§ Mrs. Patsy Calton (Cheadle) (LD)
I am as always grateful for the opportunity to raise a matter that affects my constituents. This is one that can be literally a matter of life and death, and it has an application that is wider than my constituency. I asked for the debate because of personal experience, the experience of friends and the number of cases coming to me as a constituency MP.
I have been conducting my own survey, and although there are not yet any finished figures—it is early days—we are getting a considerable number of responses. Of the approximately 60 responses that have been received in my constituency office so far, more than half report trouble of one sort or another with appointments.
I am concerned that the figures the Minister will no doubt cite to us later in the debate may tell a partial and possibly misleading story. I have initiated the debate in a spirit of helpfulness, in the hope that the Minister will act to ensure that he is not being misled. Of course, he could treat my contribution as he did yesterday, with dismissive, cheap point scoring, but the public know that there is a problem with some appointments in the NHS, and all his debating points will score nothing with the people who matter—patients who use the NHS.
I am in no way complaining about the vast majority of front-line staff. In many ways, they are the victims of the problems that I shall outline. Certainly, the nurses I meet tell me that they spend a disproportionate amount of their time chasing up appointments for patients.
Problems with appointment systems are of various types. My survey already shows quite a lot of information about cancelled and postponed out-patient appointments. About half the responses received point out such problems. The questions concern a two-year period: participants were asked whether they had had a hospital out-patient appointment in the past two years, whether the hospital had cancelled or postponed it, and how many times it had been changed.
If I take a random sample of responses, I find the following answers: four times, twice, twice, three times in the past six months, twice, one hospital twice and another hospital once, four times and three times. Clearly those replies are not entirely typical. On the whole, the people replying to the survey see themselves as having been messed about by the system. I am well aware of that. However, there is a significant number of such people. I am pleased and grateful that half the replies say that appointments have been fine, and that the respondents have been able to see the person concerned on time. However, that is not happening for a number of people.
I understand that hospitals may well collect their own data. I have been in communication before with local hospitals that have been able to explain matters to me; for example, of the five cancelled appointments that one patient told me about, she had cancelled two. When we asked her whether that was true, she said, "Yes, I had forgotten about those, sorry." I understand that patients are sometimes forgetful, but that does not alter the fact that people are telling us about this problem.
The hospitals collect their own data, which do not necessarily affect the waiting time statistics. A cancelled appointment for a check-up for a life threatening 480WH condition possibly does not show up in the Government's waiting time statistics. I can understand that a consultant may be ill, or, more often, perhaps, decide to go to a conference abroad. What seems to happen more often than not is that a block of appointments is shifted six months to the back of the queue.
Most of us coming back to work after illness or some other absence have to work a bit harder for a while to make up for lost time. I can imagine what my constituents' attitude would be to their MP saying, "Sorry, I was away for a week. I shall have to put seeing you back six months." They would not be prepared to put up with that, and I would not expect them to. What would happen if a schoolteacher said, "I missed the time when I could have written reports because I was at a conference, so they will not be ready for another six months"? That is simply not acceptable, but it happens too often in hospitals.
The Minister should investigate the issue of cancelled and postponed appointments. He should ask the Healthcare Commission to look behind the waiting time targets for out-patients' appointments to find out about cancelled appointments and how they are handled. I sincerely hope that the practice of sending appointments to patients when they are known to be on holiday, which I have come across once or twice, has stopped.
The Minister may tell us that out-patient waiting times are at a certain level, but the boxes that have been ticked do not necessarily reflect the actuality for patients. I ask him to look behind the figures. I have raised the matter with the chairman of the strategic health authority in my constituency and with others, as the problem is very worrying indeed.
I know of quite a few cancelled and postponed operations. As an MP, I have the opportunity to intervene, which I have done on several occasions. It worries me how often a patient gets what he needs simply because I have written a letter asking whether his operation can be carried out in a timely fashion after one or two cancellations. It worries me that patients who know enough to come to their MP and get themselves placed slightly further up the queue than they would otherwise be cannot do that for themselves with the same result. I want the Minister to discover what impact MPs' letters are having and why the patients themselves cannot have the same impact.
I salute the new patient advice and liaison service, which is doing a better and better job and making a difference in my constituency. However, there are problems. For example, I have a constituent, a young mother with a brain tumour, who needs an operation that will involve her being in hospital for at least a fortnight. She has two young children and her operation has been cancelled twice on the day of the operation. In such circumstances, when family arrangements have to be made, that makes things very difficult indeed. My intervention, and possibly that of the woman's husband, who wrote a letter of complaint, ensured that the third time she prepared for the operation it was actually done, but it is worrying that people have to make a fuss to get their operation.
