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Mr. Swayne: My hon. Friend is right and we are awaiting that investigation. It would not be acceptable if the regulations could create a situation in which the only out-of-hours access to the NHS was via NHS Direct, given that we are doubtful about the robustness of that organisation to deliver the service. My hon. Friend's point that there has been no evaluation of NHS Direct is accurate, although the figures that I quoted come from Sheffield university's evaluation of NHS Direct's first-wave sites, contained in the second interim report to the Department of Health, produced in February last year. Mr. Hammond: It was not robust. Mr. Swayne: It may not have been robust, but it nevertheless drew attention to a significant number of problems. My hon. Friend is correct that we must await a more thorough examination. The medical profession is deeply concerned about the way in which NHS Direct has been rolled out without any proper evaluation hitherto. It is time that that evaluation was made. We should not accept regulations that create a situation in which all out-of-hours access is through NHS Direct when so many questions still pertain to that organisation. Dr. Brand: I do not want discussion on the clause to focus solely on NHS Direct. However, it is clearly an evolving service that is having problems during its evolution. Not only has it found it difficult to cope with capacity, but there have also been significant problems with the computer programmes on which the advice is based. It can take a long time to get hold of someone, and the assessment process by an NHS Direct assessor is very time consuming. Sometimes advice is also a little too direct. One of my wife's patients told her that NHS Direct had told the mother that the child had to be seen by a doctor within an hour. It is not the role of NHS Direct to dictate how a patient should be seen, or at least I do not believe that it should be. Those issues must be resolved in time. I worry that NHS Direct is a free service to GPs. In effect, GPs are being bribed into using NHS Direct because they are pragmatic people who will use a free service. However, it is not a free good and we must recognise that public money is spent on that service. Let us hope that it works out well. My concern about the clause is that a health authority may be reluctant to sanction any other other-of-hours services as out-of-hours first-line-of-call access is free through NHS Direct. Would arrangements made by individual contractors—to have internal rotas, for example—also have to be approved by the health authority, or could those contractors retain their individual 24-hours-a-day responsibility? I was in a single-handed practice for about 15 years, and I was on call every night apart from Thursday, through a rota with colleagues. That worked well, except that one of my colleagues, who was not terribly reliable, put a message on the answer phone saying, ``If there are any problems, ring me at home''. Such methods are no longer acceptable to most practitioners, and would not be to me now, because patients' attitudes have changed. That is perhaps part of increasing consumerism, which the Government have fuelled by raising patients' expectations that there should be access to just about anything, 24 hours a day. That issue needs to be addressed, but not in this debate. Mr. Hammond: The hon. Gentleman pursues an interesting line and might further ask the Minister whether the purpose of the clause is to approve providers of out-of-hours services, or whether the regulations under it are to be used to define the routes of access to those services by making it a condition of approval that a person's service is accessed in a certain way. That would run some of the risks that the hon. Gentleman has outlined. Dr. Brand: I am grateful for that intervention, which clarifies what I was intending to say. The clause gives the Secretary of State the power, through regulations, to determine how access is provided, irrespective of local traditions or of what has worked in the past. I do not oppose the clause, because I am a realist and I know that the world has moved on during the past 20 years. However, I would like an assurance from the Minister that the clause gives neither the Secretary of State nor health authorities powers of direction that could become unreasonable, such as the power to direct not in the interests of patient care but in the interests of administrative convenience, or even the power to shuffle responsibilities among different budgets. Mr. Denham: I shall start on that final point. The clear intention of the clause is to enable the setting of standards that providers will have to meet. The focus is on those standards; that should be a considerable reassurance to the Committee. Those standards will have to be met by all accredited providers, however their services may be organised. I do not find it acceptable to require a higher standard from one provider than from another. For example, the out-of-hours review proposed that 1 per cent. of clinical records should be continuously audited by a sampling method that would measure the standard of record keeping for each provider of out-of-hours services. We would not want the out-of-hours services of some patients to be subject to that regime, but not those of others. The out-of-hours review suggested the imposition of standards on aspects of telephone access, such as the percentage of calls engaged or abandoned and the time taken to answer, and on the way in which the triage system operates. Such standards should be available to patients in all parts of the country, irrespective of the way in which the service is provided. Our focus is on those standards. The out-of-hours review suggests measures that are directly related to patient services and patient outcomes rather than to particular organisational models. For example, time limits for home visits in the case of an emergency should be subject to quality standards. It is important that record keeping and auditing should be of a consistent standard throughout the country, however the provider organises its service. Mr. Hammond: Is the Minister saying that he will not use the regulations under the clause to define certain methods of access only to out-of-hours providers?
