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111 Telephone Service

Volume 563: debated on Wednesday 5 June 2013

Motion made, and Question proposed, That the sitting be now adjourned.—(Karen Bradley.)

May I welcome you to the Chair, Mr Robertson, and say what a pleasure it is to serve under your chairmanship? I also welcome the Minister and her shadow, the hon. Member for Copeland (Mr Reed), to their places, as well as other colleagues. I am delighted to have secured this debate on the operation of the 111 telephone service and its effects on emergency services. The service is still in its early days of operation. It has yet to be introduced in my own area of North Yorkshire, although the roll-out is expected to commence in early July.

My starting point is that I believe that the 111 telephone service could be a useful tool for out-of-hours services and patient treatment, but that some alarm bells have already been set ringing in areas where it has been rolled out. It is not my intention to go through all aspects of the general practitioner contract and out-of-hours services; I want to look at the narrower point of the potential impact where the 111 telephone service is not working.

In my view, the service might offload problems on to accident and emergency and, indeed, the ambulance service. A lot depends on the content of the script that is used and who sets the script, because the time taken should be as short as possible to allow the swiftest access to nurses and medical advice for those in palliative care, terminal care and other regular patient care, such as catheter patients. The length of time before a patient, or someone acting on their behalf, is passed to a medically qualified adviser—a nurse or doctor—is absolutely crucial.

I want to refer to my family history to illustrate the very real problems being experienced. It relates to one of the pilot areas, County Durham, where my father was a GP, but had long been retired. The carers looking after him in his home, or occasionally me, had had consistent recourse to the 111 service. The last occasion when we used the service in relation to my father was on Sunday 4 November last year. I had reason to call the number, and I explained that my father showed worrying signs of a urinary tract infection. Being a doctor’s daughter, I was well qualified to talk about such infections, which my father had had, on and off, for some two or three years.

When I called 111, I got the ritual reply of sticking very closely to a script, which I found completely inappropriate at times. I explained my father’s condition, but the responder insisted on sticking religiously to the script—asking whether the patient was breathing, whether they were bleeding—and I kept saying that I was not reporting an accident but a regular condition, the symptoms of which were extremely plain, and asking whether I could, please, just be passed to a nurse or doctor. I said that we probably needed a doctor to attend to confirm that there was an infection and to administer the relevant antibiotics.

I have to say that in the end I hung up in sheer frustration, 10 or 15 minutes into the call, because I could tell that I was not getting anywhere quickly. I had previous experience of using the 111 service, and I like to think that I am not prone to flap unnecessarily, but I found that the system failed. I then called 999, and an ambulance was dispatched immediately and attended to my father within half an hour. The paramedics confirmed my suspicion that the condition was an infection, and said that the patient was too ill and frail to travel some 25 miles on country roads in an ambulance, so that was not an option. They used their direct line to call a doctor, but even then, it took three hours for one to attend. In that case, from first calling 111 to the doctor’s arrival, about three and a half to four hours had passed.

My father subsequently died on the Thursday of that week, 8 November, and I believe that the infection had obviously taken such a grip that his death would have been very difficult to prevent. He had lived to a very grand age, and we were just grateful for the treatment he did receive. However, that example shows the pressure points that need to be addressed and which, I regret to say, have not been addressed, even though I have raised the issue, in relation to my family experience, on two or three occasions.

For the 111 service to work effectively a degree of flexibility has to be built into the system and the script. It would be helpful if the Minister told us who is responsible for setting the script. I would argue that doctors, working with community or district nurses—those medically qualified—must work out the script, so that it diverts regular patients who can be taken off it at the earliest possible stage.

What is particularly poignant for me and my family is that my father had been a local GP in that area for some 30 years. He retired as a senior partner, ironically through ill health. He attended patients in all weathers and at all hours. My father was from a generation of GPs who worked all hours: he worked every other night on call and every other weekend on duty, and he always put his patients first. It is obviously a source of some regret that he did not have similar access to a GP in his own hour of need.

The 111 service was piloted in several areas, and I am drawing on my experience of the one in County Durham before the service was rolled out nationally. I want to make some suggestions and pose some questions. It would clearly make sense for regular patients—such as those in palliative care, terminal care and catheter care—to be diverted to nursing or other medically qualified staff as early as possible in the process. In North Yorkshire, the intention is that that will happen when the service is rolled out, but I want confirmation that, now the problem has been identified, it is being addressed in all areas, including pilot areas and ones opting for early roll-out. That would save more time for those who were in urgent need of care, short of the 999 service.

We must all be aware that if a patient or someone on behalf of a loved one phones, they tend to be quite distressed and distraught, and they do not want an automatic responder to stick blindly to some script that does not fit their or their loved one’s condition. If calls are not responded to quickly, those calling will simply divert to other emergency services, such as the ambulance service and accident and emergency—I am the first to admit that that is what I did in those circumstances—because people are just desperate to get medical care.

The key to the success of the 111 service is the speed and efficiency with which one’s calls are responded to and with which access is given to medical advice from doctors or nurses, so I want to take this opportunity to ask some questions. What is the average ratio of call responders—those reading out the script—to GPs and nurses on duty? It would be helpful to know that average ratio in each area where the 111 service is in use. What is the average response time to the initial call? What is the worst response time and what is the best? What is the average time before a caller is transferred to a medically qualified person? Is it normal to expect a delay of up to two hours before a medically qualified person or even the initial responder returns the call? Is it normal to face a delay of three and a half to four hours, which is what we experienced, before a doctor is dispatched, even if it truly is an emergency?

