Westminster Hall Sitting of 6 April 2000

Preamble
[MR. MICHAEL LORD in the Chair]

NHS Direct
Motion made, and Question proposed, That the sitting be now adjourned.—[Ms Stuart.]
2.30 pm
The Parliamentary Under-Secretary of State for Health (Ms Gisela Stuart): I am pleased to have this opportunity to mark the second birthday of NHS Direct and to share with hon. Members the Government's aims of improving health care delivery. People will look back on the past few weeks as a turning point in health care in this country. Arguably, it has been one of the most significant periods in the history of the national health service.
The service has faced enormous pressure and, sadly, some patients have not received the treatment that they deserve. That most have has gone largely unreported, and the tremendous efforts of NHS staff have sometimes been ill rewarded by those who are determined to pronounce the NHS past its sell-by date. My right hon. Friend the Prime Minister has made the historic declaration that, by managing the economy properly, we will be able to sustain increases in NHS funding that, in time, will bring the United Kingdom's spending up to the European Union average.
Mr. Philip Hammond: If I recall the Prime Minister's comments correctly, he said that if the Government managed the economy prudently, they would be able to bring NHS spending up to the European average as a percentage of gross domestic product within five years. However, the programme rolled out by the Chancellor of the Exchequer the week before last does not achieve that. Does the hon. Lady have any comment to make on that?
Ms Stuart: As a former Conservative Chancellor made clear in a previous health debate, we have clearly signalled the point at which we want to arrive. The Chancellor's statement was simply the first step.
Dr. Peter Brand: The Government signalled the point at which they want to arrive, but in fact there is no clarity about what that point is. Are we talking about a raw average of GDP expenditure in the European Union, or a weighted average?
Ms Stuart: I am reminded of the saying that there are lies, damned lies and statistics. We could spend the next three hours arguing the finer points of weighted and straightforward averages. We have not only given a commitment as to the point at which we want to arrive, but underpinned that commitment by announcing the largest ever cash injection into the NHS, which will provide sustainable development over the next three years at least. That is the important point.
Kali Mountford: There has been an increase of 8.75 per cent. in expenditure in my
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constituency this year—a huge increase, well above expectations. What is important is that the money is spent wisely, to achieve the sustainable growth that is needed in the NHS.
Ms Stuart: That is one of the themes that I shall take up: it is not simply a question of the sums of money that go into the service, but of the price at which the money comes. That price is a combination of a change in the delivery of the service and modernisation.
That exchange about figures signifies the sad passing of the post-war consensus on health. The Conservative party has declared for private insurance at the expense of expanding the NHS.
Mr. Hammond: The hon. Lady would not expect me to let that comment pass without an intervention. My right hon. Friend the Leader of the Opposition took the trouble on Tuesday to go to Bournemouth, where he stated loudly and clearly that, despite the allegations of Labour Ministers, the next Conservative Government will not privatise the national health service, retreat to a core model of provision or introduce any form of compulsory private insurance. Will the Under-Secretary acknowledge that?
Ms Stuart: I am happy to acknowledge that, although the hon. Gentleman should take note of the extent to which nurses who were present at Bournemouth were reassured by his right hon. Friend's statement. I concur with the nurses' judgment.
We are in new territory. I believe that the principles of the NHS are right. Its health care service is delivered according to clinical need and it is publicly funded; it is not delivered according to contributions that have been made or to one's ability to pay. However, I am convinced that practices in the NHS have to change—the NHS needs modernisation. The public often assume that modernisation involves a reduction in services, but that is not always correct.
Our approach will change the way in which things are done, because standing still will kill the NHS. Over the past 50 years, the service reached the point at which it was responsive neither to changes in people's lives, nor to the way in which technology can allow progress to be made. We are now in a different ball-game—the public have different expectations, and there have been changes in demography and in the relevant technologies.
Investment plus reform is the key to achieving a sustainable NHS. In other words, the extra resources that my right hon. Friend the Prime Minister outlined for the health service have a price tag: more money means modernisation. People will not stand for anything less. If we poured in extra billions, but failed to meet the public's expectations for a modern NHS, we should run the risk of fatally wounding the public's support for a universal, tax-funded health service. The Government will not let that happen.
Our modernisation programmes have as their starting point people's aspirations for their own health. More than ever before, people place a high value on good health. We all want to know more about our health and, if we fall ill, we want services that are of the highest quality—fast, fair and convenient. That approach involves the reinvention of the NHS, what it does and

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the way in which it is run and organised. That is what we want to do. We want to modernise the service from top to bottom and to do so across the whole system of care, from primary care and prevention to secondary treatment.
We are putting in place a new and modern model of health service provision—the building blocks are now in place. One of the most significant and publicly visible building blocks is NHS Direct, which is at the forefront of our effort to modernise the NHS. The service is already transforming many people's experience of the NHS and extending health care into the home. It is a responsive, modern and new service that allows people to take responsibility for their health and empowers them to become more proactive partners in their health care.
We cannot move ahead simply by doing what was previously done, but doing it faster; we also need to do things differently, and the use of new technology by NHS Direct allows us to do that. We know from the 750,000 calls that have so far been received that the service has changed people's lives. A lovely example occurred at the Bedfordshire and Hertfordshire site. A 70-year-old lady, who had made her prospective daughter-in-law's wedding dress, was about to attend her son's wedding, but, just before she went to church, she slipped on the stairs at home and fell. As her son was going to the telephone to dial 999, he saw a sticker on the fridge showing the phone number of NHS Direct. He rang the number. Nurses talked him through the problem and assured him that his mother was not in immediate danger; they said that she could get medical attention after she had attended the wedding, which she did. She was able to attend her son's wedding: the service changed her life because it allowed her to take the appropriate decision.
Mr. Hammond: The Under-Secretary has recounted a fascinating anecdote, but will she provide something more than anecdotes to back up her assertion that NHS Direct has changed people's lives. Does she have some hard evidence to that effect? The debate today will revolve around the evidence that NHS Direct is working, not the aspirations for it.
Ms Stuart: I certainly shall. A quick-response service, NHS Direct has the ability to upgrade a call to make it a blue-light emergency call for an ambulance. That has happened on 24,000 occasions, so it has made a real difference. I shall say more about evaluation of the service later in my speech.
NHS Direct is an example of the seamless service that we want. At a recent seminar, a health service manager spoke about her experience when, in the course of one day, she had had to call both British Gas's 24-hour line about a broken boiler, and NHS Direct about her three-year-old son's earache. She said that both services sorted out the relevant problem quickly. More important is the fact that, on both occasions, her problem was taken seriously: the people who answered the phone were calm and in control, and they made it clear that it was their responsibility to navigate the complexitites of their internal service to enable her to reach the desired result. She had rung up and she was given the complete soluion. That is the sort of response we need.
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NHS Direct is also helping to broaden the role of nurses and thereby encourage them to stay in the NHS. In particular, it has given disabled nurses and those who have had to stop working on the wards a new opportunity fully to utilise their clinical experience and expertise. We have worked in partnership with local trusts to recruit and retain staff within the NHS, and we recognise local hotspots. Flexible placement schemes enable nurses to rotate between NHS Direct and local accident and emergency departments or walk-in centres. Not only does that allow staff mobility, but it helps to maintain those nurses' wider clinical skills.
Dr. Brand: Of course it is good to give people employment opportunities. However, the use of nurses who are not fit to do a hands-on nursing job has been quoted many times by various Government spokesmen, so will the hon. Lady tell me what proportion of nurses employed by NHS Direct fit into that category?
Ms Stuart: At this point it is important to recognise that, while NHS Direct—
Dr. Brand: How many?
Ms Stuart: May I finish?
NHS Direct employs the full-time equivalent of 600 nurses. Depending on how we count them, there are between 250,000 and 300,000 nurses in the system, so NHS Direct accounts for only a small core at this stage. Even so, we must recognise that it is a new service that is just beginning to be rolled out. All the early signs tell us that what I have described is a trend, and it should not be mocked.
Dr. Brand: I do not mock it. We have been told that the service employs 600 nurses. How many of those nurses could not fulfil another nursing role because of disability? The claim is repeatedly made by Government spokesmen, but if they want to claim credit for an enlightened employment policy, they should provide evidence.
Ms Stuart: Although it would be easy simply to count the small number of nurses who have a disability, a number come back after having a baby—
Dr. Brand: Five, 10, 15?
Mr. Stuart: We can certainly go back and examine the figures, but what is important is that we recognise that the service has been rolling out for two years, having started from small beginnings. It is to go national at the end of the year, and we shall build on such trends and opportunities.
Mr. Hammond: I suspect that many of the few hon. Members in the Chamber sympathise with the Under-Secretary's aspirations for NHS Direct. However, we are concerned about the lack of hard evidence to support the Government's assertions about its achievements. We will have a sterile debate if the hon. Lady cannot back with figures her argument that it is a success.

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The hon. Member for Isle of Wight (Dr. Brand) is right to ask for the numbers. They might be low. Do the Government have any numbers? When the Under-Secretary asserts that NHS Direct provides a means of employing disabled nurses, is she merely voicing an aspiration, or stating a hard fact?
Ms Stuart: Perhaps we would have a more fruitful debate if I could get on with my speech, which will cover quite a few points that have been raised.
Kali Mountford: Will my hon. Friend give way?
Ms Stuart: I shall briefly tackle the matter raised, then give way. Fewer than half the hon. Members in the Chamber attended the last Labour party conference, but some of them may have seen on television a quadriplegic nurse from Yorkshire—one of the first to be employed by NHS Direct—giving an extremely moving speech.
Mr. Hammond: So there is one.
Ms Stuart: No, there are more.
I shall say more about the Sheffield review later, as we are extremely keen that there should be independent evaluation.
Dr. Brand: There is no mention—
Mr. Deputy Speaker: Order. This is a Chamber, not a Committee. Hon. Members may be tempted to make sedentary interventions, which can be helpful. However, it would help the Chair if they refrained from such behaviour and were a little more formal.
Ms Stuart: I promised to give way to my hon. Friend the Member for Colne Valley (Kali Mountford).
Kali Mountford: I cannot assist proceedings by providing figures, but I am interested to hear my hon. Friend's views on my visit to Wakefield NHS Direct. I did not count how many nurses working there had disabilities, but some told me that they had hurt their back lifting patients and could not continue in their former role. More importantly, however, four women there would not have returned to the NHS after having children had they not had the opportunity to work for NHS Direct. More regular and more certain working hours helped them to manage their family lives better. A goodly number of the nurses I met—there were about 40 in all—had come back into the service because NHS Direct provided a route back. We should welcome that.
Ms Stuart: I am grateful for my hon. Friend's contribution, which mirrors my own experience of visiting the sites.
I shall speak briefly about the nature of NHS Direct and how it has developed. The service was launched only two years ago. Initially, it covered only 3 per cent. of England, but it was extended last November to cover 40 per cent. of the population. Just before Christmas, the service covered 65 per cent. of the population. It has been extended at phenomenal speed, and we have been
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evaluating it continuously. As the service is rolled out, the evaluation ensures that it is always clinically safe, sustainable and growing at the right speed.
In many ways, the service has been allowed to develop organically. By the end of October 2000, the whole of England will be covered. I do not see any Members representing North Yorkshire or east Lancashire in the Chamber; those regions will be fully covered by the end of August. we have been able to expand the service because of the extraordinary dedication of nurses, call handlers, health information advisers and managers.
Over Christmas, NHS Direct showed its worth in the extraordinary number of calls that it handled, which was well above normal rates. Some of the new sites had started operating just before the Christmas period, and they coped extremely well. Sometimes, the pressure meant that the call handler had to take the first call and patients then had to be rung back. However, in the services in respect of which we carried out a satisfaction survey, we found that 90 per cent. of callers were satisfied or very satisfied with the service, with 80 per cent. very satisfied. Some 48 per cent, of callers were given advice by a nurse on how to look after themselves. Only 30 per cent. were advised to contact their GPs, compared with 48 per cent. who said that they would have done so if they had not rung NHS Direct.
Mr. Hammond: Before the Under-Secretary moves on from those statistics, does she accept that some of the 48 per cent. who said that they would have contacted their GPs—presumably the GP out-of-hours services—would, had they done so, have talked to a nurse who was operating a triage service, or to a GP on the telephone, rather than visiting the GP's surgery?
Ms Stuart: They said that if they had not rung up NHS Direct, they would have rung the GP out-of-hours service. They took a different route. It would be easy to start playing with the figures, because we are talking about small samples, but the trends are clear. The service—this brings us back to the purpose of NHS Direct—is showing signs of meeting the policy need for appropriate access.
Mr. Hammond: The reason I ask the question is that my understanding, derived from the literature that I have read, is that the cost of a telephone triage call to a GP out-of-hours service is approximately a quarter of the cost of a call to NHS Direct. If all the Under-Secretary is telling us is that people who would have rung the GP out-of-hours service for a telephone consultation are ringing NHS Direct instead, I am not sure where the benefit to the overall system comes from.
Ms Stuart: There are two points. The individual costs to NHS Direct are lower than those to a GP out-of-hours service. The purpose of NHS Direct is to provide a single gateway, which gives the right access to the next point. I recall answering parliamentary questions on that issue: if I remember rightly, the cost of a call to NHS Direct is about £8, while the cost of a call to an out-of-hours service is closer to £35 or £40. I might be wrong about the exact figures, but the cost of the NHS Direct call is certainly lower.
Only two thirds of the country is covered at the moment; economies of scale might become more apparent once the service is completely national. We are

