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NHS Appointments

Volume 487: debated on Wednesday 4 February 2009

I am pleased to have the opportunity to bring this important issue to the House and look forward to the Minister’s response. It has affected the medical histories of many of my constituents.

The system has been a problem for me and my constituents ever since it started. In turn, I have been in touch with the local foundation trust, the primary care trust and NHS Direct, and I have asked parliamentary questions—in fact, because my December question was too long, Mr. Speaker kindly offered an Adjournment debate. I shall try to do the issue some justice.

After I was told last week of the time of the debate, entirely serendipitously, the British Medical Association produced a report entitled, “Choose and Book: learning lessons from local experience”. I am not so arrogant as to think that my probing put the BMA up to it, but the report is interesting, and I hope the Minister addresses it when he responds to the debate. It talks about learning lessons from local experience, and I want the Minister to learn from my constituents’ local experience.

I will start with a disclaimer: MPs hear of the worst cases. Nobody writes to me and says, “I had a brilliant experience of choose and book” or indeed of public transport or any other public service. The scheme provides a comparatively easy route to medical care and treatment, but there is a significant minority for whom it is a major problem. I want to bring the cases of a number of my constituents to the Minister’s attention, and to draw one or two national lessons from them.

My worst case illustrates many of the features of choose and book that drive patients to distraction. Mr. I was first sent to choose and book on 19 July 2007, and first contacted me on 9 August 2007. Nine and a half months later, after much correspondence in many directions, he wrote to me again on 12 May 2008 and said:

“Me, I’m giving up but if you wish to carry on the saga be my guest!!!”

I suppose that the debate is me being Mr. I’s guest. I spoke to him yesterday, and I can report that he received his treatment last month. For him, the saga that started with a doctor’s diagnosis in July 2007 has now been completed with treatment in January 2009.

As I said, Mr. I is my worst case. What happened? On 19 July 2007, his general practitioner referred him to choose and book, gave him the telephone number, the address of the website and the password, and told him what to do. When he phoned the number, he was told that he should phone again because of a high volume of calls. He repeated that experience many times. He was referred to the website, but it did not respond to him. He did what many patients do, much to the irritation of their doctors: in frustration, he went back to his GP, because he thought that he might have got the number or password wrong. Having established that they were correct—he had a letter of confirmation from the system in due course—he tried again. Once again he was told that he should try the website because of a high volume of calls.

He eventually got on to the website, but it told him that no bookings were available for the period he had chosen, and that he should try again and seek another date. He did not want to make it hard for choose and book, so he did not try to make an appointment for the week after; instead, he tried to make an appointment for three months after his first choice. Anyone who knows choose and book knows what that means. The system would not give him an appointment because the date he selected was beyond the 18-week period in which it will accept an appointment.

Mr. I is articulate and persistent. After that trouble, he went to his GP for a third time. His GP said, “I’ll tell you what. Why don’t you phone up NHS HealthSpace?” That sounded like something to do, so Mr. I did it. What did it tell him? It told him that no appointments were available.

On 1 August, he got the first of his letters from the Appointments Line criticising him for failing to book a choose and book appointment—that was when he first wrote to me. He told me that he wanted to tell Appointments Line that he had been trying to book, but he could not do so because the standard letter from Appointments Line has no address on it—he showed me a copy of the letter to prove it. The only way in which a patient can contact the Appointments Line was by phoning the number that tells them that they cannot get through. It is absolutely ridiculous.

Patients might not be able to write to the Appointments Line, but MPs can. I now know that it is run by NHS Direct. The chief executive of NHS Direct, Mr. Matt Tee—that is not an abbreviation—sent me a letter. He invited me to comment on the application of NHS Direct for trust status. I told him in no uncertain terms that until he sorted out Appointments Line, it would not be sensible to give it such status. The letter he wrote back to me is interesting in many ways, but I like this bit:

“The Appointments Line takes over 280,000 calls a month and at present receives 0.56 complaints for every 10,000 calls.”

I thought that that was an interesting way of expressing things, but I marvel at how half a complaint managed to sneak through. How would the Appointments Line know that people wanted to complain if they cannot write or phone? There is no address to write to. People have to know that it is run by NHS Direct before they can get anywhere.

I also marvelled at another part of the letter that delightfully passes the buck for the problem:

“I agree that services should be user friendly and less bureaucratic and will do all I can both to ensure that this is the case for the services I control (such as The Appointments Line) and to encourage others to do so with the services that I do not control (such as the national Choose and Book system).”

I thought that that was a pretty neat sidestep from my constituent’s concerns. Who runs the national choose and book system? Mr. Tee said:

“We are working closely with colleagues both in the Department of Health and (specifically) in Connecting for Health, to promote improvements to the systems and software associated with Choose and Book”.

So it is not his problem; in his view, it seems to be the problem of the Department of Health, NHS Connecting for Health and the software manufacturers. Evidently, choose and book has nothing to do with the Appointments Line and everything to do with everybody else.

I would not want the Minister to think that, because I started with a case from 2007, he can respond by saying, “Yes, there were some initial teething difficulties, but everything is fine nowadays.” It is no better now. Calls still go unanswered, appointments are still unavailable and infuriating reminder letters are still sent. Unanswered calls are a problem for my constituents.

Last November, my hon. Friend the Member for North Norfolk (Norman Lamb) asked a parliamentary question and received a briefing in the Minister’s reply saying that last October, 338,000 callers tried to access the Appointments Line. According to the figures in the reply, 27,000 were not answered. One must read the small print carefully to find out that 17,000 callers found the line engaged and 10,000 found it playing Vivaldi. One in 16 calls made to the Appointments Line is unsuccessful. That is from the Minister’s own figures for last October, which show 27,000 calls not answered last October. That works out at 324,000 missed calls a year. A third of a million calls, according to his own figures, fail to get through to the Appointments Line.

The astonishing thing is that the Appointments Line met all its key performance indicators. I do not know whether any other call centre in the country, commercial or public, would meet all its key performance indicators if it left out a third of a million callers a year. If so, I hope that the Minister will brief us on which one it is. I suggest to him that the key performance indicators for the Appointments Line are not sufficiently rigorous. He is not getting his money’s worth.

The second big problem is that appointments are not available when people do get through. There are two causes for that. Well, there may be more than two causes—the BMA report suggests quite a range of them—but I will focus on just two. The first, and perhaps the one that the Minister could most easily do something about, is the 18-week waiting period, which creates a black hole beyond 18 weeks when appointments are not taken. If appointments cannot be booked more than 18 weeks ahead, when a particular clinic or consultant is fully booked, they are taken off the list of appointments available. They do not even appear. Of course, at the call centre, they cannot say, “Well, that’s because they’re booked up for the first 18 weeks”; what they say is, “They’re not on the system.” They disappear into a black hole.

