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Lord Clement-Jones: My Lords, from these Benches I join the noble Earl in thanking the noble Baroness for repeating the Statement from the other place. We welcome regular updates about NHS Direct, the Government's commitment to bring forward the roll-out of the scheme and the commitment to provide additional

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resources to do so. However, it is clear that there are a number of concerns which should be expressed in relation to the development of NHS Direct. I have already expressed those concerns to the noble Baroness.

Above all, there is the question of the relationship of NHS Direct to the specialist voluntary sector helplines. Will NHS Direct work alongside those existing helplines? Will it make sure, in addition to its triage role, that optimum cross-referral to specialist services by NHS Direct takes place whether for mental health problems, cancer or asthma?

Furthermore, is the department addressing the question of the quality of service both for NHS Direct and for the voluntary sector? They must operate within the same quality framework. With the advent of NHS Direct, will the department consider some kind of kite-marking or accreditation, perhaps along the lines of the guidelines for good practice in telephone work, drawn up by The Telephone Helpline Association? Will they ensure that those helplines that are of sufficient quality will be able to enter into service-level agreements with NHS Direct to provide specialist information, support and advice on referral?

Do we yet know enough about NHS Direct's effect on primary care services? Will the service build on the primary care experience of general practitioners? Will it build on the extremely successful Wiltshire trial and the University of Southampton research which resulted in a 40 per cent. drop in patients' visits to surgeries, halved GP's out of hours workloads and cut hospital admissions and casualty visits?

Is NHS Direct currently developing draft national guidelines or protocols? Will second-phase pilots be working next year with draft national guidelines?

In a recent Statement, the former health Minister, Alan Milburn, indicated that a national telephone line might be the way of the future. However, the Statement seems to indicate that a single local line for GP surgeries and accidents and emergencies--NHS Direct itself--might be the way forward. Which way is preferred by the department?

When will software systems be rationalised? The first three pilots have used three different software systems.

Reflecting some of the comments by the noble Earl, what are the recruitment implications for NHS Direct? Some estimate that another 15,000 nurses will be needed to provide a full national service. In the face of a major recruitment crisis, with about 12,000 nursing vacancies, will there be enough experienced nurses available to start the service?

Finally, is the December 2000 deadline for the full coverage of the whole country still the department's target, or will it be earlier as a result of bringing forward implementation for 60 per cent. of the country? We welcome the implementation of NHS Direct, but it must not be an over-hasty implementation and it must take into account some of the considerations that we have put forward.

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4.32 p.m.

Baroness Hayman: My Lords, I am grateful to the noble Earl and the noble Lord who, overall, have welcomed the announcement today of speedier implementation of national coverage by NHS Direct.

The noble Earl, Lord Howe, commented on the move towards national implementation before the results of the evaluation have been fully understood. There has always been a commitment to a national roll-out. The information that we have received so far has been so positive that we feel confident in speeding up the implementation of the next phase. Sheffield University is conducting a detailed evaluation which will give us some answers to the questions about protocols, national standards and forms of implementation. The first phase of that evaluation will be published soon.

In the developmental process it is important that we go ahead and make changes and carry out improvements to make sure that we have standardisation where appropriate as we move forward. We have clear indications that that is the right thing to do and that it is sensible to cover as much of the country as soon as possible.

I do not want to be drawn by the noble Lord, Lord Clement-Jones, on whether we will be able to bring forward the full coverage implementation date, but we are making considerable progress on the date that we have put in for the 60 per cent. coverage.

I was specifically asked about the training that those involved in providing the service receive. They receive specific and extensive training of six to eight weeks both in using the computer software available and the decision support systems. They also receive training in helpline skills, which is a separate issue. There is increasing evidence on how those skills are developed. We shall consolidate that for the national service.

The question about the quality of the service and the advice given has been raised. We have highly qualified nurses, operating expert clinical decision support systems which have been validated by local clinicians. As we move towards the national service, we shall develop national clinical standards for NHS Direct and national validation processes for the decision support systems. The nurses who give the advice also have on-line access to medical advice should they need something above and beyond their own skills or what is in the decision support mechanisms.