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talking about early figures. However, the issue is not saving money, but making sure that people access the NHS at the appropriate level and that the next step they take is the correct one.
I want to say a little about the independent evaluation. We have asked Sheffield university to provide us with an on-going assessment and evaluation. The first report was published on the first anniversary of NHS Direct, and the second was published a year later, in March. Those interim reports clearly show that the public perception of using the service is positive, and they confirm its increasing popularity and safety. Safety was initially a concern, and people asked whether the service was safe and reliable. The reports also showed that the service's successful introduction did not increase the overall demand on other services, which had been feared. Indeed, in one area, the researchers found that the introduction of NHS Direct was associated with halting the upward trend in demand for out-of-hours medical services.
In accident and emergency departments, we have seen year-on-year increases in attendance. Some people may not have accessed the service, and we hope that in future they do so before attending the accident and emergency department. Even if numbers continue to rise, there might still be people who should have used the service but did not do so. We need to be careful, but the overall increasing trend has been halted in certain sectors.
Dr. Brand: I have the second interim report, dated February 2000, which suggests that there may be a slowing of the rising demand for out-of-hours GP services; however, it provides no figures comparing trial areas with other areas that provide evolved out-of-hours services through GP co-operatives. We need a decent comparator to assess statistical significance. I hope that the Minister will urge the researchers, in their definitive report, to provide better evidence for their tentative assertions.
Ms Stuart: Although I do not claim to be a statistician, I recall the statistical discussions with Sheffield university. Comparative data started to be compiled in the early pilots to allow for continuous comparison. We were careful to ensure that advertising took place only in areas where the service was available. Data will be much more reliable when the service goes national and we can assess the knock-on effects. Nevertheless, current trends show the clear signs that I have mentioned.
Dr. Brand: That is hardly a scientific pilot study. If control is destroyed by dispersing research throughout the country, a new system cannot be compared with another system that was in the process of evolving. I am not necessarily against the service, but the hon. Lady has not provided scientific arguments in favour of it. Let us be honest and recognise that it is politically convenient for the Government to have NHS Direct; it is unworthy to use cod science to justify it.
Ms Stuart: I might have failed to make it clear that the researchers are trying hard not to destroy the basis of
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their research. Hon. Members should accept that the evaluation is independent, and that we have not even thought about political convenience. We want genuinely independent research. That is why—
Dr. Brand: Will the Minister give way?
Ms Stuart: No, I wish to make some progress. Hon. Members will have the opportunity to make their own speeches.
As I said, we have reached the evaluation stage and the trends are clear: NHS Direct is fulfilling the original policy intention of being a gateway to appropriate access to the health service and maintaining the confidence of the public. It is a success, but now the question is, where do we go from here?
A telephone service such as NHS Direct has the potential to achieve a range of objectives. Recently, NHS Direct demonstrated a new advantage. Last week, the Department of Health announced that some patients might have been exposed to hepatitis C, following the discovery that two health care workers were infected with the virus. Despite the fact that the risk of transmission was low, the patients identified as potentially at risk were sent a letter that explained what had happened and offered support and specialist clinical advice.
It became obvious that many members of the public were concerned about contact with the virus. An NHS Direct number was made available to the whole of England, so that anyone concerned about hepatitis C could gain access to 24-hour advice and information. I had long discussions about how that could be achieved. In areas that were not covered by NHS Direct, anyone ringing the NHS Direct number about hepatitis C was put through.
Hon. Members may regard what I am about to say as anecdotal, but it shows how NHS Direct can provide a service. In one four-day period, NHS Direct received calls about hepatitis C from more than 3,600 people. It was able safely to reassure 63 per cent. of the callers that they had no cause for concern, and to refer callers who might have been at risk to the NHS trust involved. That shows that, by working in partnership with other NHS services, NHS Direct can provide a fast, convenient response to concerned members of the public, while relieving pressure on the trusts, so that they can concentrate their efforts on the callers who most need their specialist advice and services.
At the recent Royal College of Nursing conference, I announced three new developments for NHS Direct. The first is the appointment of the first nurse consultant for NHS Direct, a post that is based at the Hampshire NHS Direct site. It is another example of the instrumental role of nurses being extended.
Secondly, as part of the roll-out of the national health service framework for mental health, the Government have made £1 million available to NHS Direct to provide a service responsive to the special needs of callers who want to ask about mental health. That has enabled us to establish a mental health lead for each NHS Direct site, supported by a specialist national project team. The focus will be on providing accurate and consistent advice—that is particularly important—about mental health concerns, information about local

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mental health services and on making the necessary linkages to other services to enable the fast, effective delivery of care and services to groups who sometimes find it difficult to gain access to them.
Mr. Hammond: I listened carefully to what the Minister said about mental health services. In my constituency, an acute psychiatric unit has traditionally provided a helpline service to patients in the community who suffer a crisis. Can she give me an absolute assurance that such services, which are embedded in the acute psychiatric units, will not be shut down as the NHS Direct service rolls out?
Ms Stuart: Yes I can, because NHS Direct is being developed in co-operation with, and in addition to, the available local services and with the voluntary sector. As I said earlier about the consistency of advice, I am delighted that the hon. Gentleman's constituents have access to the service that he mentioned, but many people do not. Our intention is to ensure that the service is available whenever the need arises. Precisely how it will be delivered may vary from area to area.
The third development is the NHS Direct on-line service, which the Prime Minister launched in December. It provides the public with a gateway to the best of health information on the internet. Although the internet is easily accessible and can be the source of a tremendous range of information, it can also be extremely misleading. NHS Online will be a reliable source for further advice. It received 1.5 million hits on its first day and receives more than 100,000 hits on a typical day. Even more amazing to me were the favourable reviews it received in the computer press. Internet Magazine selected it as its website of the month.
On 20 March, NHS Direct ran its first on-line live discussion, with Professor Mike Richards, who is commonly known as the cancer tsar. It facilitated a discussion about the Government's plans to improve cancer services and proved to be a real interchange.
As with the telephone service, we are keen to develop NHS Online as the leading source of information. The site will be updated regularly and by the summer, we hope to provide access to searchable information about local services such as pharmacists. It will use model technology, which in this instance is international, to provide focused local information.
There has been tremendous grass-roots development of the service. A significant characteristic is the way local communities have taken ownership of it and developed services that are responsive to the needs of their areas. In some areas, we have integrated access to out-of-hours services. This has enabled NHS Direct nurses to pass callers on seamlessly to the out-of-hours doctor, or direct them to other services, if appropriate. The caller does not have to make two calls; there is only one call, which moves on behind the scenes. It also makes for cost-effective delivery of out-of-hours care.
GPs have expressed much concern. Some feel threatened by the changes, and I acknowledge that change is always unsettling, but the Government have made it clear that GPs should not feel threatened, and we have found no evidence that they are. NHS Direct is not intended to replace them or usurp their role; it is additional to what they already do.
Mr. Hammond: What studies have the Government commissioned to compare the cost-effectiveness of delivering telephone triage services through NHS Direct as opposed to through GP out-of-hours co-operatives?
Ms Stuart: It is part of the continuing evaluation of the service. A simple calculation is that an NHS Direct call at £8 is cheaper than the GP out-of-hours service. If as a result, only 50 per cent. of patients go on to talk to their GP, that is almost an indirect saving in itself.
In discussing this new service, I stress that to focus purely on the apparent short-term saving is not to focus on the right aspect. I said initially that we are putting more money into the NHS because more money is needed, and that the price tag that comes with the extra money is a reliable and convenient—but different—way of delivering services. NHS Direct plays a vital part in that. Of course part of the evaluation will be costs, but costs alone will not be an indicator of success or failure. I like to think that, even in basic business, cost cutting is not a long-term strategy. The strategy should concern whether the service is delivering something that is needed at a competitive price.
I return to the point about evidence from GPs because concern has arisen. There was a point at which, if one had relied solely on the professional journals, one could easily have thought that this was the biggest threat ever to general practitioners. I was interested to see recently in the letter pages of newspapers that GPs are stating that it is inappropriate to attack the service, because it is helping them.
I can always tell from conversations with GPs whether the service is available in their area. Similarly, with members of the public, I always know when they have used the service and when they have not heard of it. A lovely example occurred yesterday in the Room next door during a reception for about 30 GPs. Someone asked what sounded like a hostile question. Before I had time to answer, a GP who stood next to me, whom I thought was very brave, grabbed the microphone and said, "I am a GP and you really should not attack the service. We are using it in co-operation with our out-of-hours service and it works extremely well. We find that it actually makes our work easier." The Sheffield report also stated that experience on the ground is that the benefits of the service are beginning to show. It is working with GPs. In some areas, co-operatives are working; in others, it is not a step that people wish to take. It is a question of responding to local needs.
We should also consider the knock-on effects of NHS Direct in other areas. I will examine briefly other areas of integration. Last winter saw huge and increasing pressure on our accident and emergency departments. We should examine the reasons for that, and consider whether we can control the system better, so that the facilities of A and E departments are reserved for those who really need them. At present, if someone rings NHS Direct and it becomes clear, following consultation with the nurse, that it is an urgent ambulance call, NHS Direct can upgrade it to a 999 call. There is no provision to reverse that process when someone rings 999. Often, what appears to be a real emergency—and many people's first reaction is to dial 999—turns out not to need an ambulance.