Does my hon. Friend agree that if a particular hospital or clinic disappears from the list because the waiting time is more than 18 weeks, that restricts choice rather than enhancing it?

My hon. Friend makes a good point. My constituency is adjacent to the local district general hospital, Stepping Hill hospital, which is run by the Stockport NHS Foundation Trust. I would say that more than 90 per cent. of my constituents—probably more than 95 per cent.—would expect that if they were referred from primary care to secondary care, they would be referred to Stepping Hill hospital, as it is an option more or less on their doorstep. It is in Stockport, as the name suggests. A referral to Preston, Bolton or somewhere similar is very much a second choice unless there is a specific reason to see a particular specialist. The expectation is that appointments would be booked at the local district general hospital.

My hon. Friend is articulating the frustration of many constituents who come up against the system. Does he agree that one of the fundamental problems, particularly in certain sections of society, is that people do not understand why the Government are so keen to force that system upon us? An elderly couple recently came to visit me, bringing with them all the literature sent out as a matter of course. It included an expensively produced colour booklet, letters and an information pack. There was a lot of detail for them to go through. They said, “Mark, all we did was ask for a referral from the GP to go to Stepping Hill. Why are we being offered an appointment in Bolton?”—or Wigan, or wherever it was. Those places are part of the Greater Manchester conurbation, but they are too far away for many of our constituents to travel to.

I agree absolutely with my hon. Friend. The 18-week event horizon—that is what they call it when a black hole occurs and radiation cannot get in or out—means, perhaps not surprisingly, that the local district general hospitals’ clinicians and consultants tend, on the whole, to be fully booked first. Then they disappear. It does not make a lot of sense for people to be referred to distant places.

The Minister needs to have a look at the 5 per cent. tolerance rule. Everybody in the health service has to meet the 18-week rule, but one of the things that I learned from reading the BMA report is that the Government allow a 5 per cent. tolerance rule, as I understand it, in case somebody does not turn up. There needs to be flexibility for choose and book to book appointments well beyond the 18-week event horizon at the patient’s request. That does not seem difficult.

The hon. Gentleman is making an interesting case, drawing upon experiences with constituents that I suspect all of us, as constituency Members of Parliament, have had. Is Tee correct in highlighting the fact that the problems of not being able to book an appointment through the choose and book system after 18 weeks are a good example of the centrally driven target culture distorting clinical priorities?

That is true, of course. It is also interesting to see the decisions taken about which medical procedures should be included in the 18-week limit and which should not. We could have another interesting debate about that. As somebody who recently acquired a pair of hearing aids, I happen to know that hearing is not included in the 18 weeks.

However, I do not want to go there; I return to the point made by my hon. Friend the Member for Cheadle (Mark Hunter). People who go to their GP and are referred for a medical procedure will not necessarily be rocket scientists. What they get with choose and book is a complicated way of getting in touch that involves passwords and so on. I have a letter, which I will not quote, saying, “I’m going to go and have my hip replaced. They’ve given me a password. Surely nobody else wants my hip?” There is a lack of comprehension about what the system is designed to do and why it is being done in that way.

Apart from the 18-week event horizon, there is a second factor that leads to a shortage of appointments on the system: some appointments are never put on the central database in the first place. At least one of the reasons for that is the failure of choose and book to engage the medical profession fully and the profession’s lack of confidence in it.

I would like to take the example of Stockport. When my hon. Friend the Member for Romsey (Sandra Gidley) asked a parliamentary question in November, she established that only 60 per cent. of bookings for secondary care in Stockport are made through the choose and book system; 40 per cent. are made on pre-existing manual systems of one sort or another. Because hospitals, clinics, GPs and consultants are so fed up with choose and book, they are using the old “steam” system in many parts of the country. The same parliamentary question established that take-up ranged widely in different primary care trust areas; 60 per cent. was somewhere near the norm. As a result, appointment times never get on to the system and are held back for the manual appointments to be made. The BMA has some interesting comments on that situation. Perhaps the Minister would like to come back on that point when he responds.

Therefore, not only can someone not book after the 18-week period, but many appointment times are never there to be booked in the first place. Why is that? Why do GPs not think that choose and book is the best thing since sliced bread? One of the reasons is illustrated by the case of Mr. I, who had his consultation with the GP but had to go back twice to try to establish how he could make his appointment through the system. I do not know how many people in Westminster Hall have had a referral through the choose and book system. My GP, who had no particular knowledge of my interest in the system or concern about it, did not even ask me to book through it. What he said to me was, “They’ll be sending you a letter, but in the meantime I’ll get you booked in anyway”. That was an example of a GP bypassing choose and book, because he did not want me to come back moaning that I could never get through on the phone to make the booking.

Of course, there are also the infuriating reminder letters; it is not necessarily the case that just one is sent. I actually received an apology from my PCT. If I quote from the letter that I received in September 2008 from the chief executive of my PCT, everyone will get the drift, because it is a contemporary example of the problem:

“As you will be aware, the Choose & Book is an automated system and part of the process is for reminder letters to be sent out to any patient where a referral had been made, but the appointment not yet booked. In the case…I understand that she”—

that is, my constituent—

“received at least three letters, and that on each occasion she then telephoned in an attempt to book the appointment, but was then told that there were no available slots to book her into. I can appreciate the frustration this would cause and I would ask that you pass on my most sincere apologies, on behalf of the Trust.”

The question that I suppose the Minister might be asking himself is, “Well, has he just got a couple of nutters writing in green ink, or is this something which is widespread?” I can say that it is widespread. There is the case of Mrs. M, who said:

“I was somewhat dismayed when my recent appointment came through under a different consultant and involved a very basic procedure. I realised that I was being treated as an entirely new patient, despite the very clear letter of referral that my G.P. had sent. I queried matters with the ‘choose and book’ administration and was told that my usual consultant would not be able to see me within the target time, so I would have to start all over again with a new consultant, even if it were inappropriate to do so.”

There is also the case of Mrs. H, who required a consultation with a neurosurgeon but was told that no appointment could be made within the next three months as all the appointments were taken. However, as no appointments could be made beyond the next three months, no progress could be made with the appointment at that stage.

I have a letter from Mr. B, who said:

“If patients have to chase their follow-up appointments, it suggests that either too much money has been wasted on inadequate computers or someone isn’t doing their job properly - or both? There seems to be an over-emphasis on computer technology at the expense of employing personnel needed to deliver a front line service.”

I thought of offering Mr. B a job in this debate.