What has been the knock-on effect on the ambulance and the accident and emergency services in those areas where 111 is operating? Is my reaction typical of those who feel they are being let down by 111? If someone dials 111 in North Yorkshire, they get through to the out-of-hours service, so it would be helpful to know how, in areas where 111 is being introduced, the roll-out will be operated smoothly.

In areas where 111 has not been seen to work effectively, what have been the implications for the local hospital, ambulance service and GP practices?

We are often at our best when we are sharing personal experiences, and I pay tribute to the hon. Lady’s father for his many years of service. The questions she is asking seem to be the right ones. I know from the clinical commissioning group in my area that GPs themselves have expressed frustration at the operation of this service. Does she therefore agree that, from each locality, we need to get their input and listen to their answers to those questions?

I entirely agree, and I welcome the hon. Lady’s intervention. One reason why the 111 service has not yet been rolled out in North Yorkshire is that GPs have expressed their concerns, which leads me to my next question, on the involvement of GPs in areas where the service is being rolled out. How are the legitimate concerns of GPs, such as those in her area and in mine, being addressed and met?

Concerns have been raised in North Yorkshire about the governance framework. How are those are being addressed? A key issue in my area is funding, and I would like to know how 111 is being funded and from whose budget the funding has come. The service is replacing NHS Direct, which caused similar concerns when it was rolled out, so this is not unknown territory for us as parliamentarians or for the Department. It is a little depressing that we are seeing the same problems being played out now, because they were clearly not addressed when NHS Direct was rolled out.

Let me express a very personal view—it is not a view I have picked up locally. As a GP’s daughter, a GP’s sister and the niece of a late surgeon, I believe that people just want to see their GP. They want to walk in to the surgery or phone up and speak to their own GP. Sometimes 111 can be seen as a barrier, as NHS Direct was, to seeing one’s own GP.

We have an historic debt of £12 million built up by North Yorkshire’s primary care trust. There is real concern locally that that debt will affect the funding of GP practices, and especially of the new 111 service. The funding issues are absolutely the key to 111 going forward.

Does my hon. Friend agree that one of the questions is at what level the 111 service should be sorted out? Is it something, for example, for Hampshire and Isle of Wight or for the south-east, or should it be sorted out nationally? There has been very little concern over this matter on my island, but that is perhaps because it is dealt with more locally.

I believe a local solution should be found. A question I will come to is whether there is a difference in the roll-out of the service in rural and urban areas—in my hon. Friend’s case, an island. Local solutions must be found. To me, the best solution will always be for someone to see their own GP on the day they are ill.

I hope that my hon. Friend the Minister will put our minds at rest and say that the story in the newspapers about rationing our visits to GPs is a myth. We cannot dictate how often we will be ill. If an elderly person has a chronic condition, they cannot limit the number of times they might have to call on a medical service in one year.

If I may, I will give way first to the hon. Member for Worsley and Eccles South (Barbara Keeley).

I thank the hon. Lady; she is being very generous with her time. Dr Clare Gerada of the Royal College of General Practitioners told the Health Committee yesterday that many GPs’ books are now full at 8.30 in the morning, and that if they have open slots there are often queues down the street, which she said she had not seen for years. I agree with the hon. Lady that we need more GPs, because that is what most patients want.

I know what I am going to say is controversial but perhaps I, as a woman, can say it. Some 70% of medical students are women and they are well educated and well qualified, but when they go into practice, many marry and have children—it is the normal course of events—and they then often want to work part time. Training what effectively might be two GPs working part time obviously puts a tremendous burden on the health service. I will now give way to my hon. Friend the Minister.

On the point my hon. Friend made about any rationing of or charging for GP appointments, let me assure her that that was an idea floated on a website and is not Government policy. It is reasonable for people who have an interest in such issues to be able to debate whatever they wish to debate, but it is certainly not Government policy, and I know of no good reason why it ever should be. She makes a very important point when talks about, rightly, the good number of women who are training to be doctors, but the unintended consequences.

The problem is similar in other professions, such as my original profession of law. The Chamber will welcome the Minister’s confirmation that it is not Government policy to ration or to charge for GP appointments, as we have heard under successive Governments. We are very reassured to hear that it is not their policy to ration GP visits.

How is the interface with GP out-of-hours providers being addressed? In the rural area of North Yorkshire, three and a half clinical commissioning groups cover one constituency, which poses some real practical problems. Where there are multiple GP out-of-hours providers, what regard has the Department had to the potential difficulties of rolling out the 111 service? Furthermore, are there any issues relating to delivery in rural as opposed to urban areas? I am talking in particular about the distances that GPs or nurses might have to travel to respond to calls under the 111 system.

Most worryingly, there seems to be a political vacuum here. Will my hon. Friend the Minister reassure us that there will be political accountability? Where does the political responsibility and accountability lie for any potential failings or successes of the 111 service? Does the Department plan to review the system further? I ask that because my own experience in the pilot area of County Durham has not convinced me that the review has borne any fruit. Does the Department plan to review the system after three or six months?

I congratulate my hon. Friend on securing what is a very important debate and thank her for sharing with us her genuine and very sad experiences. Does she agree that, while everybody would accept that 111 is the way ahead in reducing the burden on A and E, it is all about integration—be it urban areas or deeply rural areas such as those that she and I represent—and that there will be future improvements in GP, 111, A and E, and other services?

The 111 service is a tool and should never be a substitute for the ability visit a GP. I accept that we cannot expect GPs and their families to put up with the antisocial hours of GPs of my father’s generation, who were leaving the profession in droves. I see 111 as a useful tool—an appendage, not a substitute. There are issues that must be addressed in that regard.

