Health and Social Care Bill

Memorandum submitted by Network Europe Group (HS 38)

Network Europe Group is delighted to submit this written evidence to the Public Bill Committee as it considers the Health and Social Care Bill. In the submission we set out evidence and arguments to support our contention that:

· the Secretary of State’s proposed duty as to improvement in quality of NHS services should include a recognition of the need to secure an improvement in the quality of NHS Primary Care Telephony;

· the Secretary of State’s Mandate to the NHS Commissioning Board should include a requirement to secure such an improvement, and

· the NHS Outcomes Framework should encourage GPs and other Primary Care professionals to increase the proportion of patients getting through to their local surgery by telephone and thereby continuously improve the quality of telephony services and patient experience patients receive.

We understand the importance of Primary Care

NEG is the market leader in the provision of enhanced telephony services to NHS Primary Care, and is the preferred choice of the vast majority of GPs and other primary care professionals that use such services. Every month, around 5 million calls are made by patients to over 1,500 GP and dental surgeries in the UK using our Surgery Line solution.

For most people, most of the time in their lives, NHS Primary Care is their first port of call for healthcare. Vaccinations, check-ups, travel inoculations and advice, parent and baby clinics, prescriptions, dentistry, ante-natal and post-natal care, health visiting – all of these and more are provided every day to millions of patients and their families by NHS Primary Care.

Primary Care is also for most people the ‘human face’ of the NHS. The local GPs, nurses, midwives, dentists and other primary care professionals are embedded in the fabric of their local communities and provide a familiar reassuring face over the years to families and individuals.

It comes as no surprise to us, therefore, that NHS Primary Care plays a central role in the Government’s strategy for the future of the NHS. The Secretary of State has made clear his desire to see a radical shift in power and decision-making away from Whitehall and downwards to GPs and other Primary Care professionals. The Health and Social Care Bill is the legislative vehicle by which this reform is proposed to be enacted.

Patients are our number one concern

We do not believe it is our role to provide a view on the central contention of whether GP Commissioning Groups, Primary Care Trusts or any other arrangement is the most effective or desirable way to commission Primary Care. We are happy to work within whatever commissioning framework Parliament eventually decides should prevail in the NHS. Our sole concern is to ensure that patients are able to access a whole range of Primary Care settings in as modern, efficient and convenient way as possible, no matter what their particular organisational form.

Patients choose to use the telephone to access Primary Care

It is the telephone that most people turn to in the first instance when they wish to use Primary Care. Whether it is ringing up to make an appointment, access basic healthcare, seek reassurance, check what they need to do if their baby or partner falls ill, obtain test results or organise repeat prescriptions, most people use their telephone to do so. More people choose to make a call to their local GP rather than use any other method. They don’t just use the telephone because they have to, but because they want to.

This is borne out by the most recent results of the Department of Health’s "GP Patients’ Survey" – published shortly after the Coalition Government took office. This showed that when it comes to booking appointments – possibly the most common reason a patient contacts the GP’s surgery:

· the majority prefer to book appointments by telephone (85%);

· 34% prefer to book in person;

· Two in five (21%) prefer to book online;

· 1% or fewer would like to book by digital TV or fax machine; and

· 2% say they have no preference or it doesn’t apply to them.

N.B The DH Report containing these findings explains that "where results do not sum to 100, this is due to multiple responses or computer rounding."

Millions of patients every month get an engaged tone when they try to contact their GP practice

The NHS and the Department of Health like to talk of people’s interaction with the NHS in terms of it being a ‘patient journey’. We would argue that the initial departure point at the start of most patient journeys is picking up the telephone to make a call to the local GP surgery, dentist or other primary care setting.

That is why we feel the need to submit to the Committee evidence derived from our company data suggesting that every month over 20 million patients encounter an engaged tone when they try to contact their GP practice. They are thereby being denied the easy access to local health services which the Government recognises is the top priority for patients.

The facts are:

· Every month, over 20 million patients attempting to contact their GP are confronted by the brick wall of an engaged tone - denying them access to local healthcare services and advice; and

· Over 6 million patients encountering an engaged tone are denied access by telephone to Primary Care when they need it most – between 8am and 10am.

One of the main reasons GPs and other Primary Care professionals turn to us on behalf of their patients is to resolve the problem of those attempting to get through to the surgery being confronted with an engaged tone. This will be a painfully familiar problem to any patient or Primary Care manager whose local surgery uses a normal landline.

