’s inquiry into 111 and NHS emergency care. We will all doubtless follow the proceedings, and look forward to its conclusions and recommendations with some interest.

This debate has been a wonderful opportunity to get a number of issues off my chest; to pay tribute, I hope, to my father; and to note my disappointment at how he and others were treated in the pilot scheme. I hope the issues I have raised can be addressed. The 111 service may be a useful tool—an appendage—but we need to look closely at what more needs to be done, and I invite the Government to do so. I am fearful of delegating the operation of all emergency services outwith political control, and I return to the point about where the political accountability for 111 lies. I look forward to hearing the Minister’s considered response to the debate.

[John Robertson (in the Chair)]

I thank the hon. Lady for her speech and I offer her my condolences on the loss of her father, which I am sure applies to every colleague here.

--- Later in debate ---

[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.

Health and Social Care

Baroness McIntosh of Pickering Excerpts

Monday 13th May 2013 Commons Chamber

[Mr Hunt]

The right hon. Gentleman’s decision not to have a public inquiry that revealed extremely important information has meant that we are finally addressing the issue that his Government failed to address.

The Care Bill will include a vital element of our response to the Francis report, including regulatory clarity on who is responsible for identifying problems, driving up standards, and operating a single failure regime when urgent changes are not made.

[Miss Anne McIntosh (Thirsk and Malton) (Con)]

My right hon. Friend will be aware that there have been teething problems with the 111 telephone service, which could be an essential tool to treat people in their own homes, certainly for palliative care. Will he provide stringent new guidelines to all providers to ensure that such teething problems are addressed and to enable the 111 service to operate as it should?

Oral Answers to Questions

Baroness McIntosh of Pickering Excerpts

Tuesday 16th April 2013 Commons Chamber

[Norman Lamb]

The meetings are stacking up, but I would love to meet the hon. Lady. She should just get in touch with my office and we will get it arranged.

[Miss Anne McIntosh (Thirsk and Malton) (Con)]

I will spare my hon. Friend a meeting, but will he tell me what evidence there is to suggest that there was more awareness and earlier diagnosis when spa towns such as Harrogate and Bath provided spa facilities for those most badly affected by rheumatism and arthritis?

[Norman Lamb]

My hon. Friend makes an extremely interesting point. Although I have not agreed to meet her, I would be happy to have an informal discussion with her at some later stage.