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4 Feb 2009 : Column 273WH—continued
The hon. Member for Hazel Grove was right to highlight the significant problems. He emphasised the telephone aspect of choose and book, but from GPs whom I have met in my constituency and in my Front-Bench role, travelling around the country, I can assure him that the problem is pertinent to GPs who try to book appointments online, too. However, he should be aware—I
am sure the Minister will mention this in his closing remarks—that there is a vast range of opinion about choose and book, and some GPs find it an asset to patient care, so there is no uniform animosity towards the system. Having said that, I realise that there are significant problems.
The hon. Gentleman highlighted the 18-week problem, which I shall return to later, and the peculiarity of the complaints procedure, which seems completely unacceptable. It is not surprising that the body responsible for collating the number of complaints has very few to report, because there is no mechanism for people to express their disappointment and to complain about the procedure. He also gave some staggering and astonishing figures on unanswered calls, and the Minister must address that point urgently.
I got the feeling that the hon. Gentleman and the hon. Member for Cheadle (Mark Hunter) were suggesting trying to remove patient choice, but in an intervention on the hon. Member for North Norfolk, the hon. Member for Hazel Grove seemed to contradict what he had said earlier. Indeed, I noted that the hon. Member for North Norfolk, who is the Liberal Democrat Front-Bench spokesman, did not reiterate the idea of potentially removing patient choice. It is a key part of any patient-centric national health service.
Mark Hunter: I thank the hon. Gentleman for giving way, because that is an important point. He is right to appreciate that we were not seeking to remove choice in any way. I referred to it by saying that people should not have choice forced upon them, as the Government seek to. If one’s area is well served by the local hospital, as ours is, most people will want a referral to that hospital, not to one on the other side of the conurbation.
Mark Simmonds: I am grateful for the hon. Gentleman’s clarification of his earlier point. Ultimately, the decision should be the patient’s to make, with advice from the general practitioner, but under the current system that is not the case.
Andrew Stunell: May I reinforce the point that my hon. Friend the Member for Cheadle (Mark Hunter) made about the choice being the patient’s? If the patient wants to go to the local hospital and its appointment system is booked for the next 18 weeks, he or she is not offered that choice by the system. That is the flaw when it comes to choice. The fundamental choice for most patients is to be able to go somewhere near, and if choose and book cuts out that choice it is a failure.
Mark Simmonds: I agree. The 18-week target covers roughly only one third of activity in the acute sector of the health service anyway, but from the evidence that the hon. Gentleman and his hon. Friends have put before the House today, and from other evidence throughout the country, there is absolutely no doubt that the 18-week target not only constrains and limits choice but distorts clinical priorities. That must be fundamentally wrong.
The hon. Member for Cheadle made an interesting point by highlighting the Minister’s response to his question at Health questions in November. However, I suspect that the Minister was right: compared with what else is going on in the NHS IT system, choose and book is a relatively successful scheme, and at least it works in part. In the context of the complete shambles and mess that is the over-budget, behind-schedule totality of the NHS system, choose and book is probably a
small ray of hope. However, the hon. Member for Cheadle was also right to highlight patients’ inability to choose a consultant. It is one of the main concerns in my constituency in Lincolnshire, particularly for elderly people and people who have historically been referred to a specific consultant—where a consultant-GP relationship has existed. The operation of the choose and book system does not seem to be able to cope with that.
The contribution from the hon. Member for North Norfolk was, as always, considered and calm, and he is absolutely right that the Minister before us is not responsible for initiating this mess; he has inherited big and significant problems. Accepting and acknowledging that a significant problem must be addressed would be a start, however. It would enable the Minister to put in place a review, which we, as the Conservative party, have done, to consider the very issues that have been highlighted today—not just choose and book, but the entire remit of the NHS IT structure. Although I do not wish to make any statements about the direction of our review, I must say that we are very uncomfortable, as is the hon. Member for North Norfolk, about centrally imposing an IT system without the consultation or agreement of those who have to implement it. There must be a different answer, and there have been fundamental flaws in the system right from the start.
Having said all that, we recognise that technology is a vital part of the NHS, and in some parts there has been praise for choose and book. It has enabled doctors to provide patients with an appointment on the spot, when the patient is in the surgery, and in some cases it has allowed for greater control over appointments and enabled clinicians to track referrals and share confidential information, which is an important part of the system. There is a whole range of issues, some of which have already been raised. Instead of going into the detail of those, I shall raise some additional ones that I think need to be considered.
Choose and book does not offer choice. Of those who used it in August 2008, 66 per cent. reported not being given a choice of appointment date, 66 per cent. reported not being given a choice of appointment time and 86 per cent. reported being given a choice of fewer than four hospitals, which is supposedly the utopian position. Thirty-two per cent. reported not being given any choice of hospital at all. Part of that may be that people are determined to use their local hospital, but they should be given a choice of alternatives, not a forced appointment that may or may not be convenient for them. There is growing evidence to suggest that appointments made through choose and book are increasing the number who do not attend. University hospital, Lewisham has recently done some research and found that 18 per cent. more people did not attend appointments if the appointment was made through choose and book, as opposed to 12 per cent. for traditional GP referrals. That is a growing problem.