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In some of the pilot areas, as soon as a call comes in and the ambulance team has the grid reference and is ready to go, the call is placed in one of three categories—A, B and C. If the situation is life-threatening, or if the call is in category B, the ambulance goes. A category C call, however, does not need an immediate response. Such calls are transferred, without the need for a further telephone call, to an NHS Direct nurse, who will have the time and experience properly to triage the call and assess whether an ambulance is really needed. Although, at this stage, we do not know what the figures are, people on the ground are certain that there is scope for developing more appropriate use of the system. That takes us towards our aim of ensuring that the system is safe and robust and delivers appropriate access.
The outcome is similar in the case of developments such as more proactive outward calling by NHS Direct—for instance, reminding people to have a flu vaccination or attend an out-patient appointment. Proactive calling ensures that people are reminded about something that they needed to do and that service delivery is more efficient. In the long-term, there will be a role for NHS Direct in a more structured disease management programme for chronic conditions such as coronary heart disease or diabetes.
For too long, pharmacists, as professionals in the health community, have not been utilised as well as they could be. NHS Direct has played a significant role in bringing them to the forefront. They have tremendous experience, and one NHS Direct site—Essex, Barking and Havering—works in partnership with the National Pharmaceutical Association to pilot what they call an alternative end-point referring system, through which a caller can be referred directly to a community pharmacist. The Royal Pharmaceutical Society is involved in the pilot scheme, which went live this month. It is still at an early stage—before hon. Members ask for figures—but, so far, there is evidence that 5 per cent. of callers are referred to their pharmacist for specialist help and advice.
Mr. Hammond: I am entirely at one with the Under-Secretary in believing that pharmacists are a hugely under-utilised resource in our primary care delivery system. Does the Under-Secretary have any statistics on the percentage of callers who would have visited a pharmacist had they not called NHS Direct?
Ms Stuart: We do not have those figures. We have figures on the number of people who have done something differently as a result of their call, but they are not broken down in such a way that we would know what else they would have done or whether they would have gone to the pharmacist. Such figures might not be accurate. I have used NHS Direct twice—I refrained from saying who I was. The first time, I needed a malaria tablet and did not know whether I needed a prescription. I rang up, and was told to see a pharmacist. I do not know what I would have done otherwise whatever was most convenient, probably. A figure based on asking people what they would have done instead may not be a reliable indicator. However, we have found an appropriate level of referrals to pharmacists. For example, the figures for people calling NHS Direct with
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flu-like symptoms over the winter, show that a huge number of people were referred to self-care. At the same time, there was an unprecedented jump in the number of flu remedies sold over the counter by Boots The Chemists. We cannot establish a statistical link, but that shows a clear trend.
Mr. Hammond: I am sorry to be persistent, but I must clarify the issue. The Minister said that we could not necessarily rely on what people say they would have done. Unless I am mistaken, earlier she quoted the number of people who said that they would have gone to a GP if NHS Direct had not existed. Is that figure a reliable indicator?
Ms Stuart: I was trying to say that going to a GP is a real choice. I could either ring up, or go to see my GP, sometimes in doubt about whether I could have gone to the pharmacist. I am simply suggesting that choosing to visit the pharmacist is not as determined a decision as that of choosing to go to a GP.
One of our aims with the pilot scheme is to give consistent advice. There is scope for more training for pharmacists, who give daily advice about the next appropriate step. If training is co-ordinated with NHS nursing, a patient's access route will not matter, because the advice will be consistent within the health framework.
We discussed people who do not, but should, have access to the health service. We are working closely with the Contraceptive Education Service, an agency that provides specialist advice on contraception and pregnancy, including teenage pregnancy. That is a subject that is close to my heart, and we must tackle it. I hope that the potential of making a confidential telephone call will encourage more young people to ask for advice. NHS Direct can refer callers who require specialist or in-depth advice to the Contraceptive Education Service's helpline. That is another example of an existing helpline that should not feel threatened by NHS Direct, because it provides an additional service.
We want to use NHS Direct to reach out to other groups who do not use the health service. In homeless shelters in London, we have set up two pilots using dedicated freephones. Homeless people often find it difficult to register with a GP, and the pilots give them access. We are working with the Royal National Institute for Deaf People to undertake an audit of NHS Direct to ensure that it can respond to the needs of callers with disabilities; and with interpreter services for callers whose first language is not English to ensure that everyone, irrespective of their first language, receives a reliable service. We use confidential interpreters, and so far, NHS Direct has provided help and advice in more than 30 languages. NHS Direct continues to work with services for black and ethnic minority communities, to take account not only of preferred languages, but of cultural difference and preference.
Now I will deal with a group of people who traditionally neglect their health, and who we think need to take more care of their health: men, who form the majority in this Room, and especially young men, although they are certainly in the minority here. They do not look after their health, and we want to ensure that they are better able to take responsibility for it. The

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early stages of the scheme suggest that women, who have traditionally been the guardians of family health, are more likely to ring NHS Direct. Our research shows that women often ring on behalf of others, especially children. We hope that availability by telephone will allow men to use the service more to inquire about their own health. The on-line service on the internet may also appeal more to the young male audience.
Mr. Hammond: I intervene on the Under-Secretary again, first, because I am offended by her comment. Secondly, I accept that wanting to reach men who tend not to access medical services is a worthy aspiration, but does the evidence so far not show—as detailed in her written answer to my hon. Friend the Member for Aylesbury (Mr. Lidington)—that very few young men access that service? It is used primarily by women on behalf of children and young women on their own behalf.
Ms Stuart: The hon. Gentleman is right; that is what the current research shows. I come back to the fact that in a short period we have created a service that covers two thirds of the country; it is a national service. Now that it is set up, we must focus much more on reaching out to the people who need it. The percentage figures at this stage would not support the argument that that is already happening, but it is our aspiration to reach the groups that have not been reached.
Another figure that has not gone up—to pre-empt a further intervention—is that for the elderly population. We would expect that figure to rise and those people to use the service much more. The age profile has remained fairly static so far, but the service is available.
I have some anecdotal evidence for the success of NHS Direct. A 93-year-old gentleman told us that he had twice used the service, and that it was the best thing that had happened to the health service since 1948. It is encouraging for people to know that they can use the telephone when they need help, but really do not want to bother anyone. Elderly people, who have every right to use a service, sometimes do not want to bother anyone. Elderly people, who have every right to use a service, sometimes do not wish to cause any bother. When I spent a day with west midlands ambulance service, we made a call on someone who had had a stroke in the middle of the night, and whose wife did not want to bother anyone until 8 am because she felt that it would be antisocial to ring anyone so late. We are working towards extending the service to that kind of person. It aspires to be a safe service, provided to everyone regardless of age, gender, language, disability or culture, and it shows every sign of achieving that.
The modernisation programme, however, goes beyond NHS Direct, which is only one of the building blocks in the programme.
Dr. Brand: Before we go on to the wider issues, would the Under-Secretary tell us how much NHS Direct as she has described it will cost, after it has been rolled out over the country?
Ms Stuart: The current overall budget is £80 million. The huge potential for the service means that we have to choose which areas we want to focus on and take
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forward. My priority is mental health, provisions for which are already being implemented. Another priority is the category C triage on ambulances. We should consider whether that should be used on a one-off basis as in the hepatitis scare, and how best to roll out the programme. NHS Direct could be used for many services, but that is its current budget.
NHS Direct is a vital building block in the effort to make primary care services more accessible, given the way our lives and technology have changed. It is not only an on-line service; so far, 36 pilot walk-in services have been announced, and the total investment into that initiative will be £31 million this year. That means that 10 million people will have access to more flexible NHS care.
The key aim of the walk-in centres is to provide rapid access primary care to patients who are disadvantaged by not having access to the service immediately. That includes groups such as workers and commuters, whom we would not usually classify as disadvantaged. Members of Parliament, owing to the lives that we lead, are only too aware of the difficulties of getting in touch with our general practitioners. We in this Room are a prime target group for walk-in centres. They will also address the needs of those in deprived areas such as Tottenham and Edmonton, which have high economic and social deprivation and many refugees and asylum seekers. Since January, eight walk-in centres have been opened—in London, Sheffield, Birmingham, Newcastle, Norwich and Swindon. A further six will open this month and the remainder by December.
Primary care also needs to be modernised and expanded.
Mr. Hammond: On a point of order, Madam Deputy Speaker. Can you make it clear how wide you will allow this debate to range? I came here specifically prepared to talk about NHS Direct, which is the title of the debate. The Under-Secretary is now moving into a much wider discussion about primary care delivery, which I should be delighted to engage in but have not prepared for.
Madam Deputy Speaker (Mrs. Gwyneth Dunwoody): The content of hon. Members' speeches, including those of Ministers, is happily not a matter for the Chair. Otherwise, life might be even more exciting. The Under-Secretary has been generous about accepting interventions, and I am sure that she will bear in mind that the main subject is NHS Direct. If she is out of order, I can assure the hon. Gentleman that I shall draw her attention to the fact.
Ms Stuart: I recall, Madam Deputy Speaker, that the original title of the debate was "NHS Direct and Modernisation". I hope that you will find that my remarks relate to the modernisation of the NHS, using NHS Direct as the main example. However, hon. Members need not worry too much.
I want to come back to the point about GPs' fears about NHS Direct. One of the great advantages of the British NHS is the co-ordination of care that list-based general practice has brought about, which I understand the French, American and German systems are now seeking to replicate.
We must target access to primary care much more closely. The main role of GPs to deliver primary care will be expanded by the creation of the primary care

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trusts and primary care groups. They will be the agents of change, because they are best placed to respond to local needs. We hope, over time, to have more primary care single sites, some of them as a result of public-private partnerships, where doctors, dentists, pharmacists, opticians and nurses all provide easier care and access. People with chronic conditions such as heart disease, asthma, diabetes and depression will again have much more regular help from a single health and social care team, which will allow them to maintain a full life.
Those developments mean that we need further advances in easy access to information and use of communication and information technology, but we must also meet the public's expectation for a responsive public service. NHSnet, which is the NHS private network, is one means of affording access. Although a patient may access a service, whether it be a walk-in centre or NHS Direct, the GP is still his case manager. Those new developments in technology allow the exchange of information.
We want to ensure that every GP has access to a desktop computer linked to NHSnet, which will enable and facilitate that exchange of information. We want the consulting room to be the place where out-patient appointments are made, operations booked, test results received and diagnoses carried out, using video and telelinks to hospital specialists. All that is emerging, and extraordinary work is being done in some areas. Recently, I visited Blackburn. Bolton, Bury, Blackburn and—there was another B?
Mr. Gerry Sutcliffe: Burnley.
Ms Stuart: Thank you. Bolton, Bury, Blackburn and Burnley hospitals are linked together by a telemedicine system, whereby the maxillofacial surgeons in Blackburn and the other three A and E departments are linked up. The picture transmission quality is extremely high, which allows those specialists to assess whether a patient needs to be transferred. Again, we are using technology to modernise access to the service.
In conclusion, NHS Direct is one building block in the modernisation of the NHS, which is about redesigning the service that we deliver to patients and recognising that the public increasingly demand that all public services, including the health service, be responsive and place them at the centre of that responsiveness. In addition, it enables people to know where the right point of access is, if they do fall ill. All the early stages of evaluation have made it clear that NHS Direct is well on the way to delivering on those aspirations. The service will be available nationally by the end of the year. Piloting is going on, as is outside evaluation, which will allow us to make the right choices about how to move on. So far, NHS Direct is sending a clear sign of our commitment to a national health service that meets the challenges of the new century and the expectations of the public. This building block is showing every sign of delivering.
3.31 pm
Mr. Philip Hammond: The full title of the debate is "Second Anniversary of NHS Direct", and I shall seek to stick rigidly to that
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theme. I will start by reassuring the Minister and other hon. Members that I have no objection in principle to the concept behind NHS Direct. Indeed, my right hon. Friend the Member for Charnwood (Mr. Dorrell) claims some ownership of it as a result of the pilot schemes of telephone triage that were set up in Wiltshire under the previous Administration.
However, I have some suspicion, which is mirrored in the medical community, about the Govenment's motives. Is the service intended to replace the GP out-of-hours co-operative system? Is it intended, through the use of what is euphemistically termed an integrated access route, to become the only gateway to accessing primary medical services? Is it intended to replace the 999 ambulance service? The Under-Secretary will have reassuring answers to all those questions, but I ask her to understand that there is a background of suspicion about the Government's motivation. It arises not because of the Government's espousal of the concept of a telephone triage system, but because of the unseemly haste with which it has been rolled out and the apparent reluctance to wait for the evidence that would support that roll-out.
The Sheffield report mentioned by the Under-Secretary sets out four objectives of NHS Direct:
to offer the public a confidential, reliable and consistent source of professional advice on healthcare, 24 hours a day…to provide simple and speedy access to a comprehensive and up to date range of health and related information…to help improve quality, increase cost-effectiveness and reduce unnecessary demands on other NHS services—
and—
to allow professionals to develop their role in enabling patients to be partners in self-care.
Those objectives constitute uncontroversial aspirations, and I think that we would all share them. However, I hope that the Under-Secretary will accept that there is a requirement to measure whether the service is delivering on them. To use the scientific jargon, there is a requirement to have a base of evidence to support the continued roll-out of NHS Direct. Our debate is about whether that base of evidence exists and whether the Government's roll-out of the service is justified by the published evidence in relation to the stated objectives.
I detect a touch of defensiveness in the Government's position. On 22 February 2000, I tabled a written question asking the Secretary of State for Health whether he would
place in the Library a copy of the report his Department has received from Sheffield University on NHS Direct.
That report, which was mentioned earlier, is dated February 2000. The Under-Secretary replied:
Sheffield University's interim report is in the Library. This was published in March 1999. Sheffield university's final report on NHS Direct is expected shortly. Copies of the report will be placed in the Library.—[Official Report, 22 February 2000; Vol. 344, c. 903w.]
She did not mention the further interim report, which was on Ministers' desks at the time. Why was she anxious to throw me off the trail?
On 13 March, I tabled a written question asking the Secretary of State for Health about the
studies he has commissioned to establish how many users, as distinct from individual calls, there are of NHS Direct.