On the balance between national standardisation and local implementation, as with so much else in the NHS, we have to assure ourselves of the quality of the service provided throughout the country. However, we must not do that in so rigid a way that we take away any local sensitivity and the real benefit that knowledge of, for example, local voluntary organisations and local services can bring. That is not an impossible task, but we are moving towards a model with a number of centres rather than a single national centre. The phrase used by the Secretary of State is "horses for courses". There will be variety in the size and coverage of different schemes.

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On the nurses who will perform the important role of giving advice, as I said in the Statement, some come from other parts of the NHS, but some are returning to nursing and others come from the private sector. We believe that there will not in any way be an issue of competition with other parts of the NHS. We see valuable opportunities for retaining staff who want a different form of work from that which they have had in the past; a form that provides flexible working opportunities for those who are thinking of returning to nursing, with specific training for this particular role.

As I said earlier, there are opportunities for those who have had to leave conventional nursing because of injury. That is not an insignificant pool of people. I believe that providing a wide range of opportunities for nursing is more likely to increase retention and return-to-work rates than diminish the pool of nurses available across the NHS.

I was specifically asked about the issue of GP notification when patients call NHS Direct. Yes, GPs will be notified, but only after the patient has given his or her permission. We have to recognise the confidentiality issues that may cause some people to prefer to call a telephone helpline in some circumstances.

The noble Lord, Lord Clement-Jones, asked about the inter-relationship with the specialist helplines that already exist in many areas of healthcare. In your Lordships' House we have discussed the specialist helplines in mental health and I know that the noble Lord is particularly interested in the services that BACUP (the British Association of Cancer United Patients) provides for patients with cancer. Perhaps I may repeat that it is certainly not intended that NHS Direct should take over the role of specialist helplines. We want to work with them and to work closely with voluntary sector agencies and their helplines to ensure co-operation and synergy between the two sets of services.

Rather than the two being in competition, I believe that the availability of a well-known central point for telephone inquiries will help to increase the use of specialist helplines, rather than diminish it. I believe that that will be true as long as we ensure that the protocols for referral to the specialist services are correct and that, wherever possible, the technology ensures that a patient does not have to put down the telephone and to call another number. Instead, we should "hotline" patients through to the appropriate specialist service. The Department of Health is conducting consultations with those from that sector, with the NHS Steering Group and with other telephone advice lines. This is to ensure that we work together to provide the most appropriate form of treatment, advice and help for those who call NHS Direct.

We are looking to have a single national telephone number to give people access to NHS Direct. As I said in the Statement, there are opportunities in particular localities to provide an out-of-hours service on a specific local number. As we roll out the service we shall have to work out the specific details.

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4.41 p.m.

Baroness Gardner of Parkes: My Lords, I welcome the new NHS Direct. However, perhaps I may put a number of practical questions to the Minister. First, legal liability is now becoming a major issue in the health service. Who will be legally liable if a patient is given the wrong advice? How will we be able to differentiate between whether the patient was genuinely given the wrong advice or is fraudulently claiming to have been give the wrong advice?

Will the patients be identified? If you telephone an insurance company, you are given a warning that your call is being recorded. If you telephone a bank, you have to identify yourself in some way. What will patients have to do? How can we reconcile a patient having to identify himself with the position of a patient who wants to call anonymously, perhaps with regard to HIV? Has the Minister thought about that? If not, will the Government give some thought to it? I believe that one day such a case will go wrong, just as we hear about with regard to ambulance trusts, and it will be claimed that the patient died because the wrong advice was given. Will the general practice carry that responsibility or will the responsibility be carried centrally? Exactly where will that responsibility lie?

The Minister said that it is hoped to operate national clinical standards and that nurses will be able to call for expert advice if needed. How will a nurse know when she needs expert advice? Surely that will be extremely difficult to decide when talking to a patient over the telephone as opposed to actually seeing the patient. Perhaps that is an issue for training.

I note from the Minister's answers that NHS Direct is to be a 24-hour service. The Minister mentioned the possibility of a national number. Will it be an 0800 number or an 0345 number, which means the patients will be charged at local rates? Presumably, the number will be widely publicised, but will the Minister confirm that?

As I said, I am pleased to hear about NHS Direct. My final question is: how many human beings will be available to answer telephone lines at any one time? If the Minister, like me, has tried to telephone a phone-in line, she will know that trying to get through for a long time can be very frustrating. One has very little hope of getting through, but when one does one is often greeted by an answering machine saying that there is a queuing system. Will there be a queuing system for NHS Direct?


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