HC Deb 02 February 1999 vol 324 cc727-35 3.32 pm
The Secretary of State for Health (Mr. Frank Dobson)

I wish to make a statement on the development of NHS Direct, the nurse-led 24-hour helpline.

In March last year, we launched three NHS Direct pilot schemes in Milton Keynes, Preston and Newcastle upon Tyne. Between them, they covered more than 1.5 million people. They have proved a great success—up to the end of December, they had taken over 60,000 calls. Independent research has revealed that 97 per cent. of users are satisfied with the service provided, which they find prompt, friendly and professional. It has been particularly popular with young mothers and around 40 per cent. of calls have been about children.

Callers get through at first to a call handler, who takes their details and deals with any requests for basic information. Callers who have a specific health problem are then put through to a nurse. The nurse listens to the caller, assesses the case using what is called an expert computer-based decision-support system, and then recommends what action the caller should take. That can range from immediately summoning an emergency ambulance to advising callers to visit their general practitioner or the accident and emergency department, giving advice on how to treat someone at home, and offering simple reassurance.

A detailed survey of the three pilots showed that, for the latest quarter, 80 per cent. of callers were advised to do something different from what they had intended before they rang NHS Direct; only 9 per cent. of callers had intended to look after themselves at home, but after calling NHS Direct 38 per cent. of them were enabled to do so; 20 per cent. of callers were directed to more urgent care and 40 per cent. to less urgent care; and 530 people were transferred to the 999 service.

It rapidly became clear that the pilot schemes were a success, so last summer I authorised the extension of the scheme, with 13 call centres to cover 40 per cent. of the country—20 million people—by April this year. The first of those opened last month, covering 1.1 million people in the black country. Yesterday, a further scheme covering almost 1.6 million people opened in Essex. A further service covering Nottinghamshire opens next week and the first service in London opens in parts of west London early in March.

The other areas to be covered by about Easter are in the west country; Manchester; West Yorkshire; Hull and East Yorkshire; Hampshire; north-west Lancashire; Birmingham as well as the black country; Lambeth, Southwark and Lewisham; Buckinghamshire, Northamptonshire and Oxfordshire; and Newcastle and the north-east. Most of the services will be provided by the local ambulance trust, but they usually involve the local GP co-operatives, other NHS trusts and voluntary bodies. In some cases, local social services are involved as well.

The success of NHS Direct springs partly from the use of modern technology, properly managed and staffed by top-quality professionals with a sympathetic ear. It also depends on commanding the support of the NHS in each locality, particularly the professions involved in providing primary care. At my personal insistence, there will be a major role for GP co-operatives in the delivery of the service in many parts of the country. I am pleased to be able to report that the west London call centre, to be located in Southall, will be run by a local GP co-operative.

Our original intention was to extend NHS Direct to cover 60 per cent. of the country by April next year. However, in view of its growing success and my concern to help the NHS cope with the special problems that it is likely to encounter over the millennium period at the turn of the year, I have decided that the programme should be brought forward to aim to cover at least 60 per cent. of the country by the beginning of December this year. In some cases, that will be achieved through extensions to existing centres where the service is well established and in others it will be achieved through opening new centres. We intend to cover South Yorkshire, Leicestershire, Derbyshire, Liverpool and parts of London. NHS Direct could be particularly valuable in all those areas next winter. To achieve that, we shall be investing an additional £10 million from the NHS modernisation fund on top of the £44 million from the fund already committed to NHS Direct in the coming financial year.

NHS Direct is proving to be a modern, additional, convenient and dependable service for the people who turn to it. It is also proving to be popular and professionally satisfying with the nurses who staff it. One centre recently received more than 300 applications for 50 jobs. Applications for nursing jobs with NHS Direct have come from other parts of the NHS, from the private sector and from those returning to nursing. With the support of the Royal College of Nursing and Unison, I am keen to encourage applications from experienced nurses who have left nursing because of, say, a back injury that left them unable to carry out routine nursing tasks. Working in NHS Direct could give them the opportunity to continue to put their hard-won professional skills and experience to good use to the benefit of patients.

The new schemes should provide the basic NHS Direct advice and information service that has proved so successful in the three pilot areas of Newcastle, Preston and Milton Keynes. From July, the Newcastle centre will be working with local doctors, A and E departments and other services to provide one gateway for out-of-hours services, with a single number for patients to call. That shows the huge potential for using NHS Direct to develop new and better services for patients in a way that is also popular with the professionals involved. Building on the experience of that pilot, I will be prepared to consider similar pilots where NHS Direct has shown that it can deliver the basic service and where there is a joint commitment by NHS Direct and the local doctors and other professionals involved to deliver services in that way.