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The Under-Secretary again answered my question, on 14 March—a commendably speedy response. She said:
We have not commissioned any studies to establish how many users, as distinct from individual calls, there are of NHS Direct.—[Official Report, 14 March 2000; Vol. 346, c. 134W.]
Her answer is rather strange. If she had read the Sheffield report that her Department commissioned, she would know that that matter was analysed in the report. There is an interesting result relating to the number of multiple callers to the Milton Keynes site. That was the point that I wanted to establish and to which I shall return presently.
I have no problem with the suggestion that a sensible set of aspirations lie behind NHS Direct, or with the idea of rolling out the service when it has been proved that it can do what the Government wants it to do. However, in view of the scarcity of NHS resources—I am sure that the Under-Secretary and I at least agree that however much funding the Chancellor finds for the NHS, money will always be a scarce resource and hard allocation decisions will always have to be made—I have a problem with spending money before we are sure that it is being spent effectively. The £80 million that the Under-Secretary said would be spent on NHS Direct could put an additional 4,000 nurses on wards in hospitals. We must continuously test the cost-effectiveness of NHS Direct against such alternative uses of the money.
Earlier, I quoted the objective that involves wanting to
reduce unnecessary demands on other NHS services.
One of my concerns about the Sheffield university report and the relevant published information involves the absence of controlled studies or comparisons between the situation in NHS Direct and that in other parts of the service. The hon. Member for Isle of Wight (Dr. Brand) alluded to that concern in an earlier intervention. In order to evaluate objectively the success or otherwise of NHS Direct, we need to know about its impact on other parts of the service. To do that, we need to carry out controlled studies, which necessitates comparing the areas that have NHS Direct with those that do not.
The Under-Secretary gave us some anecdotal evidence—she cited GPs' views of the service. At the risk of offending the hon. Member for Isle of Wight, I should not for a moment suggest that GPs' views should be considered conclusive in this or any matter. However, as reducing the demands on GP services is clearly one of the intentions of NHS Direct, their views of it are informative. To the extent that NHS Direct may be seen as a direct competitor of out-of-hours GP services—both offer a telephone triage service, one run by nurses, the other primarily by doctors—it is relevant for us to consider what the doctors think about it and the relative costs of the two services.
I shall return to costs in a moment, but I am sure that the Under-Secretary, and indeed you, Madam Deputy Speaker, will indulge me a little if I quote one or two comments reported in the professional press by doctors. Pulse, a magazine widely read by practitioners and, I should say in fairness, widely quoted by me in Standing Committees considering health Bills and related material, said on 1 April:
Results of the survey of more than 200 GPs show that in GPs' experience NHS Direct caused unnecessary distress and wasted NHS resources…More than half thought patients had had their
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anxiety levels raised unnecessarily and 56 per cent. thought patients had been given inappropriate advice…Nearly a third of GPs have refused to give the service any publicity in their surgeries.
On 17 March, Pulse said:
GP co-operatives have a clear message for the government—they do not want further integration with NHS Direct. The co-ops argue that prime minister Tony Blair's "unproven pet project" is not efficient or flexible enough to join GPs' highly developed out-of-hours systems.
Ms Stuart: Given that we are all greatly concerned about surveys and data being reliable, will the hon. Gentleman agree that a survey in Pulse, based on a response to a cut-out coupon in a previous edition of Pulse from a self-selected group of 200 people who were unlikely to write in with any positive comments, may not be a good statistical basis?
Mr. Hammond: I would not suggest for a moment that I am quoting a statistically relevant sample; it is anecdotal, but the Under-Secretary herself relied on anecdote to a fair extent. I deliberately prefaced my remarks by saying that I am not seeking to use GPs' anecdotal comments as fatal to the cause of NHS Direct. I merely think that in the ideal model, if the service were working as intended, GPs could be expected to be huge beneficiaries of it and waving their little flags. The fact that many GPs and GP representative organisations express scepticism should give us pause and cause for concern.
I shall not read extensive quotes, but I suspect that the problem relates almost entirely to the speed of the roll-out. From discussions that I have had with general practitioners and their representative organisations I doubt whether they would be as concerned if the roll-out had been more measured and if it had been clear that the Government were waiting for the evidence to support the scheme before rolling it out.
Whatever the Under-Secretary tells us, she will not be able to dissuade me and, I suspect, many others from believing that, although the Government have commissioned studies to look at the effect of NHS Direct, they have already taken the decision to roll it out nationwide before they see the evidence for or against it. That must lead us to question whether the motivation is as objective as the Under-Secretary has sought to suggest.
Dr. Brand: Does the hon. Gentleman agree that the very fact of rolling out NHS Direct throughout the country means that studies to compare the effectiveness of the NHS cannot be done, because the comparators are being destroyed?
Mr. Hammond: The hon. Gentleman is right: he has made the point before that proper controlled studies will become impossible. However, as I understand it, no studies are even being done to measure the impact on other parts of the national health service. GPs' hostility may derive partly from what they may perceive as the Government's hypocritical attitude in asserting their commitment to evidence-based medicine in the NHS generally, but acting in this case in a way that is clearly not evidence-based.

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The key issue is not whether NHS Direct is appealing as a concept. Of course it is. It strikes all of us as a good idea to have an easy, convenient and relatively cheap way of accessing the system. The key issue is whether it is effective and cost-effective. The Minister might recognise those terms of reference, which the National Institute for Clinical Excellence is required to take into account in evaluating a drug. Is the drug clinically effective, is it cost-effective and is it affordable with regard to the overall level of resources available to the NHS? In other words, is it good value for money where it is clinically and cost-effective? I hope that the Minister would agree that the criteria applied by the Government to other services and treatments should also be applied to NHS Direct, and that to get a tick in the box on its second birthday, NHS Direct must pass muster against those tests.
What evidence would be required to satisfy those questions? Indeed, what studies have the Government commissioned? The Sheffield study, admirable though it is, looks narrowly at what is happening in the three initial NHS pilot sites. The KPMG study will examine nine NHS Direct sites. What worries me—
3.46 pm
Sitting suspended for a Division in the House.
4 pm
On resuming—
Mr. Hammond: I was trying to elicit from the Minister whether the Government have commissioned wider studies that will consider matters within a broader spectrum than the NHS Direct sites. Are there studies that will compare related NHS facilities with the NHS Direct sites and with GPs' out-of-hours services?
If we accept that NHS Direct must pass the hurdles that the National Institute for Clinical Excellence would apply in looking at a new procedure or process, we must consider whether NHS Direct is a clinically effective solution and then whether it is cost-effective.
The Minister was sceptical about the views of doctors; as I said earlier, GPs do not always have the answer to every problem. However, she would be disappointed if I did not quote from the New Statesman of 20 March 2000, in which a relative of the Prime Minister expressed serious concerns about NHS Direct. The article is headlined, "The idea of NHS Direct was to cut GPs' work in half by offering patients easy access to advice. When Lauren Booth tried it, she very nearly died as a result." The article is not only about her experience; it quotes some well-respected doctors, and says about one of them that
like all those in the UK, her practice is already contracted to provide a 24-hour service to its patients. NHS Direct, she feels, is duplicating an under-funded service that has existed for years—a service run by better-qualified staff…Many calls to NHS Direct get referred on to GPs anyway.
The article continues:
This means that a loop is formed with distressed patients being asked to wait for an available GP to call them back. The current favouritism for this project also leads to less important cases being passed on as "urgent" when they are not…
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The GP continues:
I must then bypass all my other waiting patients to answer these calls simply because they come via NHS Direct.
The article reports:
just as some cases labelled urgent by the computer programme used to assess each call are not urgent, so some seriously sick patients can be misdiagnosed and left at home.
An NHS consultant is quoted, stating:
one man was prescribed paracetamol when he called NHS Direct; he had a serious case of malaria. Another man was told to go to bed and rub Vick's vapour on his chest; he nearly died from meningitis.
The report continues:
All GPs know from experience that prescribing and diagnosing over the telephone is one of the most dangerous things you can do.
The article highlights questions about the quality of triage that can be carried out over the telephone. The first question is about the quality of telephone triage as compared with personal triage. GPs to whom I have spoken and comments that I have read in the available literature suggest that the visual clues that the GP or clinician gets from the patient are important in making the correct diagnosis. We should not ignore doctors' views on the dangers of making telephone diagnoses.
The Minister proudly tells us that NHS Direct has been made available in many languages, and I have seen that in action at the NHS Direct site in Surrey, where, an interpreter is used when the caller's first language is not English. However, if it is difficult and dangerous to make a diagnosis by telephone when the doctor and patient both speak English as a first language, how much more dangerous and difficult must it be to make that diagnosis third-hand over the telephone, via a non-specialist interpreter who is trying to interpret the words of a frightened and confused patient who is speaking to a doctor in a foreign language? I can understand the reason for providing such services, but I would like to see hard clinical evidence that the benefits of immediate access that the telephone triage service offers fully outweigh the inevitable risks and downside.
We must ask for evidence that a nurse-led telephone triage service provided in dedicated centres is as good as, or better than, a GP-led triage service provided by out-of-hours services or co-operatives. I accept that the quality of services provided out of hours by different groups of GPs varies and that there might be arguments for improving them, but I wonder on what evidence it was decided that £80 million could not be better and more effectively spent beefing up GP out-of-hours services than on NHS Direct. Data on the quality of triage offered via telephone are insufficient to enable a sensible analysis of what is happening to be made, or to form the basis for decisions that the Government have already made in terms of committing themselves to rolling out NHS Direct across the country.
The critical question we must ask ourselves is whether NHS Direct is achieving better outcomes? What do the Government propose to do about the wide discrepancy in next-referral patterns? Between just the three sites covered in the Sheffield report, we see significant variations in the percentage of patients who are referred to GPs, A and E and self-medication.
Has the Minister undertaken any work to discover how many callers to NHS Direct are seeking a second opinion after a GP visit? I was told anecdotally—I am

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afraid that all we have is anecdotes, because the statistics have not been published and the Government might not even have asked for them—that a significant proportion of the calls to the NHS Direct site that I visited were from patients who had already visited a GP and were seeking confirmation of what the GP told them.
In how many cases is NHS Direct merely an extra step in accessing the same care? The Minister told us, and we know from the statistics, that 40 per cent. of NHS Direct calls result in a referral to a GP. We need to know how many of those people would not have gone to the GP if they had not called NHS Direct. We also need to know what the others would have done. How many of those who were referred to self-medication would have gone to a pharmacist or self-medicated without doing so? In other words, we must evaluate on a properly controlled basis the extent to which NHS Direct changes people's behaviour patterns. The information quoted by the Minister does not come close to enabling us to do that.
What impact has NHS Direct had on waiting times for a GP appointment? If the system were working optimally, people who do not need to clutter GPs' surgeries would be dealt with on the telephone; conversely, those who need an appointment would be seen more quickly by their GP, instead of having to wait two, three, five—or in some places, 10—days for a routine appointment. No evidence has been adduced to suggest that the position on seeking a GP appointment has improved as a result of NHS Direct.
What impact has NHS Direct had on waiting times in accident and emergency departments? We may assume that some people would go to their local A and E department if they did not have the option of calling NHS Direct. If so, waiting times in A and E departments should improve in areas where the service is running, which would be a good thing. I reiterate that my criticisms are not intended to be negative. There may be good news in all cases, but the evidence is not available, so we simply do not know. I have not yet seen anything to reassure me that studies are being undertaken.
The Under-Secretary said that the GP is still the case manager. How does that work in practice when a patient rings NHS Direct? Under the current system, how does the GP get information about that call? In the ideal world mentioned by the hon. Lady, it would be possible to link all GPs on NHS net and to hold electronic patient records somewhere in the ether. At the moment, however, NHS Direct, like GP walk-in centres, is eroding continuity of care, which has been a keystone of this country's primary care.
Turning to cost-effectiveness and value for money, we must ask whether NHS Direct delivers a given outcome more cost-effectively than any other available means: the issue needs to be viewed in the context of competing demands and offering an additional service. I have seen data showing that 40 per cent. of NHS Direct callers are referred to their GP, and a further 7 per cent. to an accident and emergency department. Therefore, in almost half the cases, the cost of the NHS Direct service is a net additional cost to the cost of dealing with the patient. Substantially better clinical outcomes in the remaining 53 per cent. of cases, or some other saving in the system, are needed to justify that cost. Is the service simply an extra tier? What evidence is there that we are
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saving money or improving the national health service—two sides of the same coin—by channelling callers through NHS Direct?
Earlier, the Under-Secretary and I discussed the relative costs of providing different services. I suspect that we had a slight disagreement, and I should like clarification. The hon. Lady said that the intended cost of NHS Direct, when fully rolled out, is £80 million per annum. We are told that there is NHS Direct coverage of 65 per cent. of the country, and that an average of 8,000 calls are made every day. Arithmetic was never my best subject, but that suggests that 2.92 million calls per annum are made to the service in its present form. If we extrapolate on the basis of 100 per cent. coverage, it would equate to 4.5 million calls per annum.
At an overall budget of £80 million, my rudimentary arithmetic suggests that the cost per call to NHS Direct is £17.77, not the £8 that the Minister cites. To get to her £8, she must assume that the number of calls per 100,000 people covered will more than double as the service is rolled out nationally. I am not sure what her grounds are for believing that. Perhaps when she winds up she will put some flesh around the figures.
Let us take the Minister's figure of £8 for telephone triage via NHS Direct. In a written answer to my hon. Friend the Member for Aylesbury (Mr. Lidington), she states:
We envisage the cost of NHS Direct to be approximately £8 per telephone call. This compares favourably to the cost per accident and emergency attendance £42 (1997–98) and cost per general practitioner contact £10.55 (1996–97),—[Official Report, 22 February 2000; Vol. 344, c. 902W.]
Is that true? If it costs £8 for a patient to be diagnosed by telephone, which means that the person carrying out the diagnosis has no ability to assess the patient's symptoms visually, and it costs £10.55 to visit the surgery of a GP who can pick up the visual clues, does £8 represent a value-for-money outcome?
The Minister also took issue with me over the costs of GP out-of-hours co-operative contacts, saying that they were more expensive than NHS Direct contacts. I do not have figures here and I should be grateful if the hon. Lady could provide them. I can say that the chairman of the National Association of GP Co-operatives appears to disagree with her: he believes that GP co-ops handle twice as many calls as NHS Direct, and that their total cost is roughly half that of NHS Direct. That suggests a cost per telephone call handled that is a quarter that of NHS Direct.
Two things need to be clarified. First, if we are comparing apples with apples and we are comparing telephone triage with telephone triage, is NHS Direct really cheaper than GP out-of-hours services? Does a nurse-led dedicated service provide better clinical outcomes than a GP-led service embedded in the overall GP service, in which continuity of contact with the patient is maintained? Secondly, if the relative costs are £8 for an NHS Direct telephone contact against £10.55 for a GP consultation, does the NHS Direct contact represent value for money?
I also asked the Minister about the number of callers versus the number of calls. Modern technology obviously makes it easy to log the number of calls to NHS Direct, but I should like to know how many people are using the service. There has been an investigation