Unco-ordinated and untimely appointments, possibly—I will only say "possibly"—because of working to the targets, are affecting large numbers of 481WH patients, including in my own case. The report by CancerBACUP in May 2004 indicated that cancer patients were often left not knowing how long they would have to wait for an appointment. The all-party parliamentary group on cancer has been conducting a Select Committee-style inquiry into the tension between national targets and local decision taking and the impact on cancer services. The group has heard evidence from health professionals and civil servants, who emphasised that shortages of specialist staff such as radiographers, radiologists and chemo nurses are hampering efforts to reduce waiting times for treatment.
Equally, there is good practice, where services have been redesigned. I ask the Minister to ensure that services are redesigned to meet the needs of patients more effectively, as that would bring great benefits. Such good practice should be spread throughout the country rather than being limited to small, isolated pockets, as it really makes a difference and patients benefit tremendously.
I should also like to make the point that CancerBACUP has made, which is that the difference between urgent and non-urgent cancer patients is causing a problem. I know that Ministers have not always agreed with that, but I would argue the case again. Routinely, around a third of the patients referred who are labelled as "non-urgent"—even the urgent cases have difficulty getting through sometimes—are subsequently found to have cancer. There is a serious problem with a system that leaves a third of patients waiting for the length of time that some end up waiting. When such patients are subsequently found to have cancer, it may well be too late for treatment that can make a difference. Again, the appointments systems do not seem to reflect what is necessary.
CancerBACUP has said that it receives phone calls every week from people who are worried about how long they will have to wait for treatment. Not knowing how long one will have to wait and believing that one's prognosis is getting worse in that time is, CancerBACUP says, a source of enormous anxiety to patients and their families. I am sure that the Minister is well aware of that issue, so will he address it? The problem affected me during my treatment—I talk about my treatment and the patient pathway in the round. Not knowing when things are coming is a source of enormous stress and cannot be good for the patient.
To sum up those points, there is a tension between targets and clinical need. It is possible—many are saying this, including consultants—that targets are distorting priorities. In many cases, there appears to be a lack of co-ordination, which means that resources are wasted and additional appointments are needed. There appears to be a lack of capacity. Where targets are attached to one part of the treatment, the patient is given no indication of the total wait. For example, a two-week wait at the beginning to see a consultant does not tell the patient when the diagnostic tests will be conducted. A 62-day wait for treatment to start on a fast-growing cancer is too long and patients cannot wait that long.
Waiting to get on the list is another problem. I received a letter, which came as part of a survey, from somebody who, happily, has now had her operations. She waited for a year and a half to be put on the waiting 482WH list, which was where she clearly needed to be for bilateral hip replacements. Once on the list, she was told that she would have a 12-month wait and was operated on 363 days later—so, slightly less than a year. The normal waiting system would have made her wait another year for the second hip, but she made a lot of noise and got it four and a half months later. Happily, she managed to climb a mountain in Glen Coe in May with speed and ease, and has sent her thanks to the people who sorted her out. Two and a half years is far too long to wait for that operation; it is simply not on.
A further issue is the interface problems between hospitals. I would ask the Minister to look at that too. CancerBACUP says that the distress and inconvenience that patients suffer can be extreme when there are such problems. Patients can be left for weeks watching a cancer grow, or imagining that it is growing internally, not knowing when their appointments will come. While they wait for diagnostic test appointments, they imagine that the cancer has spread to every area as yet unchecked. Again, the problems of getting information passed between hospitals are extremely serious.
What needs to be done? May I make a plea to the Minister to push to ensure that patients do not leave a previously arranged appointment without having their next step planned and co-ordinated? That means dates for appointments, and so on. It means that GPs, nurses and other authorised persons should be able to make bookings with patients by phone or computer link before the patient leaves. I know that the Government intend that computer link-up to be available by the autumn of 2005. I applaud that and I hope that they make fast progress, but that does not alter the fact that there will still be capacity problems.
I shall make one list point, as I am aware that I have overstayed my welcome. The point that I made to the Prime Minister on 5 May was that when appointment systems are not functioning properly, disadvantaged groups are especially disadvantaged. People like me who know who to contact and who to make a fuss with will end up rising to the top of the queue, if there is a queue. It is wrong that advantaged groups should be able to push themselves forward while disadvantaged groups fall to the bottom of the queue and, according to the National Audit Office, have worse outcomes. I do not ask that everybody get pushed further down the queue, but that there is better co-ordination of appointments and better design of services so that all patients get a better crack of the whip, not just those who are sufficiently articulate to be able to push their way to the front.