Arrangements are now being made to set performance standards for NHS Direct call centres, drawing on careful evaluation of experience so far and on best practice for call centres in other sectors of the economy. We are determined to use the capacity of the national network that we are creating to provide the most dependable service. NHS Direct is a good example of the opportunities that new technology offers to help make the best possible use of the professional skill and knowledge of NHS staff, putting 21st-century technology in place for the beginning of the new century.

I am pleased with the success of NHS Direct, delighted that it can be funded from the extra £21 billion that we have found to invest in the health service, and glad to have been able to announce today that 60 per cent. of the country should have access to NHS Direct by December this year.

Mr. Alan Duncan (Rutland and Melton)

It is a happy task to give today's announcement on NHS Direct a general welcome from Conservative Members. Our objective always is to improve patient care and to see continuing improvements in the NHS. When the Government do the right thing, we will say so—and this appears to be just such a case. I hope that my warm reception for today's statement does not so shock the Secretary of State that he becomes an early user of the hotline. NHS Direct stands to be popular with nurses, patients and doctors alike. We are pleased that the Secretary of State has decided to build on a project which—as I am sure he is prepared to confirm—we started when in government.

Does the Secretary of State agree that a patient's GP should know of the advice given by NHS Direct to his patient, and by whom that advice was given? Does he accept that the success of the service will depend on the model that is adopted? Is he aware that there is some concern that ambulance trusts may not be the most appropriate providers of the service? Does he envisage lots of local units, or a few larger units? Is it not true that small and local is desirable, but that larger and more central is more economic? How will he strike the balance between the two? Will there be a single nationwide telephone number for the service?

We note that there is already evidence that nurses who have left the NHS will be attracted back to NHS Direct, but what percentage of nurses are applying from other areas of the NHS, given that there is already a shortage of nurses in those other areas? What is the right hon. Gentleman's assessment of any legal liability that might attach to the advice given by NHS Direct? What guidelines and safeguards will be put in place?

We wish NHS direct every success and we want it to add to patient care. We will watch closely the exact way in which it is implemented.

Mr. Dobson

It would be churlish not to welcome the general welcome from the hon. Gentleman—although it may be the sort of general welcome that could be matched by the Russians, who would say that their main general was "General Winter".

GPs will be informed of approaches made on the helpline, provided the person who has rung in gives permission. Confidentiality must work both ways. It applies not only to GPs patients, but to people who ring in to NHS Direct—and so it should. I have made it clear that, so far, ambulance trusts have been the principal suppliers of the call centres because they have the necessary experience and, sometimes, some capacity.

I have made it clear to GPs—and, in particular, those who are behind the GP co-operatives—that I want a greater involvement of GP co-operatives. That is why I say that it is at my insistence—rather against the advice of some of my officials—that GP co-operatives are now so extensively involved. It is also why at least one of the new centres that will come into operation shortly will be run by a GP co-operative. Whoever provides the service, co-operation among all those involved locally is crucial.

The size of units will vary from one part of the country to another. I am a great believer in horses for courses: in some places there will be large horses and in others there will be small horses, because those who are responsible for providing the service locally will decide how best to do it.

We are trying to get a single telephone number, but that is proving more difficult in our relations with BT than we or, I would have thought, most people in the country would have expected, and we will have to do something about that.

We have not as yet set any national performance standards for NHS Direct, because if we are to set sensible standards we will have to draw on the experience of the set-up. Legal liabilities for NHS Direct staff will be the same as those for all other national health service staff.

Mr. David Hinchliffe (Wakefield)

I welcome my right hon. Friend's statement. NHS Direct will seem to most people to be common sense, so it is strange that such a system was not introduced a long time ago. I welcome the fact that one of the inquiry centres will be in Wakefield.

Bearing in mind the fact that NHS Direct is about enabling people to make the best use of the NHS, will my right hon. Friend consider the marked differences in the use made of A and E departments from area to area? A while ago, my right hon. Friend the Chief Secretary to the Treasury, who was then a Health Minister, told me that more use is made of A and E in my area than in most other areas. There are reasons for that. I hope that calls to NHS Direct will be analysed and that we can examine the way in which people make different use of facilities in different parts of the country and tackle the discrepancies and the reasons for them.