Then there is the case of Mr. P, who has spinal problems that require regular injections. He needs to see a neurosurgeon too. A specific consultant was recommended but the new choose and book system would not allow direct referral.

Sometimes we get lucky and I have had a follow-up letter from Mr. P, which says:

“I would like to thank you for the enquiries you made on my behalf, it’s amazing what an MP’s letter can do!!”

Given that there are about 338,000 failed inquiries a year, I do not think that MPs can plug all the gaps in this particular system.

I want to round off with a quote from a patient who is a constituent of my hon. Friend the Member for Somerton and Frome (Mr. Heath), who contacted me when she saw that I was having this debate. She is Miss G and she wrote to me to say:

“My experience is that this is a totally pointless exercise. I recently had to book two hospital appointments in Somerset. For both of them, I received letters with a list of the hospitals where I could book my consultation and promised I could do this through the Choose and Book line but when I phoned, in both instances I was given the telephone numbers for phoning the hospitals direct to make a booking. Why did they not put those telephone numbers in the letter, saving me time and the NHS money in employing someone to give out the phone numbers?”

I have described choose and book as the NHS’s version of air traffic control. If all the landing slots are full, then the aircraft are just kept circling and kept waiting until there is clearance. That is exactly what is happening with patients, time after time after time.

Everybody knows that there is a serious problem with choose and book, but nobody wants to take responsibility. The Appointments Line says that it is not responsible, the Minister said very clearly in answer to my question in December that he was not responsible, and the PCT says that it is not responsible either.

I want the Minister to answer a few straight questions. What will he do to tackle the 330,000 or so missed calls each year to the Appointments Line? What will he do about the 18-week waiting period “black hole”? What will he do about the fact that only 60 per cent. of appointments in Stockport are made through choose and book? Whether he goes forwards or backwards, can he at least ensure that all the appointments are on the computer screen? What will he do about the duplication and expense involved? There is the expense of appointments line itself; the duplication of a manual system and of a choose and book system; the wastage of multiple automated letters, complete with postage, even when the fault is on the side of the Appointments Line itself; and of course the retention of parallel paperwork systems, when all the information is supposed to be on the computer.

There is a lot of frustration and annoyance among patients. They face a system that is designed for robots, not people. It denies local choice and blocks opportunities. I do not want my constituents’ concerns to be brushed over with a load of sloppy departmental whitewash. I want some clear, hard answers.

We have now got well past the “teething problems” excuse. We have got past the “waiting for it to get better” stage. We are right up to the “putting it right” stage, and I want to hear from the Minister today exactly how he proposes to put the choose and book system right.

It is a pleasure to contribute to the debate under your chairmanship, Mrs. Dean. I thank my constituency neighbour, my hon. Friend the Member for Hazel Grove (Andrew Stunell), for securing a debate on what all hon. Members will agree is a very important subject, certainly if our postbags are anything to judge by.

This is not the first time that I have spoken in such a debate or the first time that I have raised this issue. It is a matter of record that in Health questions last November I asked the Minister if he might agree that there is a need to review the choose and book system in the light of the many complaints that we have been receiving and the significant difficulties that it has caused, the likes of which have been so well chronicled today by my hon. Friend. The Minister replied that choose and book is

“one of the great success stories of the national programme for IT.”—[Official Report, 4 November 2008; Vol. 482, c. 102.]

I hope that my colleagues, whatever party they are in, will agree that the Minister’s response to that question showed a failure to understand the real frustration that so many of our constituents feel.

My constituents have contacted me to complain about the system and about what they perceive to be complacency in dealing with the problems that it is helping to create rather than to resolve. If the Minister would term the system a great success—that term is lifted directly from his answer to my question—I sincerely hope, for all our sakes, that we never find out what he would consider to be a failure. It is evident that the choose and book system is an unnecessary, expensive and inefficient IT and administrative system that serves only to divert money away from much-needed improvements to local health services. When one asks local people what they would prefer that money to be spent on—I am sure that many hon. Members on both sides of the House have done that—they say that they want their local surgery or hospital to be improved. They do not want money to be spent on another ridiculous and badly performing Government IT system.

My constituents want to be offered appointments at their local hospital. My hon. Friend and I share a local hospital at Stepping Hill in Stockport. People want to be offered appointments in a local hospital that is within easy travelling distance from their homes, with the best consultant to deal with their problem. They want to get their appointments quickly and to be treated well when they attend. The choose and book system is making that harder, because people are unable to get through to make appointments, as we have heard in so much detail from my hon. Friend. In some cases, when people do get through, they are told that no appointments are available at their local hospital, sometimes because those places are being booked up by people from outside the area. That is a form of madness.

With the best will in the world, and given the regard that I hold the Minister in, I think that he is being put in the position of having to defend the indefensible. I hope that he is able to respond positively to this debate. All we are asking for at this stage is a review of the system’s operational efficiency. Surely, anyone would accept, on the weight of the evidence, that there are good reasons for asking for such a review, and surely the Minister does not want to defend good money going after bad into a system that is patently failing patients.

It is not only politicians who criticise the system. The British Medical Association and local doctors do not think that it works. Indeed, many have gone on record as saying that it is getting in the way of choice. GPs want to refer patients to the specialists whom they feel are best suited to deal with their patients’ specific problems, but in many areas they cannot do that because the system allows them to make appointments only with departments, not with particular specialists.

This is not a party political issue. All of us in this place, regardless of party affiliation, want to have the best possible health service for our constituents, whom we have the privilege of representing in Parliament. Will the Minister rethink the system, which is failing the very people whom it was set up to serve? It is undoubtedly an expensive system, and the bureaucracy attached to it, with pamphlets and reminder letters being sent out, is relentless and expensive. The system confuses many people and has already proved inefficient and ineffective. Perhaps it is time for a review, so that we can consider using the money that we spend on choose and book, which has patently failed to operate properly, on improving local services instead. I am sure that we would all agree to that. I hope that the Minister will take that message firmly on board today.

Let me start by congratulating my hon. Friend the Member for Hazel Grove (Andrew Stunell) on securing this important debate. I congratulate also my hon. Friend the Member for Cheadle (Mark Hunter) on his contribution, which was also important to the debate.

Choose and book is part of the national programme for IT. It seems to me, and to most people who have looked into this issue, that the Government are in complete denial regarding the scale of the problems with that programme. The Minister is a reasonable man, and I suggest that he should take this opportunity to accept the problems that the programme has experienced. He is not responsible for instituting the system, as he has inherited this nightmare, and everyone would welcome his acceptance of the massive challenges that the national programme faces.