Will the system be reviewed, and if so will it be within three or six months? I repeat: is 111 really geared up to deal with sparsely populated rural areas such as those that a number of us here today represent? North Yorkshire has a sparsely populated rural area—one of the largest in the country—and a high number of older patients with complex medical needs, which the GPs are very cognisant of.

I welcome the Health Committee’s inquiry into 111 and NHS emergency care. We will all doubtless follow the proceedings, and look forward to its conclusions and recommendations with some interest.

This debate has been a wonderful opportunity to get a number of issues off my chest; to pay tribute, I hope, to my father; and to note my disappointment at how he and others were treated in the pilot scheme. I hope the issues I have raised can be addressed. The 111 service may be a useful tool—an appendage—but we need to look closely at what more needs to be done, and I invite the Government to do so. I am fearful of delegating the operation of all emergency services outwith political control, and I return to the point about where the political accountability for 111 lies. I look forward to hearing the Minister’s considered response to the debate.

I thank the hon. Lady for her speech and I offer her my condolences on the loss of her father, which I am sure applies to every colleague here.

It is a pleasure to speak under your chairmanship, Mr Robertson. I congratulate the hon. Member for Thirsk and Malton (Miss McIntosh) on securing this debate and on the way that she has opened it, which has been really helpful.

The British Medical Association has consistently expressed serious concerns about the transition from NHS Direct to NHS 111. I understand that the BMA wrote to the then Health Secretary—the Leader of the House of Commons, the right hon. Member for South Cambridgeshire (Mr Lansley)—in February and April 2012, to warn

“of the dangers of rushing implementation of NHS 111.”

It also wrote to Earl Howe, the Health Minister, and to the chief executive of NHS England, David Nicholson, urging them

“to delay the launch of NHS 111 beyond April 2013, due to concerns that many areas were not ready for the transition.”

Those concerns were borne out when the service was launched in Greater Manchester on 21 March, prior to the national launch one week later. I have collected information on the launch in Greater Manchester from the chief executive of Salford Royal NHS Foundation Trust. He told me:

“Significant operational problems were experienced when 111 first launched at the end of March and these problems persisted for the first two weeks of operation. 111 did not equip their call centre with the required levels of trained staff and were therefore unable to deal with the volume of calls received; some patients were left waiting up to an hour to get through on the phone lines and as a result patients just turned up at A&E/GP Out Of Hours Service causing significant capacity and demand issues.”

That is just the point that the hon. Member for Thirsk and Malton made about what people would do if they could not get through to 111.

Senior staff of the Salford clinical commissioning group told me that NHS Direct had given assurances that it had the capacity to handle calls, but after the failures that we experienced in Greater Manchester, NHS Direct admitted that it had insufficient call handlers in place. Apparently, when these problems occurred, 111 asked all GP out-of-hours providers to return to their pre-launch call-handling service. However, that was not an option for us in Salford, as our previous call handlers had transferred all their staff over to 111 under TUPE arrangements. So the problems with NHS 111 continued. Salford CCG staff also told me that the out-of-hours service in Salford came under pressure owing to this NHS 111 failure, and that pressure had to be met with increased staff capacity.

Salford Royal NHS Foundation Trust has commented that further improvement to the service is still required. It feels that

“the care pathways still need further modification to reflect local services”

and that

“there are currently gaps in alternative routes of care”,

which the 111 service is showing up. If there are issues with social care, the community team, the district nurse or self-care, that becomes apparent. The trust also said—this is important for our debate this morning—that

“there are also concerns that what we have done with this service is to replace clinician triage in Out of Hours service with computer or non-clinician advice.”

To give an example of the problems that this change has caused in Salford, I will quote the trust again:

“This has led to patients being brought to the emergency department when they are actually on end-of-life pathways”

and should have “community input”. That is just the problem that the hon. Lady talked about—that situation has happened in Salford. It is distressing to think of people who are in their last few days of life being dragged into hospital, when they should really receive care in their own community and in their own home, which is the care that they probably desire.

Salford CCG has reported that feedback forms on NHS 111 have been received from clinicians and that two “significant events” were recorded, which are under formal investigation. The feedback tends to relate to delays in treatment. The CCG also says that its

“immediate priority has been to stabilise the service after a disappointing start. Some positive improvement has occurred but long term there are serious doubts, with NHS Direct identifying the need for extra investment about the contract level to make the service effective.”

I was also told by staff at Salford Royal NHS Foundation Trust that they felt that expectations were set too high about the outcomes that 111 would deliver. They commented that NHS 111 was operating at a level and in a role that an “experienced grandmother” might historically have achieved. That is an important point; my local NHS trust thinks that is what it is getting from the service. That advice—that of an “experienced grandmother”—could be seen as helpful, but staff told me that their preference was for

“an alternative service which had at its core clinically trained primary care staff available over an extended working day, 7 days per week.”

They also believe

“that this service would be better if it was included within a single integrated urgent care service, incorporating responsibility for GP out-of-hours triage.”

I am listening to the hon. Lady’s contribution, and given her background, it is clear that she is a specialist in this area. Like her, I met staff from my local CCG and local ambulance service last week to discuss the development of this system. I note that she talks about integration. Does she agree that the integration of those various parts of the NHS system is the absolutely crucial thing going forward?

Indeed. We talk a lot about integration, but the feedback that I have received from both my local CCG and my local NHS trust is that we have just taken a backward step. We had a nurse-led service that was working fairly well, although it was not as integrated with other services as it should have been. We now have a system that is led by computer scripts and non-clinicians, in which the patients calling the service—if they get through to it—do not have confidence, and as a result, they are falling back on visiting their GPs or going straight to A and E. My point was that that single, integrated urgent care service—the single service that the hon. Gentleman just talked about—should include responsibility for GP out-of-hours triage, and at the moment it does not. The system could have been set up that way, but it was not. Does the Minister believe that the alternative that I have just put forward is the right direction for an improved NHS 111?