Mr. Dobson

Again, as a believer in horses for courses, I note that, for example, when there is a large and famous hospital in a deprived area—such as the centre of Manchester, Newcastle or Leeds, or in certain parts of London—it has been traditional that people who wanted to be attended to went to that hospital rather than to their GP. Generally speaking, it is up to the national health service to adjust itself to people's needs rather than asking people to adjust themselves to the NHS. There may be variations, but we should not necessarily seek to eliminate them; we should simply try to cope with them.

There are large variations in all forms of use of the health service, be it in the proportion of people resorting to A and E or the state of people who are put in intensive care beds. That varies from one tradition to another throughout the health service. We need more uniformity in some aspects of NHS practice.

Mr. Simon Hughes (Southwark, North and Bermondsey)

The Liberal Democrats, too, welcome the extension of NHS Direct and the fact that it will be more integrated with GP co-operatives. We are a bit suspicious that the announcement was made today because the Secretary of State felt that he needed a good news fig leaf to cover the rather less good news on which we would otherwise have been concentrating.

How many nurses will be engaged in NHS Direct? Will integration with primary care groups, trusts and GPs throughout the areas to which the service is extended be guaranteed? Have the pilot schemes demonstrated any impact on the rising tide of emergency admissions or on the demands on consultants and other practitioners? Have the pilots already shown money to have been saved and pressure moved from other places in the health service?

Mr. Dobson

It is difficult to determine the causes of all sorts of complex shifts in the national health service, especially in winter, but, roughly speaking, twice as many people are advised to do something that is less demanding on the health service as are advised to do something that is more demanding on it than they would have done had they not telephoned. The rest of the hon. Gentleman's points are all part of the Liberal Democrat leadership campaign. We are used to him spending at least a penny every Health questions and such like, and now I suppose it is "Three Coins in a Fountain".

Kali Mountford (Colne Valley)

I add my congratulations to my right hon. Friend on his announcement, especially as it includes my constituency of Colne Valley, which he visited last year at the time of a meningitis outbreak. How does my right hon. Friend envisage NHS Direct integrating with the other services that support schools, parents and hospitals at such times?

Mr. Dobson

For a start, NHS Direct is supposed to be relatively free-standing and to do its basic job of receiving calls from people who are concerned about the health of themselves, their relatives or neighbours, and giving direct advice. It is likely that, eventually, its functions will be extended to other spheres, but it is crucial that each local service demonstrates that it can do its basic task before it seeks the agreement of the other professionals in the area to extend into more complex spheres. If there were an outbreak of meningitis or something else that is very frightening for parents, the people working at NHS Direct, like everyone in the front line, would be all the more vigilant, and I am sure that arrangements would be made to inform other people in the health service if issues cropped up unexpectedly or needed to be drawn to the attention of people with greater expertise.

Mr. Stephen Dorrell (Charnwood)

I join in the general welcome for the national launch of NHS Direct. The Secretary of State's proposal will make an important contribution to the more effective use of NHS resources. He is right about that, but I have one niggle in my mind. Can he explain to the House how he has persuaded himself that an idea, the piloting of which started a year before he took office, is his idea?

Mr. Dobson

The pilot schemes for NHS Direct started after we came into office, in Milton Keynes—[HON. MEMBERS: "Wiltshire."] The pilot schemes started in Milton Keynes, Newcastle upon Tyne and Preston and Chorley. They drew on bits of experience—[HON. MEMBERS: "Ah!"] Do you remember, Madam Speaker, going to the doctor when you were a lass and he said, "Say ah"? They cannot stop doing that on the Opposition Front Bench. Obviously, the pilot schemes drew on bits of information and experience that had been gathered in this country and others. That was the only sensible thing to do, because it is best to try to make use of experience. However, the three pilot schemes, run in the way that we intended, were introduced in Milton Keynes, Newcastle upon Tyne and Preston and Chorley, by us.

Miss Anne Begg (Aberdeen, South)

I welcome my right hon. Friend's announcement today that NHS Direct will give jobs to nurses who have found it difficult to continue on the wards because of, for example, a back injury. I ask him to go further and draw on a pool of nurses who have left the profession, perhaps some time ago, because of encroaching disability or an illness, such as multiple sclerosis, and nurses who may have taken early retirement because the physical aspects of the job had become too much for them. Such people have much relevant expertise and making use of that would not exacerbate existing nurse shortages.

Mr. Dobson

I can honestly say to my hon. Friend that that is the very point that I have been making to departmental officials for a long time and I am disappointed with their performance in seeking and securing the recruitment of people who are disabled. The proportions are no greater than for the general recruitment of disabled people, despite the fact that that point has been drawn to officials' attention time and again by Ministers. It is an ideal situation to enable people with immense practical skills and experience acquired in nursing to make use of them, despite having a disability that makes it impossible for them to work on the wards.