11.15 amMr. Denham: We have no intention of using the regulations to require every patient to follow a particular procedure—as they are currently drafted, I am unsure whether we could use them in that way. However, I believe that patients will find it convenient to have to ring only one number to access advice and out-of-hours services. That service is already offered to between 2 and 3 million patients in England, as a result of the integration of NHS Direct with GP co-ops. Therefore, it is not just a fanciful concept. It already exists in large areas of west London, where the Harmoni co-op is integrated with NHS Direct. An increasing number of co-ops are integrating their services with NHS Direct. The situation will further improve as the latest triage software becomes available to the whole of NHS Direct and is integrated with out-of-hours services. An existing telephone line may be retained because, for example, a co-op may wish to offer that service to its patients; but I believe that most patients will prefer to have to remember only one number to access a wide range of services. I assume that the Committee has not discussed in detail the principle of accreditation because it generally welcomes the proposals that underlie the clause, and that are described, in particular, in the out-of-hours review. Therefore, although I could discuss the clause in more detail, it might be satisfactory to deal only with the issues raised in the debate. I am unsure whether the hon. Member for New Forest, West was objecting to the concept of NHS Direct or to the idea that there should be accreditation and standards. I assume that he accepts the idea but does not like NHS Direct. When we began to develop NHS Direct, the official Opposition used to jump up and down and say, ``We thought of it first.'' Now, just as its success is becoming apparent, they seem to have changed their tune. That is typical of their political judgment at the moment. Mr. Hammond: The Minister has rattled my cage. I reassert that my party thought of NHS Direct first; I think that our pilot scheme was in Wiltshire. We have consistently said that NHS Direct could play an important role in the overall delivery of health care services, but it must be properly evaluated before it is rolled out. Our objection is that the Government rolled out the pilot schemes nationwide without any robust study of the value for money and cost-effectiveness provided by the service. As the NHS budget is limited, that is an irresponsible way to proceed. Mr. Denham: I disagree. NHS Direct—which is clearly linked with the provision of out-of-hours services—is subject to continuous evaluation, and that evaluation is published. NHS Direct is also subject to a degree of clinical governance that is not practised in every part of the NHS. That is one of the great strengths of NHS Direct. Consultations are tape recorded, although the information contained on those recordings is confidential. Therefore, if a patient complains that he or she was told to do X, that can be checked. That would not be the case in almost any other consultation that may take place elsewhere in the health service, and it has enabled previous allegations to be substantiated. I want progress to be made with out-of-hours services, so that it becomes possible in every part of the country to access accredited out-of-hours services by ringing the NHS Direct number. At present, millions of patients already have that service. Other GP co-operatives would like to work with NHS Direct because they recognise the advantage of having NHS Direct provide a triage service. People working in other parts of the service want to see how it works in practice. That is why the implementation of the out-of-hours review is based on the development of exemplar projects over the coming years. Those projects will demonstrate to GPs who may be uncertain about which course to take that the service is a cost-effective, patient-friendly and doctor-friendly way of proceeding. That will enable those services to achieve the necessary standards of accreditation and to offer a better service to patients. When we responded to the out-of-hours review, I made it clear that we wanted to proceed on that basis. By working with those who want to move in this direction at an early stage, we will be able to demonstrate to those who have doubts that this is the right direction.
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| ©Parliamentary copyright 2001 | Prepared 25 January 2001 |