Beyond our experience in Greater Manchester, there have been many criticisms of the NHS 111 service and the shambolic transition to it from NHS Direct. Dr John Hughes, a GP from Manchester, said the service had been withdrawn in his area hours before the launch, owing to problems. He told the BBC that it was “an omnishambles” and

“a waste of public money.”

Dr Hughes has called for a full public inquiry into the procurement of that service, because he feels that it was

“forced forward to meet a political objective.”

Janet Davies of the Royal College of Nursing has argued that nurses from NHS Direct have been running NHS 111. She told the BBC for a report:

“Staff from NHS Direct, the service being abandoned, are supplementing the work of 111—staff that were being made redundant and still are at the end of this month… Specialist nurses that can talk to patients have not left and they are propping up that service.”

She felt that, unlike the nationally run NHS Direct, NHS 111 was a

“fragmented service with local contracts”,

which in her view was “very, very chaotic”. She also said that NHS 111 was an attempt to cut the cost per call, by using non-clinical staff to handle the majority of call time, and that it was

“not using qualified nurses, people with the skills to talk to people and make a sensible decision”.

She felt that the Government had thought about costs but not value. As we have seen, NHS 111 is offering poor value if patients turn away from that service, because it is far more expensive to go to A and E or a GP than to have a conversation with a trained nurse.

In Salford, patients were left waiting on phone lines for up to an hour and then turned to the more expensive options of a GP visit or A and E. Our out-of-hours service came under pressure and extra staff capacity had to be brought in. The opinion of staff at Salford Royal NHS Trust is that NHS 111 operates at a level and in a role that an “experienced grandmother” might achieve. Surely, we can and should do better.

I had not expected to be called quite so early. First, I should like to put on the record that health in Northern Ireland is a devolved matter—I understand that—but I am observing the 111 system from my position as a parliamentarian. I congratulate the hon. Member for Thirsk and Malton (Miss McIntosh) on securing this debate. She has encapsulated many people’s concerns. I appreciate the Minister’s efforts on health issues. I am sure that she will, in her response, deal with some people’s issues.

I support the idea behind this phone call triage, as it is called, and its being free to contact, bearing in mind that many GP surgeries have an 0844 number, which costs a great deal from mobiles—we have discussed that in Westminster Hall previously on many occasions, and will continue to do so—but there are clearly major issues with it. Although I accept that sometimes the girls in my office have to stay on the phone for an hour or more to fix some computer glitch with the printer or scanner, we are talking about lives in respect of this service. There have been too many difficulties to ignore.

We have background information on many areas, including those the hon. Lady touched on. Yorkshire and Humber provide examples of the figures and information, which state that there were three deaths and 19 potentially serious incidents coming through the system, clearly underlining the problems.

Does my hon. Friend agree that NHS 111 should immediately answer the phone to all those who contact it—that is obvious—offer direct, accurate communication and provide people with reassurance that they are getting an accurate diagnosis? Those things will be the judgmental touchstones upon which people will base the success, or otherwise, of 111.

I thank my hon. Friend for his intervention, which clearly outlines exactly what the 111 system should be trying to achieve. Sometimes, when hon. Members ask if I will take an intervention, they are looking over my shoulder to see what I am going to say next. My hon. Friend made exactly the point that I was going to make.

There have been lots of complaints about calls going unanswered and poor advice being given, which reiterates the point made by my hon. Friend. That follows concerns prior to the national roll-out, after pilot schemes showed disastrous results, with tales of patients waiting hours for advice and others being asked to call back later. That situation is quite unsatisfactory and must be addressed. NHS England stated:

“The safety of patients must be our paramount concern”.

So it should be, and if it is not, we want to ask why. It also said:

“NHS England will keep a careful eye on the situation to ensure NHS 111 provides not only a good service to the public, but one which is also safe.”

Examples mentioned by all hon. Members—we have them in front of us—provide information that contradicts that. In Greater Manchester, the 111 service was started and then abandoned. Dr Mary Gibbs, a GP providing out-of-hours cover when the system crashed there, said:

“Calls just weren’t coming through.”

Quite clearly, that is the issue. She stated:

“It was totally inadequate. Patients’ health was put at risk.”

The 111 service tends to be busiest when local surgeries are closed. Dr Laurence Buckman, chairman of the British Medical Association GPs committee, stated:

“We are still receiving reports that patients are facing unacceptably long waits to get through to an NHS 111 operator and suffering from further delays when waiting for calls back with medical advice should they manage to have their call answered… The quality of some of the information being given out appears, from anecdotal sources, to be questionable in some instances.”

The advice that people are being given does not always seem to have been up to scratch and is not of the quality that it should be. He added:

“If any area of the country is failing to meet high standards of care, then its NHS 111 service needs to be suspended.”

This is what the experts in the field are saying. NHS England needs to be more transparent about how the system is functioning across the country.

I met one of my local ambulance service chief executives just last Friday, who told me that, in his experience, the implementation of NHS 111 was going well and was helping to reduce demand on the ambulance service locally—and they were quite happy with the service. Although there have been problems, which the hon. Gentleman is right to highlight, plenty of people have been treated well and professionally by this service, and some health service professionals think that the service is working okay.

I thank the hon. Gentleman for his intervention. I have stated that the focus of the new system was on trying to make it better. Every hon. Member accepts that. The idea behind it is great, if it works. We elected representatives will always get the complaints. Not often do we get the wee card saying, “Thank you very much for what you’ve done for us,” but we always get the ones saying, “It’s not working well.” The hon. Gentleman is right. I accept that there will be many examples throughout the United Kingdom where the system has, perhaps, worked, but equally there are a lot of examples of where it has not worked. That is the point that I am trying to make.

