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4 Feb 2009 : Column 261WH—continued
NHS Appointments
2.30 pm
Andrew Stunell (Hazel Grove) (LD): I am pleased to have the opportunity to bring this important issue to the House and look forward to the Minister’s response. It has affected the medical histories of many of my constituents.
The system has been a problem for me and my constituents ever since it started. In turn, I have been in touch with the local foundation trust, the primary care trust and NHS Direct, and I have asked parliamentary questions—in fact, because my December question was too long, Mr. Speaker kindly offered an Adjournment debate. I shall try to do the issue some justice.
After I was told last week of the time of the debate, entirely serendipitously, the British Medical Association produced a report entitled, “Choose and Book: learning lessons from local experience”. I am not so arrogant as to think that my probing put the BMA up to it, but the report is interesting, and I hope the Minister addresses it when he responds to the debate. It talks about learning lessons from local experience, and I want the Minister to learn from my constituents’ local experience.
I will start with a disclaimer: MPs hear of the worst cases. Nobody writes to me and says, “I had a brilliant experience of choose and book” or indeed of public transport or any other public service. The scheme provides a comparatively easy route to medical care and treatment, but there is a significant minority for whom it is a major problem. I want to bring the cases of a number of my constituents to the Minister’s attention, and to draw one or two national lessons from them.
My worst case illustrates many of the features of choose and book that drive patients to distraction. Mr. I was first sent to choose and book on 19 July 2007, and first contacted me on 9 August 2007. Nine and a half months later, after much correspondence in many directions, he wrote to me again on 12 May 2008 and said:
“Me, I’m giving up but if you wish to carry on the saga be my guest!!!”
I suppose that the debate is me being Mr. I’s guest. I spoke to him yesterday, and I can report that he received his treatment last month. For him, the saga that started with a doctor’s diagnosis in July 2007 has now been completed with treatment in January 2009.
As I said, Mr. I is my worst case. What happened? On 19 July 2007, his general practitioner referred him to choose and book, gave him the telephone number, the address of the website and the password, and told him what to do. When he phoned the number, he was told that he should phone again because of a high volume of calls. He repeated that experience many times. He was referred to the website, but it did not respond to him. He did what many patients do, much to the irritation of their doctors: in frustration, he went back to his GP, because he thought that he might have got the number or password wrong. Having established that they were correct—he had a letter of confirmation from the system in due course—he tried again. Once again he was told that he should try the website because of a high volume of calls.
He eventually got on to the website, but it told him that no bookings were available for the period he had chosen, and that he should try again and seek another
date. He did not want to make it hard for choose and book, so he did not try to make an appointment for the week after; instead, he tried to make an appointment for three months after his first choice. Anyone who knows choose and book knows what that means. The system would not give him an appointment because the date he selected was beyond the 18-week period in which it will accept an appointment.
Mr. I is articulate and persistent. After that trouble, he went to his GP for a third time. His GP said, “I’ll tell you what. Why don’t you phone up NHS HealthSpace?” That sounded like something to do, so Mr. I did it. What did it tell him? It told him that no appointments were available.
On 1 August, he got the first of his letters from the Appointments Line criticising him for failing to book a choose and book appointment—that was when he first wrote to me. He told me that he wanted to tell Appointments Line that he had been trying to book, but he could not do so because the standard letter from Appointments Line has no address on it—he showed me a copy of the letter to prove it. The only way in which a patient can contact the Appointments Line was by phoning the number that tells them that they cannot get through. It is absolutely ridiculous.
Patients might not be able to write to the Appointments Line, but MPs can. I now know that it is run by NHS Direct. The chief executive of NHS Direct, Mr. Matt Tee—that is not an abbreviation—sent me a letter. He invited me to comment on the application of NHS Direct for trust status. I told him in no uncertain terms that until he sorted out Appointments Line, it would not be sensible to give it such status. The letter he wrote back to me is interesting in many ways, but I like this bit:
“The Appointments Line takes over 280,000 calls a month and at present receives 0.56 complaints for every 10,000 calls.”
I thought that that was an interesting way of expressing things, but I marvel at how half a complaint managed to sneak through. How would the Appointments Line know that people wanted to complain if they cannot write or phone? There is no address to write to. People have to know that it is run by NHS Direct before they can get anywhere.
I also marvelled at another part of the letter that delightfully passes the buck for the problem:
“I agree that services should be user friendly and less bureaucratic and will do all I can both to ensure that this is the case for the services I control (such as The Appointments Line) and to encourage others to do so with the services that I do not control (such as the national Choose and Book system).”
I thought that that was a pretty neat sidestep from my constituent’s concerns. Who runs the national choose and book system? Mr. Tee said:
“We are working closely with colleagues both in the Department of Health and (specifically) in Connecting for Health, to promote improvements to the systems and software associated with Choose and Book”.
So it is not his problem; in his view, it seems to be the problem of the Department of Health, NHS Connecting for Health and the software manufacturers. Evidently, choose and book has nothing to do with the Appointments Line and everything to do with everybody else.