My hon. Friend the Member for Hazel Grove has described the experiences of his individual constituents. I am sure that the Minister will agree that the situation in the first case that my hon. Friend described, that of Mr. I, is intolerable. We cannot accept a situation in which someone who experiences anxiety about hospital referrals has to go through such an experience. It should be incumbent on us all to realise that that is not acceptable and to find ways of changing things for the better.

The national programme was centrally flawed from the start. I went to a fascinating seminar at which someone who has been heavily involved in the national programme spoke candidly about its whole design. He said that there had been no systems review at the start, which means that there had been no process by which the different people who were building and buying the system reached agreement with those who would be using it about what they were trying to achieve. He explained that although such a review is of fundamental importance to any IT project, it had been missed from that project because of the political imperative to drive it forward. He also said that we do not have sufficient skills in the UK to deliver the programme as it was originally designed.

Many other people have made the absolutely valid point that it is stupid and wrong centrally to impose a system on a highly diverse health system without getting buy-in from the clinicians who are to use it. A small number of providers are involved: at first there were four, and now there are only two because the other two have deserted the project. Smaller IT providers, which have historically provided all the innovation, have been excluded from the project, and we now have the highly vulnerable situation in which the whole system depends on just two providers because the other two have left. We are told in a report in The Times this week that one of those that has left—Fujitsu—is pursuing a claim for some £600 million against the Government. I would be grateful if the Minister responded to that report and confirmed whether it is true.

The national programme for IT is years behind schedule. We were told by the National Audit Office that completion was expected around 2014, but that now appears to be in doubt; it looks as if the time scale will be even longer. We also know that the whole programme is billions of pounds over budget. In a response to a parliamentary question that I recently tabled, it has been revealed that the number of severe faults in NHS computer systems has almost doubled in the past three years. That potentially puts patients and their care at risk. We have to take that matter very seriously.

There are two particular problem areas in the national programme for IT. The first is the national care records system, which is the national database of all of our patient records. In this day and age, I do not know who on earth would trust the Government to look after sensitive patient records—I certainly do not. In its report this week, the Public Accounts Committee has highlighted its serious concerns about the scale of the crisis that the national care records system now faces.

This debate is on the other matter that has caused real concern: choose and book. I want to start the analysis of where we are going wrong with choose and book by establishing some principles. First, I fully accept that the concept of electronic booking and someone being able to sit with their GP or someone else in the practice and make a booking—for example, for the Stepping Hill hospital in Stockport—is an attractive proposition. For the patient to know that an appointment has been booked when they leave the GP practice is a good concept and we should not lose sight of that.

The second principle, which I absolutely support, is the concept of enabling patients to choose the clinician whom they want to see. Critically, that should be done on the advice of a person’s GP, because they will often be guiding us in the decisions that we make. As my hon. Friend pointed out, in the vast majority of cases the individual patient will want to choose their local hospital. However, there might sometimes be a good reason why someone does not want to choose their local hospital—for example, it could be that an elderly person wants to stay with a son or daughter somewhere else in the country, or that someone’s local hospital has a poor record on hospital-acquired infections. There could be all sorts of reasons why an individual might choose to go elsewhere, and people should have the right to do so.

Does my hon. Friend agree that the choice that people want to exercise is to balance convenience against the timing of the appointment? If it is a question of going to Stepping Hill in two months’ time or somewhere further away in one month’s time, they should have that choice. There should not be a black hole preventing them from exercising that choice.

I agree with that point, which I was going to come on to. Critically, when we talk about choice, we must be clear about what we mean and have a clear idea about what is a good thing for patients to have a say on. It is not just a matter of patients being able to choose hospital buildings; it is about patients having a central involvement with the clinician to whom they are referred. As my hon. Friend pointed out, the system is not good at enabling someone to choose a particular specialist or consultant. I understand that the system is theoretically capable of doing that, but in most cases the way in which it is used does not provide that choice—people are simply presented with a list of hospital buildings. People should also, of course, have a central say in the treatment options that might be available.

As my hon. Friend pointed out, there are a whole load of unacceptable practical problems with the system that individual patients, their GPs and, indeed, the people at the other end of the link—the clinicians in the hospital—are experiencing. It is worth pointing out that this problem is not peculiar to Stockport and Cheadle; I have had to take up concerns about it in Norfolk. When I raised the issue with the local hospital and primary care trust, their response was, “Yes, we agree. We’re having problems with the choose and book regional office down in Milton Keynes.” They accepted that there were problems with the operation of the system in the east of England.

We have had complaints that the system is slow. GPs get totally frustrated at the fact that it takes a long time to open up attachments and so on, so the temptation is not to use it. The system is unreliable and we are told that it crashes when people try to open attachments. The telephone system is a complete nightmare and a third of a million calls were unanswered in a year, which is completely unacceptable. When one hears the experience of Mr I, one is left with the sense that, far from personalising care—a concept that we all ought to be able to sign up to—the system is making it far more impersonal. People try their best to book an appointment but keep getting rebuffed. They then receive a letter complaining that they have not booked an appointment, and when they try to respond, they find there is no address to which to respond. This is driving people crazy, and it ought not to be necessary for Members of Parliament to intervene. Whenever people go to their MP to sort out problems, one always has the sense that there are a whole load of other people out there who may not have the wherewithal to go to their MP. Such people are left unable to get their hospital appointment booked up. That is completely unacceptable.

Another problem with choose and book relates to the central issue of choice. The great paradox of this system is that it actually constrains choice. The Government’s great claim is that the system is the central feature of offering choice to patients, but if someone happens to want to see a consultant because their GP has recommended that consultant to them, and the waiting list for that consultant is longer than 18 weeks, that choice is removed—even if it is for a speciality where a wait of 18 weeks is not damaging to someone’s health. For example, someone might want an appointment for orthopaedics and be prepared to wait a little longer, albeit in pain, because they want to go to a particular consultant. However, as my hon. Friend has pointed out, if that wait is longer than 18 weeks the choice disappears. This is centrally constrained choice. The truth is that the system has more to do with managing the 18-week target than with offering real, genuine choice for patients. If the system was about the latter, I should have the right to wait longer than 18 weeks if I wish to see a particular consultant.

I completely support the principle of informed choice guided and supported by someone’s GP, but because so many GPs are frustrated with dealing with a slow system, they refer bookings to the practice administrator. The recent British Medical Association report makes the point that the system is working reasonably well when an administrator is doing the booking. However, that administrator will not always make the right judgment. The clinicians at the hospital end of the divide often find that the wrong booking has been made—for example, for a general clinic rather than a specialist clinic. The patient then has to be referred somewhere else. I have had reports of patients being confronted by two appointments that clash. They are then left to make a judgment themselves about which appointment to take and which to cancel, and they may well make the wrong decision.