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into that question by Sheffield university, notwithstanding what the hon. Lady said in her written answer to me. It made an astounding discovery: apparently, 10 users made over 6 per cent. of all the calls to the service at Milton Keynes.
It could be argued that those people might have attended every day at the local surgery and used up GP's time—that would be a perfectly plausible counter-argument—but we need evidence. We need to know whether NHS Direct is generating demand from people who are perhaps, and I use the term with some trepidaton, abusing the system. If we are to measure the service being delivered, we must have evidence.
I spoke earlier about the objectives of the system. I reiterate my concerns that the Government have hidden objectives additional to those announced publicly. The Under-Secretary's statement about the 999 ambulance service has given some credence to my belief that the Government are anxious to put the structure in place because they have grander designs for it.
People are worried about the clinical outcomes of NHS Direct contact, but we cannot conclude definitively whether those concerns are justified until we have the evidence. There are real concerns that the expected reduction in the burden on the other parts of the health service is not happening and will not happen. The Under-Secretary supplied evidence to show a reduction in the upward trend of calls to GP out-of-hours services, but that was the only identified reduction in service demands in the Sheffield study, and it occurred in only one of the three sites. Clearly, the evidence for a reduced burden elsewhere is by no means conclusive. There is no evidence of reduced GP consultation, no evidence of reduced accident and emergency use and only limited evidence of a slowing of the rate of increase in telephone triage provided by GP out-of-hours services.
No one who evaluated the available evidence could conclude that there was an overwhelming case that NHS Direct will be both clinically effective and cost-effective. On the basis of the evidence, no one would decide to roll it out across the country. I do not reject the possibility that NHS Direct will provide benefits, be cost-effective and be affordable within the national health service budget, but there is no evidence to support the decision to roll it out nationwide.
Will the Minister explain what the Government are doing to collect the necessary evidence? The Sheffield and KPMG studies will not produce the comparative data needed to compare the cost and performance of NHS Direct with that of other potential methods of delivering a similar service. Why did the Government, with all their emphasis on evidence-based medicine, decide to roll the service out without waiting for evidence from the pilots? That decision goes against all good management practice and everything that the Government said.
The Government's attitude encourages two types of sceptic. A sceptic of the first type sees a hidden agenda, believing that the Government are anxious to get the system up and running in order to use NHS Direct to undermine GPs' independent contractor status, to undermine the 999 ambulance service, and to move
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towards a single integrated gateway to primary care. The second type of sceptic thinks that NHS Direct has been rolled out quickly because it provides a good soundbite. That is why the Government did not wait for evidence before announcing the nationwide roll-out, and why they failed to make the roll-out conditional on any of the stringent criteria that are set for drugs and treatments evaluated by NICE.
The Minister know that I am a reasonable person. I see the potential of a telephone triage service, but I am not convinced that a dedicated service separate from the GP service is necessarily the way forward, nor am I convinced that the Government have explored adequately the possibility of working within the existing GP out-of-hours service, with all the benefits of contact and continuity that that delivers. I must therefore question the Government's motives in setting up a separate service that was bound to cause friction with GPs—one that, in addition, produces a less well-qualified level of triage at a higher cost. I accept that my final words are contentious but that is how it appears to me.
The bottom line is that we have not established today—nor have the Government in the evidence they have allowed into the public domain—that NHS Direct represents the best way to spend £80 million of public money in an attempt to improve access to the national health service. The jury is out on NHS Direct. Ministers have not inspired my confidence or that of others: there is no evidence that they genuinely intend to evaluate the success or otherwise of NHS Direct, or that they are willing to probe its success or otherwise. I fear that they intend to roll it out anyway if it complies with their own criteria for measuring effectiveness in the NHS.
There is a deep suspicion that NHS Direct is a pet political project of the Prime Minister and that it would indeed be a brave Health Minister who commissioned the sort of in-depth, probing, objective analysis that might reveal that NHS Direct was not a good way of spending national health service money. I urge the Under-Secretary, in the interests of her credibility and that of Ministers at the Department of Health, to ensure that proper evidence is gathered and proper objectives undertaken, and that the service is not rolled out regardless of the evidence that the results produce.
4.26 pm
Dr. Peter Brand: I will try not to demonstrate that the length of a speech must meet the time available because we are beginning to run into time constraints.
I had to look twice to see who initiated today's Adjournment debate. I was somewhat surprised that it was the Government, because there is little to discuss. There is a service that is on probation still and being rolled forward. We have heard very little evidence, and the Minister's contribution was not as enlightening as I had hoped it would be.
I am grateful that we have been given a summary of objectives for NHS Direct. No one who works in the NHS or uses it objects to any of the objectives given as the leading role for NHS Direct, which is to offer the public a confidential, reliable and consistent source of professional advice on health care, 24 hours a day; to

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enable people to manage many of their problems themselves; to provide a comprehensive service, which is an excellent goal, to help to improve quality and cost-efectiveness—a subject to which I may return—and to allow professionals to develop their role of enabling patients to be partners in self-care. But that has been going on for many years.
The objectives in the Sheffield study have been shared by the wider NHS team for certainly half my professional lifetime. Doctors tried to lead everything and there was a paternalism among adminstrators who thought that they knew best. We now know that team work is important and that unless we take patients with us we will not get anywhere. The objectives are excellent, but there is a great need to do something about consistency, especially in primary care. I will not be anecdotal, but all of us know that there are places where it works and others where it does not. There are models that work in stable populations where there is a maximum turnover of practice population of, say, 10 per cent. a year, as against populations with a turnover of population of 60 to 70 per cent. a year. It makes a difference whether people work within five miles of their doctor's surgery or whether they are weekly boarders, as most Members of Parliament are. Different solutions are therefore required to meet the laudable objectives of the programme. Although I would not necessarily want to extend the use of walk-in clinics to rural areas or run them in parallel with traditional primary care surgeries, they make a tremendous amount of sense in commuter areas and inner cities. There must be local solutions to the delivery of a national agenda that brings quality and access.
It is therefore disappointing that the NHS Direct initiative has been heralded as a great turning point, a new territory and a new beginning. Many people in the national health service have strived to achieve those very objectives over many years, and many have succeeded. The previous Government should be commended for the initiative that funded some of the out-of-hours costs for GP co-operatives, because that gave people in the profession the enthusiasm to set things up locally, to try them out and to make them work. That also involved telephone triage, partly through doctors but also through the use of nurses and computer programmes. That idea is not new, therefore—NHS Direct has built on a lot of the experience that was obtained in primary care under previous arrangements. Some of those solutions failed and had to be bailed out, but most of them developed into successful services, and they succeeded because they were local.
My professional colleagues felt not so much anxious about, or threatened by, the Government's new measures as irritated. Having slogged their brains out to get something off the ground, they were suddenly told, "We are going to impose something from above. This is what we are calling it. It is our new initiative, and this is what it will be." That initiative is either new or a very expensive rebranding exercise. There is anxiety among the profession that a new, nationally imposed initiative may not necessarily work alongside all the excellent cooperative work that is done in many localities.
Liberal Democrats very much supported the transformation from individual fundholders to multi-funds, and we support the subsequent change to primary care groups and primary care trusts, provided
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that there is democratic accountability at trust level. We support health improvement programmes that give communities the opportunity to work together, and allow us to integrate social, environmental, some secondary care and primary care services—especially at the acute, out-of-hours, emergency point.
A lot of work has been done over the past couple of years to bring that together. In my own constituency we have a GP out-of-hours, on-call service which has nurses and outreach workers attached to it and employed by it. We have a mental health crisis intervention service and a social services immediate response unit. People wander around with little buttons around their necks and get instant access to emergency services—and very helpful that is, too. We have the ambulance service and the voluntary sector, which provides a lot of advice through helplines.
The Government had a golden opportunity to give some seedcorn money to bring some of those services together. Instead, we are getting a regional service that will take and filter all the calls and then perhaps send them down to the people who have to work together in their locality. It would have been much more sensible for a Minister to tell the people who have to write the health improvement programme, "We expect you to deliver the objectives that we want provided through NHS Direct. Those include access, consistency and the ability to demonstrate that the service is cost-effective." Those people would have got on and developed their own local solutions. What is more, their output could have been monitored by Ministers and audited for effectiveness. Unfortunately, that does not seem to be the pattern that is on offer. People in different parts of the country—my constituents in Hampshire are not unique in this—are told, "No, you've got to start. In time, you might be able to have more autonomy locally." I hope that that is not pathognomonic of a Government who want to control everything, because the solutions that work tend to be local ones.
We have heard of the study that was carried out, and I should briefly mention it. I am amazed that Ministers claim that the interim reports of December 1998 and February 2000 are evidence of anything. They simply set out how much the service is used and whether people like it. They managed to find two disasters in the whole trawl. Although those were very sad and should not have happened, such a trawl is not a scientific piece of work.
It is also amazing that the evaluation of NHS Direct makes no reference to the cost or even the comparative cost of other services. That is not an evaluation of the service. I wonder whether there should be a requirement for Departments that employ outside organisations to evaluate Government activity and initiatives to refer to the Audit Commission or to someone with experience in assessing Government activity before they commission what are, no doubt, expensive studies. It would have made sense in the early pilots—they are the only ones having their second birthday today—to have sensible, hard information from which conclusions could have been drawn about how we reach the objective that we all share. As the hon. Member for Runnymede and Weybridge (Mr. Hammond) said, there is no argument about the objectives for NHS Direct. They are those for the national health service—to provide a good, cost-