Rev. Martin Smyth (Belfast, South)

I welcome the NHS Direct scheme, and also look forward to reports covering the peripheral regions of the kingdom. I underscore what has been said about the ambulance service, which has years of experience of such work and alongside which GPs have been employed to give really professional guidance. However, may I advise the Secretary of State to be careful about using one telephone number for the whole nation, given BT's lamentable failure to cope with the recent storms in Northern Ireland?

Mr. Dobson

I shall bear in mind all the points that the hon. Gentleman has made.

Mr. Kevin Barron (Rother Valley)

I thank my right hon. Friend for his statement and for the success that NHS Direct has achieved already. The extension of the scheme into South Yorkshire will be warmly welcomed by the people there, who will regard it as a further investment in our national health service. Given what the hon. Member for Southwark, North and Bermondsey (Mr. Hughes) said, may I, as a resident of Southwark, thank my right hon. Friend for extending the scheme to my neighbours in London as well?

Mr. Dobson

As with everything else that we have done, we have tried to ensure that the new developments in the national health service are concentrated initially on the most deprived areas, as part of our general effort to raise the standard of health of people who are the most badly off more quickly than we raise the standard of health of the rest. That very proper and reasonable priority includes the introduction of NHS Direct, and we shall stick to it through thick and thin.

Mr. John Bercow (Buckingham)

Although the statement is welcome, how can the Secretary of State guarantee that nationwide implementation of the NHS Direct scheme will not be compromised by the Government's decision to raid the so-called modernisation fund to pay for the welcome increase in nurses' salaries?

Mr. Dobson

There are terms of abuse that one is not supposed to use in the House, but let us assume, for the purposes of answering his question, that the hon. Gentleman is fully equipped with all his senses. He might have noticed that the day after announcing the biggest real-terms pay increase for nurses for 10 years, I am announcing that further expenditure is to be brought forward from the modernisation fund to deal with another aspect of modernising the national health service. The modernisation fund will continue to fund all the other aspects of modernisation to which we are committed. It can do so because, as I explained earlier, we have ensured that it contains a sum to cover the likely additional increase in pay for nurses.

While we are talking about helplines, I can tell the House that the latest figure for people ringing in to express an interest in returning to nursing is 3,400—a rise of 600 in the hour that we have been talking.

Mr. Tam Dalyell (Linlithgow)

Can I ask an awkward—although I hope not malign—question? Does my right hon. Friend recall that I sent him a long and complex paper by Lord Justice Sir Philip Otton on the question of medical negligence? What happens when, in good faith, a person rings up for guidance and, in equally good faith, is given that guidance over the telephone? If that guidance turns out to be disastrously wrong, could NHS Direct be sued in the courts? Does not the potential exist for a legal nightmare, even though people might act in the best of good faith on the basis of what they are told? What is the legal position?

Mr. Dobson

As my good and hon. Friend knows, I have discussed the paper with Sir Philip Otton, and we are holding discussions with other people about the problems of litigation for the health service. However, there is no difference, in terms of liability, between advice given over the telephone through NHS Direct, advice given face to face and advice given over the telephone by anyone else. Liability would depend on whether there was a degree of negligence. That is the legal position and we cannot change it. At some point, something will go wrong—that is inevitable; face-to-face advice goes wrong, and operations go wrong even when they are carried out by the finest surgeons in the land. It is no good our pretending that that does not happen. We must try to make sure that the best-quality advice is available. but the liability for NHS Direct is just the same as it is in any part of the national health service.

Dr. Evan Harris (Oxford, West and Abingdon)

May I congratulate the Secretary of State on the apparent success of the pilots, and welcome their extension to Oxford? It remains to be seen whether my constituents will welcome our pilot or see it as adequate compensation for the millions of pounds worth of social services cuts forced on the local authority by the Government.

What research is the Secretary of State commissioning into whether the pilot schemes have already reduced attendance at A and E departments? Are the figures for Milton Keynes A and E attendances lower than the figures for surrounding areas, or has their rise been smaller? There is a danger that schemes such as the pilots, which appear welcome and worth while, may in fact increase attendances by finding untapped demand.