Professor Wendy Currie, head of information systems and management at the Warwick business school—it is part of Warwick university—has studied the national programme, including choose and book. She says that the software for choose and book started life as a billing system in the United States. It was then developed into an electronic booking system—a simple system for booking appointments from the GP’s surgery. It was nothing to do with choice or with presenting the GP and the patient with a list of four different hospitals; it was just a system for booking appointments—very sensible, as I said at the start of my remarks. The previous Secretary of State then morphed the UK system, Professor Currie says, into the central plank of the Government’s “choice” strategy. She also says that we need to get the function and technical specification right at the start. However, the software was designed for one purpose but it is being used for a different one, and all the evidence suggests that it is not sufficiently robust to cope with the demands that it faces; and this is when, nationally, only 50 per cent. of appointments are booked using the system.

Does my hon. Friend acknowledge that when the chief executive of NHS Direct reports software problems, and when the software is on version 4.6 after only three years, there is clear evidence that the IT system is not robust enough for the job that it has been asked to do?

Absolutely. There is clear and mounting evidence of the software’s inadequacy to live up to expectations. Returning to the point that I made to the Minister earlier, I hope he will concede that, for those of us who believe both in empowering patients to make decisions about which clinician to be referred to, which hospital to go to, the treatment options and so on, and in booking appointments electronically, the system does not provide patients with real choice. It causes immense frustration for clinicians who are already under enormous time pressure.

Professor Currie argues for de-scoping the contract and returning it to what it was originally intended to be: a straightforward electronic booking system. There is enormous merit in that. We may eventually get there, but it would be an enormous help if the Government conceded the scale of the problems—the monumental mess that we face. We need, first, Government recognition of the problems for clinicians and, critically, for patients, many of whom are vulnerable; secondly, as my hon. Friend the Member for Cheadle said, we need a thorough review, which the Government must act on; thirdly, we need to learn the lesson that grandiose, centrally imposed systems that are ill-thought through and do not get buy-in from clinicians are doomed to failure.

It is a pleasure to serve under your guidance, Mrs. Dean—for the first time, I think. I congratulate the hon. Member for Hazel Grove (Andrew Stunell) on securing the debate and on the excellent way in which he highlighted, in considerable detail, the concerns of many of his constituents. I suspect that he highlighted only the worst cases, and that if he had had more time he could have brought many more cases to our attention. I have had similar issues in my constituency in Lincolnshire, so they are clearly not limited to a particular part of the country. Indeed, I know that the hon. Member for North Norfolk (Norman Lamb) has had similar problems in Norfolk, across the Wash from my constituency.

The hon. Member for Hazel Grove was right to highlight the significant problems. He emphasised the telephone aspect of choose and book, but from GPs whom I have met in my constituency and in my Front-Bench role, travelling around the country, I can assure him that the problem is pertinent to GPs who try to book appointments online, too. However, he should be aware—I am sure the Minister will mention this in his closing remarks—that there is a vast range of opinion about choose and book, and some GPs find it an asset to patient care, so there is no uniform animosity towards the system. Having said that, I realise that there are significant problems.

The hon. Gentleman highlighted the 18-week problem, which I shall return to later, and the peculiarity of the complaints procedure, which seems completely unacceptable. It is not surprising that the body responsible for collating the number of complaints has very few to report, because there is no mechanism for people to express their disappointment and to complain about the procedure. He also gave some staggering and astonishing figures on unanswered calls, and the Minister must address that point urgently.

I got the feeling that the hon. Gentleman and the hon. Member for Cheadle (Mark Hunter) were suggesting trying to remove patient choice, but in an intervention on the hon. Member for North Norfolk, the hon. Member for Hazel Grove seemed to contradict what he had said earlier. Indeed, I noted that the hon. Member for North Norfolk, who is the Liberal Democrat Front-Bench spokesman, did not reiterate the idea of potentially removing patient choice. It is a key part of any patient-centric national health service.

I thank the hon. Gentleman for giving way, because that is an important point. He is right to appreciate that we were not seeking to remove choice in any way. I referred to it by saying that people should not have choice forced upon them, as the Government seek to. If one’s area is well served by the local hospital, as ours is, most people will want a referral to that hospital, not to one on the other side of the conurbation.

I am grateful for the hon. Gentleman’s clarification of his earlier point. Ultimately, the decision should be the patient’s to make, with advice from the general practitioner, but under the current system that is not the case.

May I reinforce the point that my hon. Friend the Member for Cheadle (Mark Hunter) made about the choice being the patient’s? If the patient wants to go to the local hospital and its appointment system is booked for the next 18 weeks, he or she is not offered that choice by the system. That is the flaw when it comes to choice. The fundamental choice for most patients is to be able to go somewhere near, and if choose and book cuts out that choice it is a failure.

I agree. The 18-week target covers roughly only one third of activity in the acute sector of the health service anyway, but from the evidence that the hon. Gentleman and his hon. Friends have put before the House today, and from other evidence throughout the country, there is absolutely no doubt that the 18-week target not only constrains and limits choice but distorts clinical priorities. That must be fundamentally wrong.

The hon. Member for Cheadle made an interesting point by highlighting the Minister’s response to his question at Health questions in November. However, I suspect that the Minister was right: compared with what else is going on in the NHS IT system, choose and book is a relatively successful scheme, and at least it works in part. In the context of the complete shambles and mess that is the over-budget, behind-schedule totality of the NHS system, choose and book is probably a small ray of hope. However, the hon. Member for Cheadle was also right to highlight patients’ inability to choose a consultant. It is one of the main concerns in my constituency in Lincolnshire, particularly for elderly people and people who have historically been referred to a specific consultant—where a consultant-GP relationship has existed. The operation of the choose and book system does not seem to be able to cope with that.

The contribution from the hon. Member for North Norfolk was, as always, considered and calm, and he is absolutely right that the Minister before us is not responsible for initiating this mess; he has inherited big and significant problems. Accepting and acknowledging that a significant problem must be addressed would be a start, however. It would enable the Minister to put in place a review, which we, as the Conservative party, have done, to consider the very issues that have been highlighted today—not just choose and book, but the entire remit of the NHS IT structure. Although I do not wish to make any statements about the direction of our review, I must say that we are very uncomfortable, as is the hon. Member for North Norfolk, about centrally imposing an IT system without the consultation or agreement of those who have to implement it. There must be a different answer, and there have been fundamental flaws in the system right from the start.

Having said all that, we recognise that technology is a vital part of the NHS, and in some parts there has been praise for choose and book. It has enabled doctors to provide patients with an appointment on the spot, when the patient is in the surgery, and in some cases it has allowed for greater control over appointments and enabled clinicians to track referrals and share confidential information, which is an important part of the system. There is a whole range of issues, some of which have already been raised. Instead of going into the detail of those, I shall raise some additional ones that I think need to be considered.