To get an idea of the problem, we often suggest to surgeries considering an enhanced telephony solution that they use a service provided by BT called the "Network Call Performance Report". This report, according to BT’s website "reveals the true pattern of your call traffic throughout the day." The Report includes data on how many callers to a number receive an engaged tone.

Data provided to NEG from our customer base, using this BT service, reveals that a staggering 93% of calls to a typical GP surgery encounter an engaged tone if they use a normal landline without a queuing facility. This means that fewer than 1 in 10 patients in surgeries using normal landlines get through first time to their doctor when they call.

The pattern analysis provided to GP surgeries by BT suggests that, for patients whose surgeries use normal landlines, whilst 1.6 million calls get through successfully to the local GP first time, over 20 million patient calls each month are confronted by the brick wall of an engaged tone.

By definition, a patient is more likely to encounter an engaged tone when a surgery is at its busiest. However, the pattern of calls received by a typical surgery is so consistent across the country, so marked and so extreme that it means there must be some logical explanation for it.

Just under 33 per cent of all calls made to the GP surgery take place between 8am and 10am. This makes perfect sense. These will be people who need to contact the local surgery at this particular time of day:

· before they leave for work and cannot use the phone at work for personal use;

· before they get the children to school, childcare or playgroup;

· because they themselves or a family member have been ill during the night;

· possibly because they have secured advice from NHS Direct during the night and have been advised to contact their GP; or

· in some cases, because the local surgery retains a significant proportion of appointment times for allocation solely on the day of the booking.

This means that, while just over half a million patients get through to their local surgery at the busiest times on normal landlines, over 6 million patients a month are confronted with an engaged tone when they need help most.

Confronted with the engaged tone at local level, patients are faced with the options of:

· trying an alternative and inappropriate access route, for example dialling 999 or even in some cases getting into the car to drive to the surgery;

· in the future, possibly placing undue and unnecessary stress on the proposed new national 111 number for non-emergency care;

· keeping on trying to get through and possibly being late for work or missing their morning train or lift;

· using an expensive Ringback facility to jump the queue over other callers also trying to get through;

· getting the children to school, childminder or playgroup late;

· deciding not to persevere and, therefore, missing out on getting health advice which they need; or

· giving up trying to get an appointment and possibly missing out on a needed treatment, e.g. vaccination or healthchecks.

Whatever option they choose, patients are not receiving the 21st Century high quality care which they deserve. They also are being denied the easy access to local health services which the Government recognises is the top priority for patients.

Enhanced telephony increases the number of patient calls getting through first time to over 98 out of 100.

There are a number of factors and technology options from which surgeries adopting enhanced telephony can choose, including:

· how many lines/extensions to introduce;

· whether to introduce direct dial facilities to enable patients to call the doctor, or health visitor, or practice nurse directly rather than being managed and handled centrally by a surgery switchboard;

· whether to introduce a voice or telephone activated menu of options at the start of a patient call to lower the number of calls requiring the human intervention of a receptionist or surgery call handler;

· whether to include pre-recorded locally tailored health information, for example about local arrangements for swine flu.

All of the options above can have an effect on the speed and efficiency with which patients experience telephone access to their local surgery – and we strongly believe that it is the local GPs and their practice staff who are best placed to make the decisions on what suits their patients best.

However, there is one overriding choice which makes the most significant difference to whether or not a patient telephoning their surgery – particularly at the busiest time of the day – encounters an engaged tone. This is whether or not to include an automatic call-queuing facility – whereby a patient who otherwise would encounter an engaged tone is placed in an automatic queue which handles each call equally and fairly.

Being placed in a queue is not to everyone’s liking. No solution ever pleases everyone. But we believe it to be infinitely preferable to not being able to get through to the surgery at all. And we believe the facts speak for themselves.

The facts are that compared with 20 million patient calls (93 per cent) getting the engaged tone with a normal landline:

· the percentage of calls encountering the engaged tone falls modestly but not insignificantly to 56.8% if the surgery introduces enhanced telephony incorporating additional lines, but no network queuing function – this still means that less than half of patients get through first time to their doctor when they call; and

· the percentage of calls encountering the engaged tone plummets dramatically to 1.2% if the surgery introduces enhanced telephony incorporating network queuing – this means that more than 98 out of 100 patients get through first time to their doctor when they call.

Around 5 million calls are made by patients to NEG GP sites each month and approximately 23 million calls are made each month to surgeries using normal landlines.