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effective service. However, there is no evidence in what we have before us of whether the imposed solution is the most appropriate.
Mr. Hammond: The hon. Gentleman has inspired a thought in my mind. Would it not be preferable for the Government to ask the Audit Commission to undertake an investigation into the cost-effectiveness of NHS Direct? If the Government were not minded to do that, would the hon. Gentleman join me in taking a bipartisan approach to the Public Accounts Committee to see whether we can get the National Audit Office to examine the matter in terms of the value for money offered?
Dr. Brand: I am grateful for that intervention. That would be an excellent idea. I suspect that the Government have a lot of figures that would help the Audit Commission in such an investigation.
We are not against what NHS Direct is about. It is right that people should become more knowledgeable about their illnesses and possible treatments for them. That is empowerment of people, which is absolutely correct. The use of the internet is imaginative and will definitely take off in the future. However, I am anxious about having a centralised set-up such as NHS Direct and about whether that will lead to a more centralised and formulated national health service which will try to control not only outcomes—we all want those to be excellent—but the methods by which people use the service. If it is a policy option, it may be sensible to have a national common gateway to services, because they vary in each part of the country. However, I would prefer a gateway that was tailored to localities.
The Minister has not touched on the other primary care role—gate keeping—that has probably kept the national health service from collapsing during the past 10 years when it has been starved of funds. It is difficult to maintain a gateway service without some gate-keeping responsibility, but out-of-hours co-operatives appear to have found a working solution. The nurse on telephone triage has immediate access to a doctor, and decisions can be made on clinical grounds and resource allocation grounds. If only one doctor is on call and the other has to be got out of bed, a decision must be made about whom to see first and who can come into the hospital or the accident and emergency department. Such important decisions can be made only by an integrated team whose members know each other and, preferably, work in the same place. That would be extremely difficult to deliver from an NHS call centre that was 150 miles away and manned by people whom one had never met. I must flag up that concern.
I know that the Minister believes in what she is doing. I respect her a great deal, but I wish that she would produce more evidence to justify her faith in the service. We all have faith in the national health service, but the past few years have demonstrated that we cannot live by faith alone. The money is welcome, but we would also like management that can be seen to be in the interests of the service and can deliver in the most cost-effective way.
More important, the service should bring together all the elements that constitute health care. The Minister would agree that health care is about more than just
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ensuring the absence of disease. Much of NHS Direct's work will be reassurance. I started my professional career as an honorary granny on a housing estate in which everyone had two children and £2,200 a year, which fact dates me somewhat. None of those people had family support. Many people remain in that position. A service such as NHS Direct is valuable, but it must fit into the panoply of support. The central initiative arises at a time when local integration is taking place, and it risks stopping rather than promoting that integration.
I do not want to start talking about money, but £80 million could have been used imaginatively and to great effect to improve existing structures that were delivering the services and meeting the objectives. Instead, it will be used to set up a parallel service, which the Minister described as an addition, and that may not be the most cost-effective way of meeting the objectives that we all support.
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Mr. David Tredinnick: I am not sure whether we can describe the debate as heated, but before you took the Chair, Madam Deputy Speaker, the Chamber was certainly heated. As you will be here throughout the summer, it might be in your interests and those of hon. Members to know that the central heating system has broken down and that there are problems with the valves. Having served on a Committee that used the Room for a year during the previous Parliament—perhaps the last to consider a private Bill, a railway Bill—I can assure you that this is a hot Chamber in the summer, because of the heat generated by the roof. I am sure that you will want to investigate that.
I am especially delighted to have been called, because I have a long-standing interest in health matters, particularly complementary medicine. It is a pleasure to take part in a debate with the Minister, the hon. Member for Colne Valley (Kali Mountford), the hon. Member for Isle of Wight (Dr. Brand)—a medical doctor—and my hon. Friend the Member for Runnymede and Weybridge (Mr. Hammond).
We are talking about a new initiative with a budget of £80 million. I support what the hon. Member for Isle of Wight said and I support the service's objectives. The four principal objectives are to provide advice on health care 24 hours a day, provide simple and speedy access to information, improve the quality and cost-effectiveness of health service provision and—perhaps the most important in the long term—encourage patients to be partners in their own health care. That is an important concept, although I am not sure whether it is original—I think that the Conservatives introduced it. However, NHS Direct is an important initiative.
I support my hon. Friend the Member for Runnymede and Weybridge, who said from the Conservative Front Bench that the key issue is cost-effectiveness. Is the service affordable in the context of other demands? Does it represent value for money? I am not sure that the Minister has answered that question yet.
I also support what the hon. Member for Isle of Wight said: the Minister could perhaps have said a bit more in her opening speech in support of the new initiative. In

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fact, he questioned whether she really believed in it at all. The Minister referred to the expectations of the public and the extra billions that were being put into the health service. She called it the reinvention of the health service and said that the stakes were going up and that there were 750,000 calls a day to the service.
The Minister told a lovely story about a lady on her way to a wedding, who had a problem that was solved by NHS Direct. She could also have referred to the problem that Elizabeth Thompson faced: she rang NHS Direct, saying that she was suffering from indigestion, and was diagnosed with the symptoms of a heart attack. Those two stories illustrate not only the potential benefits of the new system, but the potential problems.
Another key issue which the Minister mentioned concerned how we should broaden the role of nurses. My hon. Friend the Member for Runnymede and Weybridge perhaps did not refer to that, which might leave me to deal with it. At Bournemouth, we heard the Government announce that some grades of nurse should have more responsibility. I will not speak for long, because I know that the hon. Member for Colne Valley is anxious to contribute. As a Back Bencher, I know what it is like not having an opportunity to speak when one has waited for a long time.
What advice do the carefully selected nurses on the line at NHS Direct give? If the role of nurses is broadened to give them more responsibility, presumably they can talk about more things. If patients are going to get into a partnership with the NHS through NHS Direct, they want to talk about what they want to talk about.
There is increasing evidence that the public—4 million to 5 million people a year—are talking about and acting on complementary medicine. The Government have really missed a trick. If ever there were a case for new Labour showing that it was progressive and concerned about new things that people outside the House are worried about, surely it is complementary and alternative medicine. One can hardly pick up a Sunday or daily newspaper without a complementary or alternative therapy being described.
The number of patients attending complementary practices represents about 20 per cent. of the public, and about 75 per cent. of the public support NHS access to complementary medicine. The reasons for that are a continuing scepticism about drugs and side effects, a continuing media optimism about and support for complementary therapies and, as a study has shown, the public's growing wish to take more responsibility for health choices. Surely that is identical to the objective set out by the Under-Secretary. It is borne out by evidence on doctor attitudes, which shows that 28 per cent. of GP practices in my own county of Leicestershire provide complementary services in the health service. I should point out that that was under the previous Administration. The figure may have gone down since then, but I must not engage in political knockabout, as we are short of time. Evidence also shows that 20 per cent. of nurses in Leicestershire and 34 per cent. of midwives use complementary therapies.
How does that fit in with NHS Direct? The Under-Secretary may say that we must put safety first. Huge strides have been made in regulating complementary and alternative medicine. Now, if ever, is the time for the
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Under-Secretary to examine how nurses may use alternative services and reduce the pressure on conventional services. The hon. Member for Isle of Wight, who practised as a doctor before he was elected, used to provide such services: perhaps he still does—I do not want his entire patient list to collapse as a result of my remarks.
How can alternative services be used by NHS Direct to reduce the burden on doctors? I picked up from a House of Commons cafeteria a leaflet stating that powerful stress relief is freely available to Members of Parliament in the form of acupressure treatment, one of several complementary therapies offered at Westminster gym. If that is available to hon. Members, should it not be available to the public?
The British Complementary Medicine Association confirms in a press release its intention to keep improving standards, backing the Department of Health's submission to the Lords Sub-Committee on Complementary and Alternative Medicine. It complains that some further education teachers of such therapies do not have sufficiently high standards. It offers a general advice service on complementary medicine. I am trying to be generous and wish to make a couple more remarks, but I do not want to take too long.
Madam Deputy Speaker: Order. I am not seeking to limit the hon. Gentleman's remarks. I do not think that he has an interest in that matter and know that he will be careful about commercials. It may help if he avoids reading certain things into the record.
Mr. Tredinnick: I completely misunderstood you, Madam Deputy Speaker.
Madam Deputy Speaker: You are not the first man to do that.
Mr. Tredinnick: Having served with you on the Liaison Committee, Madam Deputy Speaker, I am appalled to have made such a mistake. I certainly was not trying to make a commercial—that is the last thing that I want to do. I have no interest—registered or otherwise—at all in the British Complementary Medicine Association, but it does represent complementary medicine outside the House. I did not wish to promote it; rather, I was pointing out that regulation is improving.
Homeopathic doctors have been regulated since 1950. Osteopathy has been regulated since 1993, when the Osteopaths Bill was enacted—I was a member of the Committee that considered that Bill. I also sat on the Standing Committee that considered the Bill that became the Chiropractos Act 1994.
A range of measures are being taken to make complementary therapies safer. The Anglo-European College of Chiropractic is applying for designation as a fit and proper institution to receive public funds from the Department for Education and Employment. Shiatsu uses finger-pressure treatment to stimulate the body's energy, described by the Chinese as chi. The Shiatsu Society has high standards and was established in 1981 and has nearly 1,700 members. It has an assessment panel and code of ethics, holds a practitioner register and requires practitioner insurance.

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That is another example of improved standards. Indeed, the previous Government facilitated approved standards for reflexology, aromatherapy, and hypnotherapy. There are now new standards for homeopathy. Last week, at the homeopathic college in Regents Park—
Madam Deputy Speaker: Order. The debate is about NHS Direct and I hope that the hon. Gentleman will remember that.
Mr. Tredinnick: I certainly will, Madam Deputy Speaker. I merely wanted to draw attention to the fact that five homeopathic bodies have come together with a new form of regulation. The Minister should have some confidence about allowing NHS Direct nurses to refer certain cases to complementary therapists. Complementary therapy has a role to play. For example, stress can be reduced by lavender drops; arnica relieves back pain; Optrex, which contains witch-hazel, helps to relieve eye problems; and breathing exercises can help various ailments. There are tremendous opportunities for nurses, some of whom have experience of such complementary remedies. The next question is whether they will be allowed to use it.
Dr. Brand: There is a problem about legal liability. The hon. Gentleman has explained that some alternative practitioners are registered and may carry insurance, but if an NHS Direct nurse advises seeing an alternative practitioner, the problem is whether she will be liable if the advice proves inappropriate.
Mr. Tredinnick: The hon. Gentleman makes a good point. Another issue is whether there should be a national register of complementary therapists, but we had better not go over that ground.
Many nurses on the NHS Direct helpline have experience of complementary therapies. The Minister should find out what they are and establish whether such nurses could make some referrals. That could relieve the pressure on the surgery of the hon. Member for Isle of Wight and those of other doctors. The Government should not miss this trick. It is really worth exploring. So many people could be helped.
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Kali Mountford: I thank the hon. Member for Bosworth (Mr. Tredinnick) for being generous with his brevity. We started the afternoon seeming as if we had time for a meandering stroll, but I am now in the 100 yd dash, so I shall attempt to keep my remarks as succinct as possible.
I do not know whether I am the only Back-Bench Member with NHS Direct in my constituency, as I have not studied the constituencies of all hon. Members present. I wish to talk about the experience of patients using NHS Direct and about modernisation of the NHS more widely.
My first point of call has to be the opening of NHS Direct in Wakefield, which serves my constituency. I had the honour and privilege to attend it with the former Secretary of State for Health, my right hon. Friend the
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Member for Holborn and St. Pancras (Mr. Dobson). It was an eye-opening experience. The service had been running a little while. Its staff obviously wanted us to see them at their best, but I cannot believe that anyone who attended that day could fail to be impressed by the professionalism of the staff and the experience that they brought to their work. The nurses drew on more than their experience of being nurses; their life experiences were important too. When I attended, there was only one male nurse, and I noticed that all the nurses were a little older, had families and a rich experience of life as well as of the NHS, which made them so suitable for this work.
The new technology was also interesting and I was allowed a little practice. I cannot profess to have been good with it, but it gave me some comfort to know that it worked. For example, I had recently had a tiny accident with my finger, so the staff suggested demonstrating what would have happened if I had called them. It was an enlightening experience. The advice that I would have got, had I been sensible enough to take it, would have made my finger better a lot quicker. As it was, I had a huge finger which throbbed unnecessarily. The process was so logical and precise that even someone like me could avoid making a mistake. The nurses brought their own wealth of experience to the system. Although they used it far better than I could have done, the technology was impressive.
I was particularly impressed by the technology that was used for interpretation. While I was there, a call came in from someone who had English as a second language. The service was very effective, certainly a more effective service than my GPs have available to them. They have to ring the local authority, which has some interpreters available and loans them out from time to time to people who need them. They may have to be booked two weeks or a month in advance because there is such a high demand for interpreters who can do such work. The hon. Member for Isle of Wight (Dr. Brand) shakes his head. I can only tell him of my own experience.
Mr. Hammond: I may be mistaken, and no doubt the Minister will correct me, but my understanding from my visit to NHS Direct was that the interpretation service is that provided by BT and available to anyone. Indeed, the GPs in the hon. Lady's constituency could make use of it, if they wished to, but it is not cheap.
Kali Mountford: That is obviously true. But the hon. Member for Runnymede and Weybridge (Mr. Hammond) was arguing that, when people went to see their GP, they had a one-on-one experience. Clearly it makes sense for a telephone advice line to use another telephone advice line because the conversation takes place on a linked network. The same would not be true in a GP's surgery. I cannot speak for every practice in my constituency, but few GPs at my practice would do that. They would wait until another individual could attend or refer the patient elsewhere.
A number of people in the local hospital can give such advice and when I attended hospital recently I witnessed that, too. That obviously is beneficial in those circumstances. But we cannot simply denounce the fact that interpreters are available through BT who are

