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.