Another problem is that the system does not seem to be able to cope adequately with complex referrals. This needs to be looked at to ensure a simple process, not added administrative layers. Other Members referred to technical problems with the system. It crashes, then takes a long time to reboot. By the time the GP can access it, the patient is no longer sitting in front of them
so they have no choice but to use the telephone system, in which case they get into the problems that were highlighted by the hon. Member for Hazel Grove.
We spoke earlier about GPs not being able to refer to a specific consultant, which is of great concern and certainly needs to be addressed. It is clear that insufficient appropriate appointments are accessible to the choose and book system. Trusts do not currently put all the available appointments on the system. They hold many back for paper referrals and some for tertiary referrals, and some trusts do not make any appointments available after the 18-week limit that was discussed earlier. There is also inaccurate information. GPs are unable to find the clinic they want to refer a patient to—it might not be on the system, or it is not where the doctor expects it to be. Such problems should reduce over time, but they have been going on for a significant time without getting much better. I am sure the Minister is aware of the dummy appointments problem: in order to meet waiting time targets, trusts tell people that they must accept dummy appointments and then not turn up. That is completely unacceptable.
Another challenge is exactly how the system has helped consultants. The explosion of administration and bureaucracy seems to have had very little positive impact on their working practices. There is absolutely no doubt that patients are being sent to the wrong clinics and consultants. Consultants then have to re-refer patients who should never have been referred to them to specialists in sub-groups. That may be a function of the system or of non-clinical input to the computer system.
The British Medical Association criticised choose and book in a recent report, but it is not the only organisation that has been critical. The Royal College of Surgeons said that choose and book is “detrimental to patient care”. That is a significant statement from such an august body. Not all GPs have signed up to choose and book. I was shown a press release from a newspaper in Norfolk in which the hon. Members for North Norfolk and for Norwich, North (Dr. Gibson) were extremely critical of the impact of choose and book on their constituents in Norfolk. Indeed, some GP practices are not using it at all, as they see it as such a problem in terms of patient care.
The concerns go much wider than choose and book. There are significant problems with NHS IT systems. A Public Accounts Committee report published on 27 January was heavily critical of the Department’s IT programme and referred to unacceptable confidentiality agreements. The Committee was “unconvinced” by the programme’s centralised contracts, and said that they had not provided the taxpayer with value for money. There is a significant way to go to put the situation right.
I reiterate the point made by the hon. Member for North Norfolk about the abandoned Fujitsu contract for the southern area, which poses serious risks. The programme’s new deadline of 2015 is unlikely to be met—the original programme was supposed to be completed by 2010. It would be helpful if the Minister could give us some indication of the compensation— is it £600 million or some other figure?—that Fujitsu wants. If he cannot give specific numbers, it would certainly be a help if he could tell the House the stage that the process has reached.
The Minister will be aware, as other hon. Members may be, of the concern that the Public Accounts Committee
raised about the number of suppliers providing IT going down to two—BT and Computer Sciences Corporation—and the impact that that may have on the future of IT contracts.
I shall conclude with some questions for the Minister. If he does not have time to reply to them today, perhaps he could do so in writing subsequently and place a copy of his letter in the Library. It would be interesting to know how much the Department has spent to date on implementing choose and book. When does the Minister expect to reach his March 2007 target of 90 per cent. delivery of referrals through choose and book? I believe that the current figure is just below 50 per cent. Clearly, the Government are significantly off the timeline that they originally envisaged.
Could the Minister tell us what evidence he has that patient outcomes are better from using choose and book, and what analysis his Department is doing to try to prove that such systems enhance patient care and outcomes? What steps is he taking to ensure that patient choice is not constrained by trusts attempting to meet 18-week targets? Could he give his estimate of the number of GPs and GP practices that are not using the system at all? What will he do about that?
Finally, will the Minister publish impact assessments for choose and book, particularly in respect of the elderly, who often find the system difficult to navigate? Some do not have access to the internet, and run into the problems with the telephone system that were so well articulated by the hon. Member for Hazel Grove.
3.38 pm
The Minister of State, Department of Health (Mr. Ben Bradshaw): I congratulate the hon. Member for Hazel Grove (Andrew Stunell) on securing this debate.
I believe hon. Members on both sides of the House appreciate that modern health care is a complex service. There are in the NHS more than 170 acute care hospitals and some 150 independent providers. Each one offers a wide and increasingly specialised set of clinical services. On any given day, every one of England’s 36,000 GPs will refer, on average, one patient to a hospital for some form of elective treatment. It is clearly not possible for a GP to know of every consultant in every specialism in every hospital in the country. I believe that there is consensus in Westminster Hall today that the old paper-based system would be completely unable to cope with the complexity and speed of modern health care, or to fulfil the right of the patient to choose, which I believe most of us accept.