Mr. Dobson

We must look at the net effect. Clearly, some people who would be reluctant to dial 999 for an ambulance or to try to get their doctor out in the middle of the night will ring up NHS Direct in the knowledge that a 24-hour helpline exists for them. As I have said, one survey shows that 530-odd people were immediately put in touch with an emergency ambulance when they called. It is almost impossible to calculate how many of those people were additional to those using the ambulance service or going to accident and emergency departments.

There have been attempts to analyse the figures, but the relationship between them and what happens on, for example, Tyneside—involving, say, the Royal Victoria infirmary or the Freeman hospital, which are both in Newcastle—and NHS Direct is difficult to discern. I have told the people involved in the schemes that we do not want to come up with a lot of false claims, and, at present, any direct claims could be false and misleading. Roughly speaking, 40 per cent. of calls have involved people who were advised to do something less than they had intended, and 20 per cent. resulted in people being told to do something more. There may be a net gain, but that is not the object of the exercise: the object is to make top-quality advice available on the phone for people who are bothered about their health.

Dr. Phyllis Starkey (Milton Keynes, South-West)

May I pass on the warm feelings of the people of Milton Keynes about the success of the national health service pilot in our area, which is efficiently run by the Two Shires Ambulance NHS trust? I accept the point that my right hon. Friend the Secretary of State made in his reply to the hon. Member for Oxford, West and Abingdon (Dr. Harris) about the difficulty of analysing different uses of the service. However, will the analysis of the use of NHS Direct in Milton Keynes be made available to Buckinghamshire health authority, so that it may use the information as one of its indices of health care need in the area and ensure that the needs of Milton Keynes are rather more fairly funded within the county than they have been heretofore?

Mr. Dobson

Certainly, all the information will be made readily available. There is nothing commercially secret about it. When I went to the opening ceremony at Milton Keynes, I was somewhat disturbed to observe that the local coroner turned up.

Mrs. Virginia Bottomley (South-West Surrey)

Like others, I wonder why we are debating NHS Direct, not the acute problems caused by the nurses' pay award. Will NHS Direct help my authority, which has received less than 1.7 per cent. growth money, and which has an inflation allowance of 2.5 per cent? The pay award will cost twice that, and the authority's share of the modernisation fund, which is apparently intended to pay for NHS Direct, will cover less than 25 per cent. of the cost.

Many of the Secretary of State's hon. Friends have thanked him for what he has done for their constituencies, but other areas of the country that have enormous demand are being offered a deaf ear by the Government when they ask how on earth they are to cope. Please will the right hon. Gentleman find a way to assist constituencies such as mine, through NHS Direct or in any other way?

As to the scheme, has the Secretary of State learnt any lessons about the GP practices from which the callers come? Traditionally, many people might have contacted their GP, who has a 24-hour commitment, with their queries. I imagine that the Secretary of State will learn some interesting information about those who make enormous demands on the NHS Direct service and those who use the services of their GP. How will the Secretary of State ensure that there is appropriate feedback about the use of the service and what that reveals about the rest of the NHS?

Mr. Dobson

The right hon. Lady has raised two points. The fact is that, next year, funding to the national health service will increase by 5.7 per cent. in real terms. A substantial chunk of that increase will go to Surrey—although it is true that it will not be as substantial a chunk as would have been allocated under the rigged system that we inherited from the Conservatives. We are trying to target our efforts at the most deprived areas where people are least healthy, which is a wholly laudable priority. The financial officers in the health service in the right hon. Lady's area should not be in despair. If they cannot manage with the money they have, they are not doing a very good job because they are receiving much more funding.

NHS Direct is a perfectly good scheme which was welcomed at its inception by the British Medical Association. Doctors in each area are enthusiastic about it once it is in operation. They have initial doubts about the scheme's likely impact: some are concerned that it will take work away from them and others are concerned that it may add to their work load. If, like her colleagues, the right hon. Lady is an expert on the Wiltshire scheme, she will know that it appeared to reduce GP work loads in Wiltshire. However, we do not know whether that is a typical outcome: it may vary between different parts of the country.

Mr. John Gunnell (Morley and Rothwell)

As the calls to NHS Direct will be incoming, will the nurse who responds initially be able to call the patient back if she is concerned about her original advice or the patient's condition? Will she pass on the call to another health service agency or person who will then make that contact?

Mr. Dobson

The person who first receives the call will take a note of telephone numbers, addresses and names. Therefore, either the nurse who gives the advice or some other professional will be in a position to get back to the caller if they have reconsidered their advice or they want to check that everything is okay after several hours. Callers are often advised, "Go to bed and tuck yourself in, and I'll ring back in a few hours to see how you are." It is a very flexible service, which is one reason why it is so popular.