§ The Parliamentary Under-Secretary of State for Health (Dr. Stephen Ladyman)
Once again, I commend the hon. Member for Cheadle (Mrs. Calton) on securing an Adjournment debate. On this occasion, I agree with a great deal of what she had to say. Very little is as frustrating for people as having appointments cancelled, not being able to get the appointment they need and seeing mistakes being made. Those are issues that we must tackle, and indeed we are tackling them.
The hon. Lady began by saying that she hopes I will not be dismissive of her as I was yesterday. One reason why I was dismissive was her inconsistency. Yesterday, 483WH she told us why we should scrap all the targets. Today, she gave us a good case for having targets for different types of people, why the targets that we have are not tight enough and why we need to build capacity so that we can improve waiting time targets
§ Dr. Ladyman
Let me make some points first. I need to answer the case that the hon. Lady made, and I have only 15 minutes in which to do it.
We are reducing the maximum waiting time for operations. We have reduced it from 18 to nine months already, and we intend to reduce it further. We have reduced the first out-patient appointment waiting time from 26 to 17 weeks. Setting targets was one of the tools that we used to do that. The hon. Lady said that those waiting times do not include the time a person waits for a consultant's referral or for diagnostics. That is true, which is why, in the NHS improvement plan, we set a target for 2008 of a complete patient journey time of 18 weeks from seeing a GP to receiving treatment.
The hon. Lady mentioned cancelled appointments. She seemed to imply—although perhaps I am overstating this—that cancelling appointments might assist people in meeting waiting time targets. I assure her that cancelling appointments in no way alters how the maximum waiting time is measured. Trusts and commissioners are unlikely to achieve the standards that we have set for out-patient waiting times if they allow consultations to be cancelled without good reason.
To be sure that the public can be confident of the accuracy of published NHS waiting times, we have asked the Audit Commission to examine how NHS trusts manage information on waiting lists and waiting times. A spot check programme began in 2002. We agree that when, occasionally, appointments have to be cancelled, it is essential that trusts keep closely in touch with patients to rearrange appointments. The new booking system, which I shall talk about later, will support the NHS in doing that.
We offer other guarantees to patients. Work is being undertaken by the Healthcare Commission to ensure that we do not allow clinical priorities to be distorted by waiting lists. We offer a guarantee, which was introduced in the national health service plan five years ago, for patients whose operations are cancelled at the last minute for non-clinical reasons. The example that the hon. Lady gave of an operation twice being cancelled on the day of the operation should not be happening, because the guarantee, which came into effect in April 2003, says that if operations are cancelled at the last minute, patients are given a new firm date quickly so that they have certainty about their readmission to hospital and capacity is not wasted. If they cannot be offered another appointment within 28 days of their operation being cancelled, the national health service will fund the patient's treatment at a time and hospital of the patient's choosing. We are putting in place guarantees to deal with exactly the sort of case the hon. Lady mentioned. They are terribly difficult to deal with.
The hon. Lady talked about people who know sufficient to go to their MP. Many people come to see me at my surgery because their operations have been 484WH cancelled. I do not know what it is like in her trust, but if I identify a mishandled case, my trust responds by raising its priority to deal with the error and ensure that the patient is seen within an appropriate time scale. If, on the other hand, someone has come to me to see whether they can jump the queue, the matter continues to be dealt with according to its clinical priority and writing an MP's letter has no impact. That is the way it ought to be.
The hon. Lady is right to identify the patient advice and liaison service, which is increasingly helpful in many constituencies, including my own and hers. It was introduced so that people would not have to go to their MP to have things sorted out and there would be somewhere in the hospital to have issues dealt with through the national health service. It is proving increasingly successful.
The reduction of waiting times and the improvement of patient access are very high on our agenda. We are working to bring down waiting times from referral to treatment to 18 weeks, but clinical assessment of clinical priority will always be the key determinant of how quickly someone is treated.
In developing our health care service, we are taking into account the patient's experience through patient surveys and other systems to provide better feedback. All surveys focus on issues that patients say are important, not issues decided centrally. The development of national standards, including the national service frameworks, is an important part of ensuring that clinical priority always comes first.