We highlight such issues for a purpose, not to be dogmatic, angry or always to be negative in our comments, but to try to look towards improvement. I always try to think that my comments will be constructive criticism, which can be taken on board to make things better. My idea as an elected representative over the years, as a councillor and a Member of the Legislative Assembly in a previous life, has always been to try make comments in that way.

I am conscious of my position as a Northern Ireland Member of Parliament, because health is a devolved matter and I am ever mindful of the cuts in funding faced by all Departments in an effort to reduce the deficit—every pound spent must be well spent—but, from my perspective, I urge that the Northern Ireland Direct system continue until the kinks are ironed out here. On health, we will follow, as we often do, what happens here on the UK mainland, so, from a Northern Ireland perspective, I want to make sure that the system’s fall downs and problems are ironed out and sorted out before we take on the system—if we take it on.

I have been looking at the system with great interest, because one of my jobs here as MP for Strangford and my party’s health spokesman is to consider the systems across on the mainland. Many of my queries to Ministers here in questions on health and to my Health Minister back in Northern Ireland come from what colleagues say to me and from what these debates bring out. I am interested in seeing how this system works or will work, or does not work. If it does not work, I will convey that to my Minister in Northern Ireland, to ensure that when making a decision there we will look at how it can happen. I will certainly not be urging our Health Minister in Northern Ireland to use his precious funding to implement this scheme as it stands.

It is a pleasure to be called to speak under your chairmanship for what I think is the first time, Mr Robertson. I extend my most sincere thanks to the hon. Member for Thirsk and Malton (Miss McIntosh) for securing this important debate. We have worked closely on a number of issues during my time in Parliament, and she is rightly respected across the House as an independently minded Member. I must express my most sincere sympathies to her, but also my profound thanks for the real courage she has shown in sharing her family’s experiences with us.

It is a mark of the severity of the crisis our A and Es are experiencing that Members of all shades of political persuasion have spoken at some length about their constituents’ experiences. It is no exaggeration to state that members of the public are very concerned about the situation regarding NHS 111. A and E is arguably the most visible part of our NHS, and what happens there is felt throughout the system. From the patient waiting at home for an ambulance to the person waiting on a trolley for a bed, what happens in A and E touches every patient in the NHS.

The crisis in A and E has happened on this Government’s watch. When Labour left office, A and E was performing well, with 98% of patients seen within four hours. However, the number of patients waiting for more than four hours has now doubled, and ambulance queues have doubled too. Let us not forget that the target for the number of patients seen within four hours in A and E has been reduced under this Government, from 98% to 95%. Today’s debate is therefore extremely important, and the Government must finally offer some real solutions to address the crisis they have caused.

I find it incredible that the shadow Minister states that the issue was caused by this Government. A lot of my constituents are having to ring 999 because 50,000 beds were taken out of our hospitals nationally on his party’s watch; wards were closed in my local hospital on his party’s watch. Elderly, vulnerable patients who do not have local hospital beds to go to are now forced to ring 999 to get access to emergency services, so it is pretty shameless of the hon. Gentleman to attempt to politicise the issue.

I have to say I am staggered by the hon. Gentleman’s manufactured indignation. I do not know how long he has been a Member of the House, but he will recall that, between 1997 and 2010, the Labour party took the NHS budget from about £30 billion to £110 billion. However, on every occasion the budget was put before the House of Commons, the Conservative party voted against an increase. He should think again about his manufactured indignation.

I am going to make some progress, because I want to get on to the substantive issues in play.

When Labour first suggested a new NHS 111 service, we were clear—the hon. Gentleman should listen—that it would not replace NHS Direct. Our manifesto in 2010 said:

“A new national 111 telephone number will make nonemergency services far easier for people to access and book.”

The 111 service was planned to help people find an emergency dentist, a late-night pharmacy or an out-of-hours primary care GP. This Government scrapped that and instead pressed ahead with the botched implementation of a system that just could not cope with what it was expected to do. They were warned, but, as usual, they did not listen.

There is no doubt that the 111 service is not fit for purpose. The statistics show it, the examples given by Members today show it and, most importantly, patient testimonies show it. Indeed, the Minister herself acknowledged it in response to the right hon. Member for Mid Sussex (Nicholas Soames) in late May, when she stated:

“We recognise that the service has not been good enough and we are working closely with NHS England to ensure improvement in performance. NHS England have put a number of measures in place already.”—[Official Report, 21 May 2013; Vol. 563, c. 740W.]

I hope the Minister will outline what those measures are and what their effects have been, because the contributions we have heard today suggest they are having a negligible effect.

The implementation of the system has undoubtedly caused serious problems; indeed, in my area, NHS Direct is having to be maintained alongside the 111 service to cope with demand. The Minister must explain in detail how a botched, fragmented implementation was allowed to happen despite there being a significant pilot scheme.

On the issue of propping up NHS 111, I wonder whether this is the point at which to give credit to the NHS Direct nurses whom Janet Davies of the Royal College of Nursing cited. Even though some of them are being made redundant, they were prepared to prop up the service during its few weeks in places such as Greater Manchester. We really should give those nurses credit. What a dreadful experience, just before they were made redundant, to have to prop up the service that was replacing them.

I could not agree more. We must give credit to all the people in the NHS coping and labouring under a creaking system right now. The case of the NHS Direct nurses my hon. Friend draws our attention to, who are about to be made redundant but are propping up the system, speaks volumes about their commitment to the ethos underpinning the NHS. I thank my hon. Friend for that contribution.