Choose and book does not offer choice. Of those who used it in August 2008, 66 per cent. reported not being given a choice of appointment date, 66 per cent. reported not being given a choice of appointment time and 86 per cent. reported being given a choice of fewer than four hospitals, which is supposedly the utopian position. Thirty-two per cent. reported not being given any choice of hospital at all. Part of that may be that people are determined to use their local hospital, but they should be given a choice of alternatives, not a forced appointment that may or may not be convenient for them. There is growing evidence to suggest that appointments made through choose and book are increasing the number who do not attend. University hospital, Lewisham has recently done some research and found that 18 per cent. more people did not attend appointments if the appointment was made through choose and book, as opposed to 12 per cent. for traditional GP referrals. That is a growing problem.

Another problem is that the system does not seem to be able to cope adequately with complex referrals. This needs to be looked at to ensure a simple process, not added administrative layers. Other Members referred to technical problems with the system. It crashes, then takes a long time to reboot. By the time the GP can access it, the patient is no longer sitting in front of them so they have no choice but to use the telephone system, in which case they get into the problems that were highlighted by the hon. Member for Hazel Grove.

We spoke earlier about GPs not being able to refer to a specific consultant, which is of great concern and certainly needs to be addressed. It is clear that insufficient appropriate appointments are accessible to the choose and book system. Trusts do not currently put all the available appointments on the system. They hold many back for paper referrals and some for tertiary referrals, and some trusts do not make any appointments available after the 18-week limit that was discussed earlier. There is also inaccurate information. GPs are unable to find the clinic they want to refer a patient to—it might not be on the system, or it is not where the doctor expects it to be. Such problems should reduce over time, but they have been going on for a significant time without getting much better. I am sure the Minister is aware of the dummy appointments problem: in order to meet waiting time targets, trusts tell people that they must accept dummy appointments and then not turn up. That is completely unacceptable.

Another challenge is exactly how the system has helped consultants. The explosion of administration and bureaucracy seems to have had very little positive impact on their working practices. There is absolutely no doubt that patients are being sent to the wrong clinics and consultants. Consultants then have to re-refer patients who should never have been referred to them to specialists in sub-groups. That may be a function of the system or of non-clinical input to the computer system.

The British Medical Association criticised choose and book in a recent report, but it is not the only organisation that has been critical. The Royal College of Surgeons said that choose and book is “detrimental to patient care”. That is a significant statement from such an august body. Not all GPs have signed up to choose and book. I was shown a press release from a newspaper in Norfolk in which the hon. Members for North Norfolk and for Norwich, North (Dr. Gibson) were extremely critical of the impact of choose and book on their constituents in Norfolk. Indeed, some GP practices are not using it at all, as they see it as such a problem in terms of patient care.

The concerns go much wider than choose and book. There are significant problems with NHS IT systems. A Public Accounts Committee report published on 27 January was heavily critical of the Department’s IT programme and referred to unacceptable confidentiality agreements. The Committee was “unconvinced” by the programme’s centralised contracts, and said that they had not provided the taxpayer with value for money. There is a significant way to go to put the situation right.

I reiterate the point made by the hon. Member for North Norfolk about the abandoned Fujitsu contract for the southern area, which poses serious risks. The programme’s new deadline of 2015 is unlikely to be met—the original programme was supposed to be completed by 2010. It would be helpful if the Minister could give us some indication of the compensation— is it £600 million or some other figure?—that Fujitsu wants. If he cannot give specific numbers, it would certainly be a help if he could tell the House the stage that the process has reached.

The Minister will be aware, as other hon. Members may be, of the concern that the Public Accounts Committee raised about the number of suppliers providing IT going down to two—BT and Computer Sciences Corporation—and the impact that that may have on the future of IT contracts.

I shall conclude with some questions for the Minister. If he does not have time to reply to them today, perhaps he could do so in writing subsequently and place a copy of his letter in the Library. It would be interesting to know how much the Department has spent to date on implementing choose and book. When does the Minister expect to reach his March 2007 target of 90 per cent. delivery of referrals through choose and book? I believe that the current figure is just below 50 per cent. Clearly, the Government are significantly off the timeline that they originally envisaged.

Could the Minister tell us what evidence he has that patient outcomes are better from using choose and book, and what analysis his Department is doing to try to prove that such systems enhance patient care and outcomes? What steps is he taking to ensure that patient choice is not constrained by trusts attempting to meet 18-week targets? Could he give his estimate of the number of GPs and GP practices that are not using the system at all? What will he do about that?

Finally, will the Minister publish impact assessments for choose and book, particularly in respect of the elderly, who often find the system difficult to navigate? Some do not have access to the internet, and run into the problems with the telephone system that were so well articulated by the hon. Member for Hazel Grove.

I congratulate the hon. Member for Hazel Grove (Andrew Stunell) on securing this debate.

I believe hon. Members on both sides of the House appreciate that modern health care is a complex service. There are in the NHS more than 170 acute care hospitals and some 150 independent providers. Each one offers a wide and increasingly specialised set of clinical services. On any given day, every one of England’s 36,000 GPs will refer, on average, one patient to a hospital for some form of elective treatment. It is clearly not possible for a GP to know of every consultant in every specialism in every hospital in the country. I believe that there is consensus in Westminster Hall today that the old paper-based system would be completely unable to cope with the complexity and speed of modern health care, or to fulfil the right of the patient to choose, which I believe most of us accept.

The paper-based system was far more cumbersome and much more expensive. For decades, the NHS creaked and groaned under the weight of millions of letters booking, confirming and rearranging appointments. Letters were lost, misdirected or misfiled. If a GP referred a patient to a hospital consultant—one of their choice, not the patient’s—the patient would leave the practice and enter a state of limbo. They would not have a clue when their appointment would be. They would find out just before it was due, when the hospital would send a letter. The appointment, which would be at a time convenient to the hospital, was made without any consideration of the patient’s needs. In summary, the old system assumed that the patient was the passive recipient of care, not an engaged participant.

Just last week, the British social attitudes survey reported that 95 per cent. of people say that they want some degree of choice over which hospital they attend and the kind of treatment that they receive. Of course, from 1 April this year a patient’s choice of elective care will become a legal right through the NHS constitution. Since choose and book was initiated, more than 10 million people have been referred through it. As of November last year, more than half of all out-patient referrals used choose and book and the latest figures that we have, those for January, show that that figure is up, at 57 per cent. In January, more than 600,000 patients used the system, with more than 30,000 referrals made in a single day last week. Usage has doubled over the last year. Last week, 90 per cent. of GP practices used choose and book.