I would not want the Minister to think that, because I started with a case from 2007, he can respond by saying, “Yes, there were some initial teething difficulties, but everything is fine nowadays.” It is no better now. Calls still go unanswered, appointments are still unavailable and infuriating reminder letters are still sent. Unanswered calls are a problem for my constituents.
Last November, my hon. Friend the Member for North Norfolk (Norman Lamb) asked a parliamentary question and received a briefing in the Minister’s reply saying that last October, 338,000 callers tried to access the Appointments Line. According to the figures in the reply, 27,000 were not answered. One must read the small print carefully to find out that 17,000 callers found the line engaged and 10,000 found it playing Vivaldi. One in 16 calls made to the Appointments Line is unsuccessful. That is from the Minister’s own figures for last October, which show 27,000 calls not answered last October. That works out at 324,000 missed calls a year. A third of a million calls, according to his own figures, fail to get through to the Appointments Line.
The astonishing thing is that the Appointments Line met all its key performance indicators. I do not know whether any other call centre in the country, commercial or public, would meet all its key performance indicators if it left out a third of a million callers a year. If so, I hope that the Minister will brief us on which one it is. I suggest to him that the key performance indicators for the Appointments Line are not sufficiently rigorous. He is not getting his money’s worth.
The second big problem is that appointments are not available when people do get through. There are two causes for that. Well, there may be more than two causes—the BMA report suggests quite a range of them—but I will focus on just two. The first, and perhaps the one that the Minister could most easily do something about, is the 18-week waiting period, which creates a black hole beyond 18 weeks when appointments are not taken. If appointments cannot be booked more than 18 weeks ahead, when a particular clinic or consultant is fully booked, they are taken off the list of appointments available. They do not even appear. Of course, at the call centre, they cannot say, “Well, that’s because they’re booked up for the first 18 weeks”; what they say is, “They’re not on the system.” They disappear into a black hole.
Norman Lamb (North Norfolk) (LD): Does my hon. Friend agree that if a particular hospital or clinic disappears from the list because the waiting time is more than 18 weeks, that restricts choice rather than enhancing it?
Andrew Stunell: My hon. Friend makes a good point. My constituency is adjacent to the local district general hospital, Stepping Hill hospital, which is run by the Stockport NHS Foundation Trust. I would say that more than 90 per cent. of my constituents—probably more than 95 per cent.—would expect that if they were referred from primary care to secondary care, they would be referred to Stepping Hill hospital, as it is an option more or less on their doorstep. It is in Stockport, as the name suggests. A referral to Preston, Bolton or somewhere similar is very much a second choice unless there is a specific reason to see a particular specialist. The expectation is that appointments would be booked at the local district general hospital.
Mark Hunter (Cheadle) (LD): My hon. Friend is articulating the frustration of many constituents who come up against the system. Does he agree that one of the fundamental problems, particularly in certain sections of society, is that people do not understand why the Government are so keen to force that system upon us? An elderly couple recently came to visit me, bringing with them all the literature sent out as a matter of course. It included an expensively produced colour booklet, letters and an information pack. There was a lot of detail for them to go through. They said, “Mark, all we did was ask for a referral from the GP to go to Stepping Hill. Why are we being offered an appointment in Bolton?”—or Wigan, or wherever it was. Those places are part of the Greater Manchester conurbation, but they are too far away for many of our constituents to travel to.
Andrew Stunell: I agree absolutely with my hon. Friend. The 18-week event horizon—that is what they call it when a black hole occurs and radiation cannot get in or out—means, perhaps not surprisingly, that the local district general hospitals’ clinicians and consultants tend, on the whole, to be fully booked first. Then they disappear. It does not make a lot of sense for people to be referred to distant places.
The Minister needs to have a look at the 5 per cent. tolerance rule. Everybody in the health service has to meet the 18-week rule, but one of the things that I learned from reading the BMA report is that the Government allow a 5 per cent. tolerance rule, as I understand it, in case somebody does not turn up. There needs to be flexibility for choose and book to book appointments well beyond the 18-week event horizon at the patient’s request. That does not seem difficult.
Mark Simmonds (Boston and Skegness) (Con): The hon. Gentleman is making an interesting case, drawing upon experiences with constituents that I suspect all of us, as constituency Members of Parliament, have had. Is Tee correct in highlighting the fact that the problems of not being able to book an appointment through the choose and book system after 18 weeks are a good example of the centrally driven target culture distorting clinical priorities?
Andrew Stunell: That is true, of course. It is also interesting to see the decisions taken about which medical procedures should be included in the 18-week limit and which should not. We could have another interesting debate about that. As somebody who recently acquired a pair of hearing aids, I happen to know that hearing is not included in the 18 weeks.
However, I do not want to go there; I return to the point made by my hon. Friend the Member for Cheadle (Mark Hunter). People who go to their GP and are referred for a medical procedure will not necessarily be rocket scientists. What they get with choose and book is a complicated way of getting in touch that involves passwords and so on. I have a letter, which I will not quote, saying, “I’m going to go and have my hip replaced. They’ve given me a password. Surely nobody else wants my hip?” There is a lack of comprehension about what the system is designed to do and why it is being done in that way.