The 111 service data for March published by NHS England show that only 122 patients responded to the NHS 111 patient experience survey. When the Minister responds in a few minutes, I hope she will not try to justify the implementation of a system that needs to serve millions of people on the basis of the experiences of just 122 patients.

The main purpose of the debate is to look at the implementation of NHS 111 and its impact on A and E attendances. There is no better place to look than the Isle of Wight—the hon. Member for Isle of Wight (Mr Turner) was present earlier. The 111 service there went live on 25 October 2011. The area has had a long time to address teething problems and to ensure that the service operates properly. What has A and E performance looked like over the past few months? Since the end of September, almost 2,000 patients have waited more than four hours, and the trust has missed its target for 23 out of 35 weeks. That is hardly a ringing endorsement of the system, even when it has had a chance to bed in.

Consultants on the Isle of Wight have even said that although patient numbers would be falling and the pressure would be easing if NHS 111 was working as intended, that is not happening—patient numbers are rising, and the pressure on the NHS is increasing. Indeed, Chris Smith, the director of NHS 111 on the Isle of Wight told the BBC that the service is fragmented and that that has led to problems. In response to the hon. Member for Tewkesbury (Mr Robertson), the Minister said that every NHS 111 provider is able to handle inquiries from any part of the UK, but I would challenge her to repeat that assertion today, given Mr Smith’s comments. If a system is fragmented, and CCGs are commissioning different providers, it will be almost impossible for those trained to handle calls to work within different systems. For example, the process for referring people through the system in an area with which they are unfamiliar will be totally alien to them, which is bound to cause further problems.

That brings me to my final point about the system. Following Labour’s A and E summit in Westminster last week, it was revealed to us that 111 call handlers do not necessarily have clinical backgrounds, as my hon. Friend the Member for Worsley and Eccles South (Barbara Keeley) said. Even more shockingly, it was revealed that some areas have an enforced threshold on how many calls nurses can answer, and that that was as low as one in five. The fragmentation of the system means that the figure varies from area to area, because it would have been negotiated in local contracts. Therefore, the service provided is not universal. That is in stark contrast to NHS Direct, under which 60% of calls were directed to nurses. Under 111, however, the figure stands at less than 20%. Does the Minister believe that the low level of engagement between trained medical practitioners and patients in the service is contributing to A and E pressures?

The chaotic reorganisation of the NHS is clearly producing a deteriorating experience for patients. In the last week of March, one patient in the south-east waited for 11 hours and 29 minutes for a call back. In the area covered by NHS Gloucestershire and NHS Swindon, 43% of calls lasting longer than 30 seconds were abandoned by the patient before they were answered. Will the Minister outline the lessons that have been learned from that experience and explain what measures will be put in place to ensure it is not repeated on a national scale?

In four weeks, the 111 service will be live across the country, and the Government need to be more honest about how the service is performing before wider implementation. Royal colleges, patient groups and other stakeholders have long warned the Government that the health and social care reforms brought about by the Health and Social Care Act 2012 would be distracting and cause chaos, and that such top-down reforms would stop the clinically driven reforms needed to help address the crisis in A and E.

That there is now a crisis engulfing accident and emergency services is beyond doubt. It was caused by the Government. We have heard today of a political vacuum and we have heard legitimate fears about the lack of accountability. Patients deserve better; we all do. If the hon. Member for Thirsk and Malton will allow me to say so, her family and her father deserve better. I hope that the Minister will take the time to address all the issues, and to outline the Government’s plan to deal with the current A and E crisis that they have caused.

It is a pleasure to serve under your chairmanship, Mr Robertson, for what I believe is the first time.

My hon. Friend the Member for Thirsk and Malton (Miss McIntosh) made an admirable speech, raising many points and asking many questions—some of which, I will say bluntly, I will not be able to answer in my speech. I assure her that she will receive an answer to those by way of a letter. Before I discuss her speech, I want to deal with the points raised by the hon. Member for Copeland (Mr Reed). It does neither him nor his party any credit to use the serious problem in A and E as a political device to attack the coalition Government. It is not as simple as that. To suggest that the problem has been caused by the Government is plain, simple rubbish. It is accepted that there are many complex reasons for the situation, although I am reliably informed that the number of people being seen within the four-hour target is improving and that many accident and emergency departments are achieving the target, and have been doing so for some weeks. Some, indeed, are exceeding it.

There is much evidence emerging that a firm grip is being taken on the situation, but things are complex. There is no magic bullet. It does not matter which party is in power, the Government would face the problem that we have, because there are many causes. One of them, which people on all sides of the argument have identified, is the fact that we do not have the out-of-hours service we want.

The Minister says that the issue is complex and accuses the shadow Health Minister of making political points. It is about time that Health Ministers stopped making excuses. They have been in office three years and it is time they started to take responsibility for what they are doing.

I have gathered evidence, and the causes of what has happened clearly include insufficient call handlers, which is not complex—it is just a shortage of staff. Another factor is the replacement of trained nurses and trained clinician input for phone triage with computer-led or non-clinician advice. Those things are not complex. They are just wrong.

I am not for a moment saying that there are not difficulties and problems in 111. We know there are, but if only the issue were as simple as solving the 111 problems. The out-of-hours service is just one of many factors. [Interruption.] I want to make some progress on this point: 111 is one factor among the failings in relation to the sort of out-of-hours service that people want. We have also had the difficulty of a long, cold winter, which has added pressures—that is something that often happens. Also, there are 1 million more people attending A and E. That is not the fault of the Government. We have not suddenly caused it. It is because of changes—

I will take interventions, but I want to make these points first.