I acknowledge that sometimes the system has been slow and that occasionally there have been problems with system availability, but virtually all the problems that hon. Members have raised today are problems not with the national choose and book system, but with how individual primary care trusts, hospitals and GPs have implemented it or engaged with it.

I have been advised by the PCT in the hon. Gentleman’s constituency that he raised three specific cases with it relating to choose and book between February and December 2007. I think that the case of Mr. I—the hon. Gentleman will correct me if I am wrong—was the second of those cases, which the PCT tells me it heard about from him in November 2007. Clearly, the case as outlined by the hon. Gentleman is unacceptable. It is difficult to know where the fault lies without hearing more details about individual cases, although it seems, from what he says, to lay mainly with the telephone booking service.

I am informed by the PCT that it tried to contact the patient that the hon. Gentleman mentioned to investigate his case, but did not receive any response, and that it further tried to contact the patient but was unsuccessful. However, in the last letter that the patient sent to the PCT, he stated that he did not wish to pursue the case further. Obviously, if there is still a problem relating to Mr. I’s case—or with any of the other individual cases that the hon. Gentleman raises—I should be happy to look into it.

The hon. Gentleman mentioned the case of another patient, whom he did not identify, saying that they were referred to hospital during 2008 but told that it was unable to take referrals because it needed to meet its 18-week target. We picked that matter up last year, when it was raised by another hon. Member whose patients use Stockport hospital and, with the intervention of the chief executive of the strategic health authority, the foundation trust in Stockport was told in no uncertain terms that that was not acceptable behaviour. The hospital responded by reopening its referrals and those referrals remain open now.

I am encouraged to hear that, but we hear time and again of hospitals where the wait would be longer than 18 weeks automatically disappearing off the list of choices. Is the Minister saying that that will no longer be the case and that, even if the wait would be 20 or 25 weeks, the patient will have the right to choose that option?

I will come on to that in a bit more detail in a moment. The basic principle is that patient choice is paramount. However, providers and individual surgeons should not be able to use that excuse not to meet the 18-week target.

As I have already mentioned, some GPs do not use choose and book because they might have heard bad things about it a year ago and they have not tried since. GPs need to take the time to get to grips with that system and really understand how it can benefit their patients, which will mean working with their PCT to address problems that might frustrate them. Similarly, many PCTs have set up their IT systems to make the most of choose and book and others have not and, as hon. Members have acknowledged, there is wide variation in performance among PCTs. Some PCTs do not train their staff, including their GPs, in how to make the best use of the system, some do not agree with their local providers how services should be displayed and some do not use the clear provisions in their contracts with providers to enable referrals to flow freely through choose and book. We are pressing PCTs to work closely with their GPs, and providers to resolve these issues.

Stockport PCT is performing above average. Although the hon. Member for Hazel Grove has come to me with a number of individual cases, the latest performance of his PCT is at about 64 per cent. However, the one in Staffordshire, which the hon. Member for Cheadle (Mark Hunter) mentioned, which straddles areas is not performing quite as well. Of course, Norfolk is one of the poorest performers in the country.

I appreciate the Minister giving way. I did acknowledge that Stockport was about average, with the 60 per cent. figure being mentioned in the recent figures that he published in a parliamentary answer. I notice that Devon is at 73 per cent., Norfolk at 33 per cent. and Lincolnshire, for what it’s worth, at 42 per cent. There is a wide variety of figures, as he says, but there is still the need to get to grips with a system that denies patients the choice of appointments that they need.

For the Minister’s benefit, can I just confirm that Cheadle comes under the PCT for Stockport, Greater Manchester, not the one in Staffordshire?

I want to clarify one of the Minister’s responses that he made a moment or two ago. He seemed to suggest—I want to be careful not to put words into his mouth—that the responsibility for the problems might lie with the PCT, rather than with the system itself. In the cases mentioned by hon. Members, it is of course systematic failure that is endemic in the structure that has been built up. Will he clarify that response and say just how much of the responsibility for this lies with the individual PCTs, since, as he has already said, Stockport PCT is generally a high-performing one.

It is above average: the latest figure is 64 per cent. for Stockport and the latest average figure is 57 per cent. Forgive me. I tried to inquire with officials exactly which PCT area Cheadle constituency straddled and I was told it straddled another one as well; it would simplify matters if it were just Stockport. However, Stockport is an above-average performer. The range of performance, from 95 per cent. by one of the best PCTs to down in double figures, still, for some of the worst, shows that where the PCTs grip the scheme, implement it properly and engage with their GPs and providers, the system can work.

The simple answer to the hon. Gentleman’s question is that it is the responsibility of PCTs. I am being urged on by hon. Members, who usually urge Ministers not to interfere so much from the centre in local issues and local implementation. I am happy to take away individual concerns raised by hon. Members, but I am afraid that it is not—I do not think that they are suggesting it—a Minister’s job to micro-manage the implementation of every single PCT’s choose and book system. It is the PCT’s responsibility to do it on behalf of their patients.

The Minister is generous in giving way again. I personally sought clarification because, frankly, I suspect that when, as hon. Members, we go back and have our regular meetings with our local PCTs, as most of us do, we will find that the PCT will be astounded by the Minister’s replying that the responsibility for these problems lies largely with them and is not down to systematic failure, as we believe.

I talked to the chief executive of the hon. Gentleman’s PCT yesterday and he assured me that he was happy with the system and that it was not a systematic problem, as the hon. Gentleman is implying. It is a problem in some cases of GPs not engaging with it and in other cases of the PCT’s system not working properly. It is also sometimes due to providers not putting information up and not using the system as it should be used, which I am coming on to.

As I was saying, some PCTs do not use the clear provisions in their contracts with providers to ensure that referrals flow freely through the system. PCTs need to work with their GPs and providers to resolve that issue. Some hospitals pay too little attention to how their services are displayed on choose and book and they ignore the instances of patients not being able to book appointments for their services. Strategic health authorities—the regional bodies—are working closely with PCTs and providers to tackle that.

The most important ingredient in all this is local leadership. How choose and book is used in Barnsley and in Leeds is a good example. Those two health communities are separated only by the M1 motorway. The system is no less available in Leeds than in Barnsley. In Barnsley, choose and book utilisation has been in excess of 95 per cent. for several months, but across the motorway in Leeds, utilisation is yet to rise above a percentage rate in the mid-20s. Why? The critical factor is the leadership in Barnsley, where the acute trust has really engaged and got behind choose and book.