The paper-based system was far more cumbersome and much more expensive. For decades, the NHS creaked and groaned under the weight of millions of letters booking, confirming and rearranging appointments. Letters were lost, misdirected or misfiled. If a GP referred a patient to a hospital consultant—one of their choice, not the patient’s—the patient would leave the practice and enter a state of limbo. They would not have a clue when their appointment would be. They would find out just before it was due, when the hospital would send a letter. The appointment, which would be at a time convenient to the hospital, was made without any consideration of the patient’s needs. In summary, the old system assumed that the patient was the passive recipient of care, not an engaged participant.
Just last week, the British social attitudes survey reported that 95 per cent. of people say that they want some degree of choice over which hospital they attend and the kind of treatment that they receive. Of course, from 1 April this year a patient’s choice of elective care will become a legal right through the NHS constitution. Since choose and book was initiated, more than 10 million people have been referred through it. As of November last year, more than half of all out-patient referrals used choose and book and the latest figures that we have, those for January, show that that figure is up, at 57 per cent. In January, more than 600,000 patients used the system, with more than 30,000 referrals made in a single day last week. Usage has doubled over the last year. Last week, 90 per cent. of GP practices used choose and book.
I acknowledge that sometimes the system has been slow and that occasionally there have been problems with system availability, but virtually all the problems that hon. Members have raised today are problems not with the national choose and book system, but with how individual primary care trusts, hospitals and GPs have implemented it or engaged with it.
I have been advised by the PCT in the hon. Gentleman’s constituency that he raised three specific cases with it relating to choose and book between February and December 2007. I think that the case of Mr. I—the hon. Gentleman will correct me if I am wrong—was the second of those cases, which the PCT tells me it heard about from him in November 2007. Clearly, the case as outlined by the hon. Gentleman is unacceptable. It is difficult to know where the fault lies without hearing more details about individual cases, although it seems, from what he says, to lay mainly with the telephone booking service.
I am informed by the PCT that it tried to contact the patient that the hon. Gentleman mentioned to investigate his case, but did not receive any response, and that it further tried to contact the patient but was unsuccessful. However, in the last letter that the patient sent to the PCT, he stated that he did not wish to pursue the case further. Obviously, if there is still a problem relating to Mr. I’s case—or with any of the other individual cases that the hon. Gentleman raises—I should be happy to look into it.
The hon. Gentleman mentioned the case of another patient, whom he did not identify, saying that they were referred to hospital during 2008 but told that it was unable to take referrals because it needed to meet its 18-week target. We picked that matter up last year, when it was raised by another hon. Member whose patients use Stockport hospital and, with the intervention of the chief executive of the strategic health authority, the foundation trust in Stockport was told in no uncertain terms that that was not acceptable behaviour. The hospital responded by reopening its referrals and those referrals remain open now.
Norman Lamb: I am encouraged to hear that, but we hear time and again of hospitals where the wait would be longer than 18 weeks automatically disappearing off the list of choices. Is the Minister saying that that will no longer be the case and that, even if the wait would be 20 or 25 weeks, the patient will have the right to choose that option?
Mr. Bradshaw: I will come on to that in a bit more detail in a moment. The basic principle is that patient choice is paramount. However, providers and individual surgeons should not be able to use that excuse not to meet the 18-week target.
As I have already mentioned, some GPs do not use choose and book because they might have heard bad things about it a year ago and they have not tried since. GPs need to take the time to get to grips with that system and really understand how it can benefit their patients, which will mean working with their PCT to address problems that might frustrate them. Similarly, many PCTs have set up their IT systems to make the most of choose and book and others have not and, as hon. Members have acknowledged, there is wide variation in performance among PCTs. Some PCTs do not train their staff, including their GPs, in how to make the best use of the system, some do not agree with their local providers how services should be displayed and some do not use the clear provisions in their contracts with providers to enable referrals to flow freely through choose and book. We are pressing PCTs to work closely with their GPs, and providers to resolve these issues.
Stockport PCT is performing above average. Although the hon. Member for Hazel Grove has come to me with a number of individual cases, the latest performance of his PCT is at about 64 per cent. However, the one in Staffordshire, which the hon. Member for Cheadle (Mark Hunter) mentioned, which straddles areas is not performing quite as well. Of course, Norfolk is one of the poorest performers in the country.
Andrew Stunell: I appreciate the Minister giving way. I did acknowledge that Stockport was about average, with the 60 per cent. figure being mentioned in the recent figures that he published in a parliamentary answer. I notice that Devon is at 73 per cent., Norfolk at 33 per cent. and Lincolnshire, for what it’s worth, at 42 per cent. There is a wide variety of figures, as he says, but there is still the need to get to grips with a system that denies patients the choice of appointments that they need.
Mr. Bradshaw: I will come on to that in a moment.
Mark Hunter: For the Minister’s benefit, can I just confirm that Cheadle comes under the PCT for Stockport, Greater Manchester, not the one in Staffordshire?
I want to clarify one of the Minister’s responses that he made a moment or two ago. He seemed to suggest—I want to be careful not to put words into his mouth—that the responsibility for the problems might lie with the PCT, rather than with the system itself. In the cases mentioned by hon. Members, it is of course systematic failure that is endemic in the structure that has been built up. Will he clarify that response and say just how much of the responsibility for this lies with the individual PCTs, since, as he has already said, Stockport PCT is generally a high-performing one.
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