The population is also living considerably longer. That is good and welcome, but there are many frail elderly people with complex illnesses and diseases, so they attend A and E in a way they did not previously. In addition, we suffered under the previous Government from a lack of integration between health and social care. That was one of the things that the Health and Social Care Act 2012 addressed, and will solve. It is about better integration. The hon. Member for Copeland sneers at that.

He laughs at it, Hansard will record. It is not a laughing matter at all. What I was describing is one of the achievements of the Act. I am confident it will deliver.

The Minister is making sensible points. As to manufactured indignation, if that is what it is, mine comes from the fact that I spend 30 to 40 hours a week volunteering in the NHS as a first responder, and I spent 30 hours doing so last weekend.

A big issue that creates pressure in the NHS is the lack of integration between social care and health services, and a lack of proper intermediate care facilities. We do not have the step-up, step-down facilities that we need to deal with the ageing population. That is one of the biggest problems in my area and a reason for increased pressure.

I, too, know that it does no one any favours to make out that someone forcefully and passionately giving a view based on their experience is manufacturing it. I know that that is not true of my hon. Friend, and I thank him for his valuable contribution. He is right.

I think casual outside observers will struggle with the concept that politicians from different political parties should seek to have different political opinions about the services and Department for which the Minister is responsible. She makes an almost Kafkaesque defence of the Government’s NHS record, but will she accept that the awful implementation of the 111 scheme, the collapse of adult social care, the closure of walk-in centres and the huge pressures on the NHS elsewhere in the system have resulted in the crisis in A and E?

I will not accept any of what the hon. Gentleman says, because he does his cause no service when he makes cheap political points. The matter is hugely complex, but it is wrong to say that the Government caused the problems in A and E. He is wrong in that. It is difficult and complex.

No, I will not. The responsibility, if we are honest—would not it be refreshing if we could for once have an honest debate about the national health service?—probably goes back 10 or 20 years, a period encompassing Governments of different political colours. I am happy to say that—by which I do not mean I am happy that those Governments have failed, but people may think the honesty is refreshing.

I want to deal now with the excellent speech of my hon. Friend the Member for Thirsk and Malton. I pay tribute to her and her work in this place, but also to the considerable efforts and work of her late father. I am sure that if he could have heard his daughter’s speech he would have been very proud. I remember my own father saying that out of all evil comes some good, and perhaps some good may come from her late father’s terrible experience of 111 and the fact that he died shortly thereafter.

I pay tribute to all GPs. There are huge difficulties with the GP contract, which was introduced in, I think, 2004. The consequences have included the loss of the out-of-hours service that I enjoyed as a child, teenager and young woman. With few exceptions, we have wonderful general practitioners, and many whom I know, including my own, and others who are friends of mine, work long, difficult hours. It is important to make that point.

As you know, Mr Robertson, during the recess, far from enjoying holidays, as the popular press makes out, we go back to our constituencies and use the time to make or renew contact with, for example, our local clinical commissioning group or ambulance trust. Alternatively we just go out and about, as I have done, knocking on doors and talking to people. One of the things I did during my recess was meet the head of the A and E department of the Queen’s medical centre, which is the local hospital in my constituency of Broxtowe in Nottingham. The head happens to be one of my constituents, and they tell me that there is much improvement at the Queen’s medical centre, as I know from the stats and so on. I also talked to GPs, and the CCG in my constituency now opens its doors for Saturday morning surgeries, which do not replace any other surgeries; they are extra facilities. The CCG has done that for two simple reasons: first, to improve the service it gives to its patients, and, secondly, in recognition of the need to reduce the pressure on the A and E department of the Queen’s medical centre.

It is right and fair to say that many GPs look with concern at what is happening in many of our A and Es, and with 111, which is commissioned in some areas by CCGs and in other parts of England by clusters of GPs. They are by no means fools. What motivates anyone to enter the medical profession, in my experience, is a real desire to serve people. They want to help and treat people. They are motivated by the very best of motives, so of course our GPs are concerned about the situation.

There is much work to be done with the GP contract to improve out-of-hours service, but we also have to be honest in this debate. There are often urban myths and anecdotes, but it is a fact that many GPs have already said that, far too often, people who come to see them in their surgeries, who attend A and E or who dial 999 or 111, are calling when they do not need to make that call or that appointment. They might be better off making their pharmacist their first port of call.

I thank my hon. Friend for allowing me to intervene and for recognising not only the work my father did, but the work that all GPs do in very trying circumstances. May I bring her back to the Government’s framework, to which I referred, and the very real issues that GPs have raised in North Yorkshire about different GP out-of-hours providers suddenly working with one 111 provider? How will those issues be resolved?

Indeed. I will answer as many of my hon. Friend’s questions as I can. There are some questions I will not be able to answer, but I will certainly write to her.

One of the reasons we introduced pilot schemes was to learn from them, and I can tell my hon. Friend a few things as a result. The university of Sheffield did an evaluation report, which said that there was “no statistically significant” impact on services in most of the pilot areas. Importantly, NHS England is collecting data on 111 and its impact on other services, especially, as one would imagine, on A and E. NHS England is in a position to monitor that, and it will report in due course. I am told that the April data will be published this Friday.

I am reliably informed that the A and E performance of York Teaching Hospital NHS Foundation Trust, which serves my hon. Friend’s constituency, is that in 2013-14 so far, 96.1% of people have been seen within the four-hour target. That is above target. I think the average across England for people being seen in A and E is some 55 minutes.

This question is not a trap in any way, shape or form. The Minister just said that NHS England is assessing data on the performance of 111 thus far, which will be made available in due course. This is an empirical question: will the system be rolled out across the country without the data on the effect of the 111 service on the rest of the system being fully understood?