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accessed directly by NHS Direct. There is a definite benefit to that individual whose conversation I witnessed. The hon. Gentleman did not seem enthusiastic about the service earlier. Having seen what I saw, I am.
Hon. Members have taken us on a debate about qualitative studies and hard scientific studies. It has almost been like being back at college and having debates with hard scientists, as I did as a social scientist, about the quality of data and what can and cannot be accepted. I still defend my position that there is genuine benefit from looking at so-called soft results. [Interruption.] The hon. Member for Isle of Wight was quite disparaging about the Sheffield study. Sheffield university is a highly thought-of university. Its study gives some genuine results. It does not give the sort of hard data that hon. Gentlemen want, but numbers are not the only issue. People's experience has some merit.
Dr. Brand: I was disparaging not so much Sheffield university's study as the parameters that were set for it. It excluded all costs. Is the hon. Lady really telling us that the NHS should be run on a touchy-feely, feel-good basis or do we need hard information? Why do we have NICE in that case?
Kali Mountford: Obviously there is a place for all sorts of data. I had the impression from the debate so far that the hon. Gentlemen disparaged soft information which could add much to people's experience of the NHS and has a value. That does not mean that we do not have to count the heads too. There is some hard evidence—as a social scientist I would count it as hard evidence—that there has been a genuine change in people's behaviour and their experience of the NHS. Anecdotal evidence may not be what the hon. Gentlemen have valued so far in the debate, but I will give some nevertheless. It is not often that people come foward with thank yous.
Mr. Hammond: Will the hon. Lady give way?
Kali Mountford: Time is short, but I will.
Mr. Hammond: It does not seem that short to me. The hon. Lady is making a big issue about hard versus soft evidence. The Government have set out a series of objective tests that institutions such as NICE must use. Does the hon. Lady not think that the right way to allocate scarce resources in the NHS is to ensure that anything that we do is clinically and cost-effective?
Kali Mountford: I have already made this point. There is a place for both. Although I accept that cost-effectiveness and clinical effectiveness must be measured, those are not the only data that should be examined. The evidence shows that there have been some genuine benefits in a fairly short time and I suggest that that is of value.
Dr. Brand: Would the hon. Lady therefore agree that the Audit Commission might consider this matter, because additional soft evidence is excellent, but is of use only if it is additional to hard evidence, which must include costs?
Kali Mountford: That is an interesting point and not one that I would necessarily throw away with the bath
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water, but it was not the point that I was trying to make. Because they have the Sheffield report in front of them, the hon. Members for Isle of Wight and for Runnymede and Weybridge have concentrated heavily on it. The hon. Member for Isle of Wight made a suggestion that had some value, but that does not mean that we can simply take the report apart, disparage it and say that it offers nothing to the debate. I do not believe that it does.
I will return to the anecdotal evidence of my constituents who, when a new service is introduced by the Government, do not generally ring me up to tell me about their wonderful experiences. The difference here is that NHS Direct is extremely popular. I do not suggest that everything that Governments do must be popular, but it would be ludicrous to deny that popularity is a measure of success.
Mr. Hammond: The hon. Lady, no doubt inadvertently, has precisely made my case for me. The concern is that the Government have rolled out NHS Direct without sufficient hard evidence of its effectiveness because it is popular and will help them to curry favour with the electorate. That is my concern.
Kali Mountford: The hon. Gentleman talked earlier about sceptics. That was rather cynical. Popularity in itself is not the only thing that should concern us. However, when the first feedback that a Member of Parliament receives from her constituents is a flurry of unsolicited responses about their marvellous experiences, I, for one, will not ignore it. That does not mean that it does not need to be backed up with further evidence. I should be quite surprised if in this, as in all things, the Government do not check progress and continually monitor the service's effectiveness.
This afternoon's debate about the introduction of NHS Direct and what it is doing shows us that we must consider our constituents' response to that service. I shall tell hon. Members about three people. In their different ways they illustrate some points. The first concerns Shirley. She went to her GP. It was her first port of call. She went to the surgery with an ordinary appointment because, like me, she had a swollen finger. It did not seem important or too worrying, but it did not seem to go away and she did not feel too well. The GP precribed some drugs, and she went away feeling happy. Unfortunately, her hand got significantly worse.
Shirley was in agonising pain by the middle of the night, which is when people get especially anxious, having left things all day, hoping that they will feel better. She did not want to disturb anyone and, anxious not to waste anyone's time—many constituents who contact me feel the same—she called NHS Direct. She was told, "You must go to the A and E department in the morning, or even now if the pain is too bad. You are not having the sort of response that we would expect from the treatment that you had. You really need to be looked at again." She went to the A and E department and was admitted with a blood disorder that had not been detected. She stayed in hospital for a fortnight before Christmas and has still not fully recovered.
NHS Direct gave Shirley valuable advice. She might not have taken it; instead, she might have wrapped her hand in ice, thinking that she had something in it and that that was what she should do. We do not know what

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the outcome would have been if she had done that and waited until she could get another appointment with her GP a week later.
Mr. Hammond: The hon. Lady has introduced a new element into the debate. Hitherto, we have been talking about NHS Direct as a first point of contact. However, the hon. Lady seems to be advocating that a patient who is already under the doctor and not responding to treatment should go to NHS Direct instead of going back to the doctor. Is that really an appropriate way to build on the continuity of care in our GP service?
Kali Mountford: The hon. Gentleman misses the point. Patients will make their own decisions. We can tell them, "This must always be your first point of contact," but they will do what they think best in the circumstances. We have talked about NHS Direct as an addition to out-of-hours services, and that is how Shirley was using it.
The second patient to whom I want to refer is Victoria. Hon. Members have already observed that many of the people who call NHS Direct are women, and all three of the cases to which I shall refer involve women. Victoria thought that she had had indigestion for four days. It was very troublesome, and she finally rang NHS Direct, thinking that it was so trivial that she should not disturb her GP but wanting advice about whether to go to the pharmacy to get something like Gaviscon. NHS Direct quickly got an ambulance to her because she was having a heart attack. She was admitted to hospital for some time. Although she is now fully recovered, she must have continued coronary heart care. Her words to me were that NHS Direct had saved her life, because she was going to ignore the gathering pain.
The next story is fairly typical, and concerns my grandson. There was a bad flu epidemic over Christmas, and my daughter thought that her son had flu, like everyone else. He got worse and worse, and she got more anxious. She could not get hold of me because I was here, so she rang her GP. She could not get a response because it was late at night. Three or four calls later, she had spoken to no one at all, just an answering machine. I do know why that was, but she did not feel that was an adequate response.
Dr. BrandI would be concerned if my colleagues were breaking their terms of service. I hope that the answering machine gave a number that she could have rung to obtain out-of-hours advice.
Kali Mountford: The sorry tale is that, when she called that number, she spoke to a person who said that he could not deal with her call for some hours. She was very anxious about her son, who was feeling very poorly by this time. Again, NHS Direct referred her son quickly to a hospital, and he was admitted. He stayed there for a week, having contracted a serious virus. He was very poorly for some time.
Mr. Tredinnick: The hon. Lady has spoken eloquently. I sat down a little early in the hope that she
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would have an opportunity to speak. All of us hope that the Minister will respond to the points raised. I hope that the hon. Lady will bear that in mind.
Kali MountfordOf course I will. I was trying to raise some points, but I have taken many interventions from other hon. Members. I am sure that, had I not done so, I would have finished speaking earlier.
The point of all those cases—I could quote dozens of similar stories from my constituency—is that they are typical of the fact that people got a service, often late at night, that they felt was not available to them in some other way and they took different decisions from those that they might have taken. That made a real difference to their life and health. Surely that is what the health service should be about. I am disappointed—[Interruption.] Does the hon. Gentleman wish to intervene?
Dr. Brand: No.
Kali Mountford: I am sorry, but I thought that the hon. Gentleman wanted to intervene. It was obviously a trick of the eye.
My enthusiasm for NHS Direct has grown out of not only my experience, but that of my constituents. Obviously, if people want to take the line of hard evidence so that we can add up the number of people employed and the number receiving the service, there is a role for that. But some of this afternoon's evidence caused me some concern. At one point the hon. Member for Runnymede and Weybridge said that he was comparing apples with apples. To do that, one has to be sure that what constitutes apples is identical, but, in the case of which he spoke, that was not at all clear. After all, in any attempt to compare the cost of the delivery of the service with the delivery of an out-of-hours GP service, I should have to know what was included in the cost make-up. For example, it would make little sense to me to suggest that the cost of a nurse's time is greater than that of a GP's time. The last time that I looked at pay scales, a nurse's salary was significantly less than a GP's. Although that is not the only item included in the scale of costs, it is significant.
Mr. Hammond: I thank the hon. Lady. The point is that GPs are not paid overtime for providing their out-of-hours service. There is a fixed cost to the NHS. Although I understand entirely what the hon. Lady says, does she accept that the Government have identified a need to look at the clinical and cost-effectiveness of any service that the NHS proposes to introduce before valuable and scarce NHS money is spent on it?
Kali Mountford: We return to the issue and the answer is the same. I have never said that that would be a bad idea. What I do think is that, with new NHS Direct pilots—I am not sure whether we can call them that—less than two years old, we ought to rejoice in the experiences of people who have been helped by NHS Direct. Simply focusing on the bums-on-seats approach does not allow a true evaluation of the service so far. We shall have to wait until people tell us that they would have made a different choice. People in the three cases that I outlined earlier benefited from the service.