I remind the hon. Lady that the implementation of national service frameworks is mandatory on the national health service. The frameworks are targets. She and many of her hon. and right hon. Friends support much of the work being done under the national service frameworks, so they are, by implication, supporting a target. We must accept that.
§ Mrs. Calton
The Minister pushes the case on targets somewhat. All of us would accept that a change of culture needed to take place in the health service and that some targets have assisted that change. He would accept, too, that there are misgivings about the effects that some of those targets are having two or three steps down the line and that some are producing unwanted effects. I ask him to be a little less dismissive of the concerns about targets, because there are legitimate concerns.
§ Dr. Ladyman
Again, I agree with the hon. Lady. This is a point that we have made consistently: it was necessary to change the culture of the national health service, which is why we had to have many clear targets. Whenever one tries to change the culture of an organisation and how it works, firm leadership and firm management of the direction of travel are necessary.
We have made progress, so we have announced that we will reduce the number of targets and examine the way that targets are working to produce cleverer, better and more appropriate targets—targeted targets, if the hon. Lady will. I cannot give her an announcement 485WH today, because we will be publishing shortly the Department's public service agreements and the planning and priorities framework. However, when they are published, I am fairly confident that she will see the current 62 targets dramatically reduced. They will be much broader and different from the current targets, but they will still be targets; they will still be mandatory and there will still be clear, central leadership. That will allow a lot of local decision making and prioritisation, but there will still be a clear central vision of what the NHS needs to become, which is important.
I will deal now with specific points that the hon. Lady made about appointments. We have been talking mostly about secondary care, but I need to reflect for a moment on primary care. We have set a target of patients being able to see a GP within 48 hours and a primary care professional within 24 hours by December this year. Nationally, the vast majority of patients—about 98 per cent.—can now be offered a GP appointment within two working days. That compares with 75 per cent. two years ago, so there has been progress.
I am grateful to the GPs and nurses who have made that possible. Through the primary care collaborative approach, the national primary care development team, led by Sir John Oldham, has supported more than 5,000 practices, covering more than 32 million patients, in taking up the advanced access methodology to improve access for patients. Advanced access involves doing a lot of simple things differently. I think the hon. Lady said that service redesign could help a great deal in achieving targets. Patients benefit from advanced access, as do staff. It has reduced waiting times to see a GP by about 50 per cent., so it is an important step forward.
The target of seeing a GP within 48 hours or another primary care professional within 24 hours does not prevent people from making their own choice. They may want to see a GP at a later date because that is more convenient, and that choice should be available.
The hon. Lady mentioned our plan to use IT systems to streamline and co-ordinate improvements, which is a huge and important project. Over the next four years, the culture of waiting that has long been a feature of the NHS will be replaced by a personalised approach to care. The information systems that we put in place will enable patients to choose more convenient and higher-quality personalised care. An individual personal care record, for example, will enable health professionals to 486WH have easy and rapid access to patients' medical histories at any time. It will also allow patients to influence how they are treated in a way that they cannot do now.
The booking of hospital appointments is a cornerstone of our reforms; it is central to the provision of a new, modern service, as the hon. Lady said it needed to be. By the end of next year, an electronic booking system will make it easier for patients to arrange appointments that suit them. That will be a fundamental change in how hospital appointments are booked. As she said, at the moment people have to wait for a letter or postcard; they do not know when it will come. They have to leave the hospital and come back, hoping that sooner or later the postcard will follow them. All that will change.
Appointments used to be made clinic by clinic. Each clinic, and sometimes each consultant, had a different way of booking appointments, which was expensive, time-consuming and the cause of many mistakes. Now, 96 per cent. of day cases and more than two thirds of out-patient appointments and in-patient elective admissions are booked. That is a considerable achievement in a relatively short time.
By December next year, all NHS patients will be able to choose between a range of providers for hospital appointments and they will be able to book their appointment for a date and time that suits them. Gone will be the misery of wondering when they might make the front of the queue; they will know exactly when the appointment is and that it does not clash with another commitment.
We will go further, so that by 2008 there will be independently assessed health care providers providing treatment within a maximum agreed price range that people can choose from. People will be able to sit in their GP's surgery, or even on the sofa at home, and not only choose a consultant, but make a booking that suits them to receive treatment.
Underpinning those changes will be a booking management service to support patients in making, amending and cancelling appointments, because quite frequently it is patients who do that. We will bring to an end the traditional system of NHS waiting lists; that will genuinely put patients at the centre of their NHS treatment. That will create a fundamental shift in how we do things and completely revolutionise the national health service. Those changes—