I am sure that hon. Members who have spoken in this debate would like me to look into the individual cases that they have mentioned and I will certainly do that, but if they are having problems, as a first port of call they should go to their PCTs. If they have a problem with their PCTs, they may, by all means, come back to me.

The hon. Member for North Norfolk (Norman Lamb), in his comments on the speech made by the hon. Member for Hazel Grove, said that some of his constituents had complained—perhaps he was making a national point here—that they could not see particular consultants because they cannot choose to wait to be referred to a consultant owing to the 18-week target. Such practice is totally unacceptable. If a patient wishes to wait longer to see a specific consultant, they are perfectly entitled to do so. The point that I was making after the hon. Gentleman’s earlier intervention was that we must not allow individual consultants or trusts to claim that they are so popular that there is no way in which they can meet the 18-week-maximum target. Hospitals are obliged to accept all referrals to the services listed on choose and book that are clinically appropriate. They cannot turn referrals away even if they are struggling to meet waiting time targets. It is important that we stick to the principle that patients choose the hospital, not the other way round.

What the Minister is saying is encouraging, but we are told that, time and again, hospitals where the wait is longer than 18 weeks are being “greyed out”—that is the phrase. The option disappears from the list available on choose and book. That is what is happening. If the Minister says that it is unacceptable, what steps will he take to address it?

I shall come on to that in a second, but yes, it is unacceptable. I want to take up a point made by the hon. Member for Hazel Grove about the 5 per cent. tolerance level for the 18-week waiting target. He was not right to say that that includes people who do not turn up. The 5 per cent. tolerance is for people who choose, for whatever reason, to delay their treatment, or for cases in which there is a clinical reason to delay the treatment. They may need to get their blood pressure down, for example. It would not be right to penalise a provider in respect of the 18-week performance target just because people did not turn up. I wanted to disabuse the hon. Gentleman of that impression.

Sometimes the hospital that a patient wants will have no appointment slots available on choose and book at the time they want to book. That should not mean that they have to go elsewhere. If a patient cannot book an appointment, their details should be sent to the hospital of their choice, so that that choice is honoured. There are many places where that problem has been resolved and appointments on the choose and book system are almost always available. Where that is not happening, it is important that we hear about it and that strategic health authorities hear about it and work closely with the primary care trusts and the trusts to resolve the problem everywhere.

The hon. Gentleman asked three specific questions. First, he asked about missed calls. The information that I have is that the performance of the national Appointments Line is carefully monitored and is generally considered good. Where it falls below accepted standards, it incurs financial penalties. Since April 2007, 95 per cent. of calls have been answered within 30 seconds, and the key performance indicator relating to the busy tone has been met 86 per cent. of the time. I think that the hon. Gentleman was referring to patients who chose not to complete their call. That would be registered as a call that was not connected. It is perfectly possible—indeed, it is quite likely—that they called back and their calls were answered. However, we regularly review the performance of the Appointments Line against the call standards and I would be happy to write to him in more detail about that if he would like me to do so.

Secondly, the hon. Gentleman referred to the 18-week black hole, which I have just dealt with. Patients should be able to choose to wait longer than 18 weeks if they want to do so, but we must not let hospitals off the hook about bringing down waiting times, which all patients appreciate. Thirdly, the hon. Gentleman wanted me to ensure that all appointments are on the screen. We are targeting the trusts that have a high rate of unavailable slots appearing on the screen. Many hospitals have tackled the problem effectively. We want to ensure that they all do.

I want to come back to the Appointments Line question—it seems to be an orphan. The figures that I cited were drawn directly from a parliamentary reply that the Minister gave my hon. Friend the Member for North Norfolk (Norman Lamb) in January. That showed clearly that a large number of people could not get through, a large number of people were “Vivaldi-ed” and simply gave up after 30 seconds or more of the call. I advise the Minister to read the small print of his answer. That gives us a total of 330,000 calls in a year that are not being responded to. Whether people give up because they cannot stand the music any more or because the line is engaged, they still give up.

Yes, but the hon. Gentleman is ignoring the fact that those people may have rung back on another occasion and got their appointments. If it will be helpful, I will write to him to give him the clarification that he seeks.

To begin with, choose and book provided a choice of only four or five providers. As I am sure hon. Members will be aware, however, last April, after a major upgrade, we gave patients the ability to choose at referral whichever service would meet their needs. The new system also made it easier for GPs and their patients to navigate through the options available. It is interesting to note that following a peak between April and July last year, the Department has been receiving significantly fewer letters from the public making complaints about choose and book.

A decade ago, people could wait up to two years for a hospital appointment, but thanks to the investment and reform and the introduction of systems such as choose and book, that is no longer the case. Now, the average wait from GP referral to treatment is just eight weeks and no one need wait more than 18 weeks unless they choose to do so. In June this year, further enhancements will be made to the choose and book system that will help hospitals to give their services standardised and accurate names. That will give GPs an experience much more like using Google and information that is far more accurate, enabling them to help their patients in the best way possible.

Hon. Members referred to the recent BMA report. Although that report makes constructive suggestions on how the system can be improved, it clearly shows that the system can work when local engagement, particularly with clinicians, is effective. Its conclusion—section 4—states that the problems encountered were

“not due to the functionality of the system but due to broader issues such as…processes in place and capacity issues...The clinicians interviewed felt that Choose and Book could potentially bring benefits and that a paper chase of referrals letters between GPs and around the hospital is not best practice.”

The hon. Member for Boston and Skegness (Mark Simmonds) referred to the recent Lewisham report, which was published, I think, today. Although we are still looking into that, because it landed on my desk only yesterday, we were rather surprised by the findings at Lewisham that seemed to suggest that choose and book increased the rate of did-not-attends. All the other evidence suggests that choose and book significantly reduces did-not-attends. It is logical that if a patient is actively involved in decisions about their care, their attendance is likely to improve.

We understand that further research is being undertaken in Lewisham on those findings to find an explanation for them. Three previous pieces of research—at Ashford and St. Peter’s Hospitals NHS Trust, at Kettering general hospital and at Doncaster and Bassetlaw hospitals—found a reduction in do-not-attend rates of 32, 33 and 60 per cent. respectively, so there seems to be a conflict with the findings in Lewisham. I point out that Lewisham is an even poorer performer than Norfolk on choose and book. It may be that there is a more general problem, in that Lewisham has not embraced the system, rather than a particular problem with the system itself.

I have spoken about the importance of choice—a concept that most of us believe in and support. The issue that we are debating today is about GPs, primary care trusts and NHS and independent sector hospitals making a choice—making a choice to work with, understand and use choose and book properly, or to ignore it and wonder why it does not work. For their patients’ sake, and with the help of hon. Members, I hope that they choose the former.