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The Minister said that evaluation of the NHS in general is not always only about money. I should be most disturbed if the time ever came when NHS Direct could be evaluated only by its cost-effectiveness and emphasis on cost. Effectiveness and experience, yes. Cost must play a role; it would be ridiculous to spend money unwisely. Having said that, focusing on cost alone gives me concern and pause for thought.
Dr. Brand: Does the hon. Lady not recognise my frustration in having to cut exercise programmes on prescription, hydrotherapy on prescription and some alternative therapies available on the NHS purely on cost grounds? Costs cannot be isolated, however worthy one's objectives.
Kali Mountford: I am tempted to go on a detour in my meandering to address that point. We would have to examine existing problems in the NHS and establish why budgets have been so strained and constrained in recent years, and then determine what could be done as a result of the recent Budget.
Mr. Tredinnick: May I tempt the hon. Lady into the 15 minutes' injury time which is available because we voted in the Chamber earlier? Are not many complementary and alternative therapies much cheaper than the drugs offered in the health service?
Madam Deputy Speaker: Order. I hope that hon. Members will not relax too much on the basis of injury time. I must point out again that the subject of the debate remains NHS Direct.
Kali Mountford: Thank you, Madam Deputy Speaker, for rescuing me.
We spoke earlier about measuring effectiveness, but there has not been much of that in respect of complementary and alternative medicine. The hon. Member for Bosworth talked about regulation, but no one wants an unregulated health service. NHS Direct is regulated and I should like to redraw hon. Members' attention to my own experience of seeing it work for myself. I recall the true professionalism of those nurses, which was equal to that of any others in the health service. They gave me the comfort of knowing that the service would be beneficial and valuable.
I also experienced the service as a whole, rather than just in relation to individual patients. My own grandson was taken ill during the flu epidemic. People were reading newspaper reports of dreadful stresses on NHS Direct. In my own constituency, I undertook to phone around a few GPs, as did the local newspaper. The paper sought stories of disaster, but I sought to find out what was going on. I heard about GPs sitting by the phone waiting for calls. NHS Direct had already taken people to the right place for the right treatment—at the pharmacy, unless their condition had developed to the extent that extra intervention was necessary.
Most flu epidemics can be controlled by proper use of over-the-counter drugs. Not everyone needs a GP in those circumstances. Fluid treatments are well understood in most families, yet people become anxious. The calls to NHS Direct saved a lot of strain on GP services and helped accident and emergency services in hospitals to manage the unexpected winter crisis. In my constituency, the crisis never arrived.
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Only last Friday I discussed a range of issues with my area health authority. I shall not trouble the Chamber with the details this afternoon, but one important point emerged. Although it had not made its own detailed evaluation of what happened that winter and whether NHS Direct made a lesser or bigger contribution, it was clear that the winter period had been managed well. The health authority acknowledged that NHS Direct had made a significant impact on the management of the treatment of patients over that time.
Mr. Hammond: I sense that the hon. Lady is coming to the end of her speech, so I wish to try one more time to establish whether she supports the Government's initiative in introducing the National Institute for Clinical Excellence and the criteria set by the Government for measuring the appropriateness of treatments and processes in the NHS. If so, does she accept that the same criteria must apply to evaluation of NHS Direct?
Kali Mountford: The hon. Gentleman seems to suggest that different forms of evaluation are mutually exclusive. I can only repeat what I have said already. I do not know why the hon. Gentleman is trying to extract a different reply now from the one that I have already given.
The Minister referred to the development of NHS Direct. When my right hon. Friend the Member for Holborn and St. Pancras was the Secretary of State for Health, I raised a point with him about the further development of NHS Direct's links not only with GPs—those links are already in place—but with the wider community. At that time, there was a meningitis scare in my constituency, and I saw a role for NHS Direct in providing a service to anxious parents.
I was fascinated by some of the Minister's comments about examining what more could be done with pharmacists, and what could be done to deal with teenage pregnancies. Tackling local crises such as meningitis outbreaks, or, as is common in my constituency, cryptosporidium problems relating to spring water, may be part of NHS Direct's future. That would add to NHS services, and I hope that NHS Direct will develop in that way. Notwithstanding what hon. Members said about wanting hard data, my experience of NHS Direct has been good, and my enthusiasm for it remains.
5.25 pm
Ms Stuart: This has been a fascinating debate, which has at times reminded me of a letter that I read in Pulse from a Scottish general practitioner. He went to great lengths to say that NHS Direct was a total waste of time and effort, and that it had made absolutely no difference to his practice. Then I read his address and I thought, "Yes, of course, it wouldn't have, because they don't have NHS Direct in Scotland."
In the light of some of the comments that were made, I want to remind hon. Members what NHS Direct is about. Some may remember the notion of cards. A nice little NHS Direct card says that
NHS Direct is a 24 hour nurse-led confidential helpline providing advice and information on: what to do if you're feeling

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ill; health concerns for you or your family; local health services; self-help and support organisations.
I suggest that one could not attempt to give that card to NICE to assess with its clinical evaluation criteria. We are not comparing apples with apples. The effectiveness of NHS Direct services is assessed while they are used and rolled out, and that means a long time scale.
The hon. Member for Runnymede and Weybridge (Mr. Hammond) was absolutely right to say that we need assessment, but that must be carried out in a controlled way which gives proper perspective. All the concerns that the services are changing behaviour need time to be examined. We need longitudinal studies as well as localised in-depth studies. Several assessments are being undertaken. Over Christmas, for example, we picked three sites in which to assess satisfaction. In the west midlands, NHS Direct undertook a study that showed that 95 per cent. of referrals to GPs were appropriate. All those actions must be considered.
Mr. Hammond: Will the Minister give way?
Ms Stuart: I will, but I will not be so indulgent in allowing interventions as the day goes on, because I must put right several misconceptions.
Mr. Hammond: The point that I have tried to make throughout the debate is not, as the Minister said, that I am hostile to NHS Direct as a concept. By piloting a scheme, the Government imply that they will examine the results and appraise the evidence, and base their decision on that. I have asked the Minister to tell us how that is being done, and to present evidence, because we have not seen any in a form that could justify the decision to roll out NHS Direct nationwide.
Ms Stuart: The concept of using the telephone line as NHS Direct does, and of using nurse triage over the telephone, is extensively established in the United Sates, where it has been tested. It is inappropriate to assume that the service was started without any background. Commercial call centre experience can help in dealing with telephone calls, and clinical experience can also be relied on. The service has been tested for clinical safety, and its record on clinical accidents is exemplary.
At the moment, NHS Direct projects starting up may use call handlers, or have a link with a GP co-operative or ambulance trust. The roll-out is an extension and is responsive to local needs. As we move on and as national procurement is made, we have to decide whether, for example, regional centres should interact with local centres. The roll-out is extremely controlled and project managed, and is continually assessed.
It was argued that the Sheffield evidence was insufficient and that unconvincing data demonstrated that the programme had not been carefully tested. I got the impression that hon. Members believe that NHS Direct should not be on offer because it cannot be measured, even though they accept that NHS Direct is working, the public understand the advice and the service is used extensively. Let me assure hon. Members that the roll-out and triage are tested.
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Comments were also made about the scepticism of some GPs. The service is completely new, and it is always difficult to explain such a thing to someone who has not worked with it. There is a tendancy to liken the service to out-of-hours services and so on. It is, however, an additional service, which brings me to the comments of the hon. Member for Isle of Wight (Dr. Brand), who is a responsible general practitioner who feels that he has been doing such things.
Unfortunately, however, not all the hon. Gentleman's colleagues are like him. Some doctors do not have access to such a service, and hon. Members requiring evidence on that should refer to the last edition of the patient survey. The chances of getting out-of-hours service, a GP coming out to visit and access to information vary tremendously across the country. It is not helpful to be told that something would have happened if the money had been granted.
The hon. Member for Isle of Wight rightly said that the NHS has always had such ambitions and aspirations. For 50 years, however, no such service was implemented, but it is now being put into operation coherently. Good advice and good systems are available, and there are good examples of integration with the mental health service, as the hon. Member for Runnymede and Weybridge said. We want a health service with national coverage that is responsive and delivers 24-hour service, regardless of where those using it live. Salami-slicing remarks suggesting that such a service was already available are therefore untrue.
There is a misunderstanding about whether the system is diagnostic. The system does not tell people the nature of their disease. If offers a risk assessment of their symptoms and suggests appropriate follow-up and advice. That brings me to a certain New Statesman writer, to whom I shall respond by saying that anyone who rings NHS Direct is at liberty to take or refuse the advice. If people choose not to see their GP, even though advised to do so, that is their choice. Criticising the service is not appropriate if one has not followed its advice.
All the evidence is that those who ring understand the service. When I read the Sheffield evaluation stating that 98 per cent. of NHS Direct callers understand the advice that they were given, my initial reaction was to wonder why that was so remarkable. However, I reconsidered the matter, and my thoughts are relevant to the question about NHS Direct being used as a second opinion. Often, patients seeing their GP do not have enough time or do not take in information fully—a position with which we are all familiar. NHS Direct is sometimes used to get reassurance.
There is nothing wrong or inappropriate in that, but it is not true to say that such seeking of second opinion does not already take place. I talked to an A and E doctor last weekend who, when he worked as a GP and did Sunday duty, would sometimes run into patients who had visited him during the week and had come to the A and E department for a second opinion.
I come now to the NHS Direct cost analysis. We have made extensive use of the experience of commercial call centres. One could make an easy analogy and ask,

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"What does it cost to call the telephone banks, and how does that compare with NHS Direct?" That would not be an entirely accurate comparison, however, because the strength of NHS Direct is that it brings together commercial call centre experience with qualified nurses who take the patients seriously. The nurses have time to speak to the patients at length—the call can last five minutes or half an hour. A mother can ring and say that her child is unwell, and the nurse can ring back half an hour later and ask whether the child is all right. The mother may say that the child still has a high temperature or that he is all right and watching television. That kind of responsiveness, and that ability to give time to the patient, is often overlooked in the delivery of medical services.
That brings me on to the point made by the hon. Member for Bosworth (Mr. Tredinnick). Medicine means more than just traditional medicine in the accepted sense—an important part of a decent health care system is the element of care. Patients like NHS Direct because the nurses are responsive and because the programme uses nurses' ability to communicate, which is one of their strongest points and should not be underestimated.
The hon. Member for Bosworth was worried that we were overlooking complementary medicine, but a nurse would never neglect to advise a patient to contact his or her GP or pharmacist, for example, or to see the A and E department. NHS Direct links in with the health information service, which provides the best advice on what complementary medicine is available in which area. Although the nurses cannot perhaps recommend a specific course of action, they can recommend a next step. Nurses on NHS Direct can also provide advice to someone who rings about a bereavement, because they have links with Cruise and the Samaritans.
That brings me to the point that was made about repeat callers. I do not have the statistics in my head, but the percentage of the population that takes up GPs' or acute health service time represents a narrow band. Surprisingly, it almost contradicts the principle that 20 per cent. of the population uses 80 per cent. of the resources. Some repeat calling is appropriate, but there are people who call only for the support and may have mental health or other problems. Again, NHS Direct channels such calls either to the statutory or to the alternative service; and again that is right and proper.
Mr. Hammond: What the Minister says makes sense in a world that is not resource constrained. Given that there are those constraints in the NHS, does the Minister agree with the point that I have tried to make before, that the Government's own criteria of clinical and cost-effectiveness must be applied? The onus is on her to demonstrate that those criteria have been applied in rolling out NHS Direct.
Ms Stuart: Of course, there has been a cost evaluation, and the cost of the calls provided and of billing, the ratio of staffing and the levels of efficiency have been compared with those for other services. However, it is an additional service that will continue to be assessed.
I will not give way any more because a couple of important points must be addressed. My hon. Friend the Member for Colne Valley (Kali Mountford) gave
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her moving account of her own and her constituents' life-changing experiences. We should remember that the protocol used by nurses is not like the out-of-hours service, whereby GPs use their long years of experience to give advice. NHS Direct nurses follow a protocol, which is repeatable and clinically safe, to give advice.
My hon. Friend also mentioned meningitis. As anyone who works in the health service knows, meningitis is one of the most fiendishly difficult diseases to recognise in its early stages. It also progresses incredibly quickly. A GP may see a child at 3 pm with just a high temperature. Half an hour later, that child may show the classic symptoms of meningitis. That is accepted. I was taken through how a nurse would explain to a mother how to carry out the glass test for suspected meningitis. A mother would not go to a GP at 5, 6, 7 or 8 pm, but she would be happy to make regular calls to NHS Direct. Therefore, it does provide something new, which the technology simply did not provide previously.
My hon. Friend gave valuable insights into the psychology of the issue. That is for the long term. She drew on her experience as a social scientist. This is hard science, but it is also social science. We operate clinically based, evidence-based medicine. However, we are also irrational human beings; we have fears and uncertainties. NHS Direct is partly aimed at empowering patients to have the confidence to take the next step. We need to focus more on giving people some responsibility for their own health. That means that extra advice is sometimes needed. People need the confidence sometimes to consult their pharmacist, to administer a self-remedy, or to know that it is safe to say, "I'll just stay in bed and see how I feel tomorrow." At the same time, people need the means of checking whether something sounds more urgent. It will no doubt take time to achieve all that, and integration with other services.
The extension of NHS Direct was also mentioned. In Essex, a pilot scheme has begun, whereby NHS Direct and social services work together. The provision of health services must be much more seamless. Health services and social services have to work much more closely together, so NHS Direct is bringing that about as well.
The debate has been extremely valuable, and I hope that hon. Members have listened. I urge anyone who has not used NHS Direct to do so, to gain an understanding of what it is all about. The health service has reached a stage at which the status quo is not acceptable. We need to change. Life styles are changing.
Mr. Tredinnick: One of the things which I wanted to tease out concerns the complementary services. We have nurses in Leicestershire who are trained in aromatherapy, because there is a big centre for that in my constituency, and who can offer sound advice on how to relieve stress and other ailments. What happens when they pick up the telephone? Do they have to go through the health information service, or refer people to A and E, pharmacists, or GPs, or can they make suggestions?
Ms Stuart: They would not make suggestions. People would either ask, for example, where they could access aromatherapy, or say that they needed to see a doctor and ask what was the next step. NHS Direct is a way of modernising the service. It is a telephone line, supported by NHS Online and the printed NHS guides that form a book, produced as a result of the 20 most common
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symptoms presented, which gives advice. NHS Direct is one vital building block in modernising the NHS, empowering the patient and delivering a fast, reliable and modern service.
Question put and agreed to.
Adjourned accordingly at seventeen minutes to Six o'clock.