I do not know the answer, and I will not start speculating because it invariably gets one into terrible trouble.

I am more than happy to write to the hon. Gentleman with some sort of answer from either NHS England or the Department.

I should say, of course, that we know that 111 has not been successful in the way it should have been in many parts of the country, and we know that there were particular problems over the bank holiday and Easter periods, but we also know that it has now been rolled out to 90% of England. NHS England is monitoring, overseeing and collecting the data, as we would all hope.

I will do my very best to respond to the content of today’s debate and the questions that have been raised, with apologies for those questions that I do not answer.

The ratio of call handlers to professionals, about which my hon. Friend the Member for Thirsk and Malton asked, is 4:1. That ratio is not specified, however. There is no prescription that it must be 4:1. As 111 is locally commissioned in the way that I have explained, it is for local commissioners to decide whether to change that ratio, depending on the particular needs of the people in their area. One of the great benefits of the 2012 Act is that we have enabled local commissioners, either as a CCG or as a cluster, to commission services to meet the specific needs of their patients. I hope that will mean that a cluster or CCG in a rural area, obviously knowing that its patients live in a rural area, will ensure that its service is tailor-made to suit the needs of those patients, which may be different from the needs of patients in, say, a city and its surrounding suburbs. That is one of the joys of local commissioning.

My hon. Friend asked whether the three to three-and-a-half hours—in truth, I think it was really four hours—before her father was seen is normal, and the unequivocal answer is no. Is it acceptable? In my view, it is certainly not acceptable.

My hon. Friend then asked who pays. She is concerned about whether the debt in which her primary care trust found itself will have an impact. The 111 service is paid for by CCGs, which is one reason why CCGs are involved in the local commissioning of the service.

How are the concerns of GPs being addressed? The NHS is having a review in the way that I described. My hon. Friend the Member for Brigg and Goole (Andrew Percy), who must be a member of the Select Committee on Health—that shows my profound ignorance, and I apologise to him—has helpfully reminded me that Dr Gerada, who is the chair of the Royal College of General Practitioners, said in her evidence yesterday that she has not seen such queues since the flu epidemic of two to three years ago. She said that the reasons for the high demand are mixed and complex, including the nasty flu virus that went around earlier this year and at the end of last year. I reiterate my point: if only it were so simple to cure the problems in A and E.

The Minister talked earlier about the issue being about out-of-hours service. The NHS 111 problems in Greater Manchester put greater pressure on our out-of-hours service. She said there was a long winter, but 111 was rolled out at the end of March. Does she think that was a sensible time? It was not even the end of a very hard and long winter. Finally, she said that we have had more A and E attendances, but the problems have caused further pressure on A and E. The point many hon. Members have made, which I hope she accepts, is that the chaotic launch of NHS 111 in the end part of winter caused more problems than it solved.

Again, I do not think it is as simple as that. Of course we have not been happy with the roll-out of 111, which is accepted. The service has not been the success that we had hoped. We agree on that.

We on the Health Committee were provided with figures yesterday showing that referrals to A and E from NHS 111 were about half the amount of those from NHS Direct, but that there had been an increase in referrals to out-of-hours and GP services. The link between NHS 111 and pressures on A and E is perhaps not proven.

I am grateful for that intervention. I know that the university of Sheffield specifically examined the pilot and found that in most pilot areas, there was no impact. However, we also know that NHS England is monitoring the situation, reviewing the data and analysing all the different, complex problems causing pressure on A and E to ensure that we make the improvements that we want.

My right hon. Friend the Member for Thirsk and Malton—[Interruption.] Well, I am going to make her right hon. for the moment. It will not be put into Hansard, so no one will know; it is just between us. She made an important point about providing for people receiving palliative care, catheter treatment and so on. She said that perhaps they needed a different script. There is much merit in that. Again, I would hope that the commissioning services would put that aspect in the script. She asked specifically about the script. I am reliably informed that it has been written by clinicians at the highest levels, but I also know that there is concern at a senior level about the fact that it takes an average of 20 minutes to go through a prescriptive script.

There is a wider problem here. We live in an age in which it is increasingly difficult to rely on common sense. When somebody rings up and says, “My father is a retired GP. We’ve been here before, and he has all the symptoms of a urinary tract infection,” they should not be asked whether he is still breathing. A large dose of common sense would mean that that question would not be asked, nor would “Is he bleeding?” and so forth. That is the stuff of nonsense.

I apologise for not being here at the beginning of this excellent debate, and I congratulate my hon. Friend the Member for Thirsk and Malton (Miss McIntosh) on securing it. I have been in regular correspondence with the 111 service in the west midlands region, and with the other related services. I am satisfied that some of the teething problems will be resolved, but my local hospital asked me to raise one question with the Minister. Will she look into the treatment algorithms used by 111? There is a belief in the hospital that they are more likely to result in a referral to A and E than those used by the previous service.

I am grateful for that intervention, because I have heard that anecdotally as well. It is an important question. I cannot give my hon. Friend a full answer, but I will do all that I can to provide it in a letter if she will allow me. That concern has been raised with me on a constituency basis.

As I said from the outset, 111, which is a good service in theory and should be of considerable benefit to health professionals and, most importantly, to patients and all others concerned in the national health service, has not gone as smoothly as we had hoped. That is conceded, and one should not make party political points from it. However, the service has improved, it continues to improve and it is being monitored. I am grateful to my hon. Friend the Member for Thirsk and Malton for bringing this matter to the attention of the House, and I apologise to her for any questions that remain unanswered. I will reply to her and will address all the other points raised by hon. Members in this debate.

Sitting suspended.