Apart from the 18-week event horizon, there is a second factor that leads to a shortage of appointments on the system: some appointments are never put on the central database in the first place. At least one of the reasons for that is the failure of choose and book to engage the medical profession fully and the profession’s lack of confidence in it.
I would like to take the example of Stockport. When my hon. Friend the Member for Romsey (Sandra Gidley) asked a parliamentary question in November, she established that only 60 per cent. of bookings for secondary care in Stockport are made through the choose and book system; 40 per cent. are made on pre-existing manual systems of one sort or another. Because hospitals, clinics, GPs and consultants are so fed up with choose and book, they are using the old “steam” system in many parts of the country. The same parliamentary question established that take-up ranged widely in different primary care trust areas; 60 per cent. was somewhere near the norm. As a result, appointment times never get on to the system and are held back for the manual appointments to be made. The BMA has some interesting comments on that situation. Perhaps the Minister would like to come back on that point when he responds.
Therefore, not only can someone not book after the 18-week period, but many appointment times are never there to be booked in the first place. Why is that? Why do GPs not think that choose and book is the best thing since sliced bread? One of the reasons is illustrated by the case of Mr. I, who had his consultation with the GP but had to go back twice to try to establish how he could make his appointment through the system. I do not know how many people in Westminster Hall have had a referral through the choose and book system. My GP, who had no particular knowledge of my interest in the system or concern about it, did not even ask me to book through it. What he said to me was, “They’ll be sending you a letter, but in the meantime I’ll get you booked in anyway”. That was an example of a GP bypassing choose and book, because he did not want me to come back moaning that I could never get through on the phone to make the booking.
Of course, there are also the infuriating reminder letters; it is not necessarily the case that just one is sent. I actually received an apology from my PCT. If I quote from the letter that I received in September 2008 from the chief executive of my PCT, everyone will get the drift, because it is a contemporary example of the problem:
“As you will be aware, the Choose & Book is an automated system and part of the process is for reminder letters to be sent out to any patient where a referral had been made, but the appointment not yet booked. In the case...I understand that she”—
“received at least three letters, and that on each occasion she then telephoned in an attempt to book the appointment, but was then told that there were no available slots to book her into. I can appreciate the frustration this would cause and I would ask that you pass on my most sincere apologies, on behalf of the Trust.”
The question that I suppose the Minister might be asking himself is, “Well, has he just got a couple of nutters writing in green ink, or is this something which is widespread?” I can say that it is widespread. There is the case of Mrs. M, who said:
“I was somewhat dismayed when my recent appointment came through under a different consultant and involved a very basic procedure. I realised that I was being treated as an entirely new
patient, despite the very clear letter of referral that my G.P. had sent. I queried matters with the ‘choose and book’ administration and was told that my usual consultant would not be able to see me within the target time, so I would have to start all over again with a new consultant, even if it were inappropriate to do so.”
There is also the case of Mrs. H, who required a consultation with a neurosurgeon but was told that no appointment could be made within the next three months as all the appointments were taken. However, as no appointments could be made beyond the next three months, no progress could be made with the appointment at that stage.
I have a letter from Mr. B, who said:
“If patients have to chase their follow-up appointments, it suggests that either too much money has been wasted on inadequate computers or someone isn’t doing their job properly - or both? There seems to be an over-emphasis on computer technology at the expense of employing personnel needed to deliver a front line service.”
I thought of offering Mr. B a job in this debate.
Then there is the case of Mr. P, who has spinal problems that require regular injections. He needs to see a neurosurgeon too. A specific consultant was recommended but the new choose and book system would not allow direct referral.
Sometimes we get lucky and I have had a follow-up letter from Mr. P, which says:
“I would like to thank you for the enquiries you made on my behalf, it’s amazing what an MP’s letter can do!!”
Given that there are about 338,000 failed inquiries a year, I do not think that MPs can plug all the gaps in this particular system.
I want to round off with a quote from a patient who is a constituent of my hon. Friend the Member for Somerton and Frome (Mr. Heath), who contacted me when she saw that I was having this debate. She is Miss G and she wrote to me to say:
“My experience is that this is a totally pointless exercise. I recently had to book two hospital appointments in Somerset. For both of them, I received letters with a list of the hospitals where I could book my consultation and promised I could do this through the Choose and Book line but when I phoned, in both instances I was given the telephone numbers for phoning the hospitals direct to make a booking. Why did they not put those telephone numbers in the letter, saving me time and the NHS money in employing someone to give out the phone numbers?”
I have described choose and book as the NHS’s version of air traffic control. If all the landing slots are full, then the aircraft are just kept circling and kept waiting until there is clearance. That is exactly what is happening with patients, time after time after time.
Everybody knows that there is a serious problem with choose and book, but nobody wants to take responsibility. The Appointments Line says that it is not responsible, the Minister said very clearly in answer to my question in December that he was not responsible, and the PCT says that it is not responsible either.
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