Using these totals, our analysis shows:

· over 20 million patient calls each month using landlines are confronted by the brick wall of an engaged tone when they try to get through to the local surgery and 1.6 million calls get through first time;

· if surgeries adopted enhanced telephony solutions, but no network queuing function, this total would fall to 13 million patient calls each month encountering the engaged tone and 10 million patients getting through first time; and

· if surgeries adopted enhanced telephony solutions with network queuing function, the total would plummet to under 270,000 patient calls each month being confronted by the brick wall of an engaged tone and over 22 million getting through first time.

Patient experience and quality of service significantly increases with the use of enhanced telephony

The popularity with patients of surgeries using enhanced telephony - and the significant increase in quality of experience, access and service - is further borne out by the GP Patient Survey data.

NEG has carried out an analysis of the GP Patient Survey data, comparing the returns from a cohort of over 750 surgeries using NEG Surgery Line with the Survey’s overall national findings. The NEG surgeries in this cohort serve over three quarters of a million patients.

This analysis confirms that the introduction of enhanced telephony results in transformed access and services for patients and increased patient satisfaction: showing that:

· patients at NEG surgeries using enhanced telephony find it twice as easy to get through to the surgery on the telephone;

· patients at NEG surgeries using enhanced telephony find it more than twice as easy to speak to a doctor on the telephone;

· patients at NEG surgeries using enhanced telephony find it 3 times as easy to obtain test results on the telephone; and 

· more than 9 out of 10 patients at NEG surgeries using enhanced telephony obtain test results easily on the telephone, compared with 1 in 3 nationally.

The Secretary of State’s duty as to improvement in quality of services and mandate to the NHS Commissioning Board should include improving the quality of NHS Telephony

Clause 2 of the Bill is entitled "The Secretary of State’s duty as to improvement in quality of services". It states

"The Secretary of State must exercise the functions of the Secretary of State in relation to the health service with a view to securing continuous improvement in the quality of services provided to individuals for or in connection with

(a) the prevention, diagnosis or treatment of illness, or

(b) the protection or improvement of public health.

In discharging the duty under subsection (1) the Secretary of State must, in particular, act with a view to securing continuous improvement in the outcomes that are achieved from the provision of the services.

The outcomes relevant for the purposes of subsection (2) include, in particular, outcomes which show-

(a) the effectiveness of the services,

(b) the safety of the services, and

(c) the quality of the experience undergone by patients."

Clause 19 of the Bill concerns the Secretary of State’s Mandate to the proposed NHS Commissioning Board

It states, "Before the start of each financial year, the Secretary of State must publish and lay before Parliament a document to be known as "the mandate". The Secretary of State must specify in the mandate the objectives that the Secretary of State considers the Board should seek to achieve in the exercise of its functions during that financial year"

Given the evidence we have set out above, we would contend that the Secretary of State’s duty must include a recognition of the need to secure an improvement in the quality of NHS Primary Care telephony and that the Secretary of State’s Mandate to the NHS Commissioning Board should include a requirement to secure such an improvement.

A focus on outcomes is essential and telephony should be a mandatory element in the NHS Outcomes Framework

Clause 19 of the Bill sets out duties on the NHS Commissioning Board which mirror the general duties of the Secretary of State. It states:

"The Board must exercise its functions with a view to securing continuous improvement in the quality of services provided to individuals for or in connection with-

(a) the prevention, diagnosis or treatment of illness, or

(b) the protection or improvement of public health.

In discharging its duty under subsection (1), the Board must, in 25 particular, act with a view to securing continuous improvement in the outcomes that are achieved from the provision of the services.

The outcomes relevant for the purposes of subsection (2) include, in particular, outcomes which show-

(a) the effectiveness of the services,

(b) the safety of the services, and

(c) the quality of the experience undergone by patients.

In discharging its duty under subsection (1), the Board must have regard to any document published by the Secretary of State for the purposes of this section"

We understand that this Clause provides the mechanism through which the Board can receive its mandate to have regard to the NHS Outcomes Framework.

We are only able to retain our leading market position through constant innovation in the products we provide and the high quality services we enable local GPs and Primary Care professionals to deliver to the local patients they serve.

But we also know, as a successful business in a highly competitive marketplace, that delivering quality and innovation cannot be left to chance. It has to be consciously pursued and visibly demonstrated – not just internally within an organisation, but externally to its customers.

That is why we wholeheartedly endorse the Government’s intention to create a new NHS Outcomes Framework. We recognise that the Government wants its proposed Outcomes Framework to concentrate on outcomes that matter for patients, not simply process measures. However, we strongly contend that the simple ability for a patient to be able to contact their local GP or other Primary Care setting without encountering the engaged tone is a crucial outcome in itself from which all other aspects of patient access, quality of services and experience flow.

February 2011