Mr Desmond Swayne (New Forest West, Conservative)

I beg to move amendment No. 168, in page 14, line 21, leave out `another' and insert `any other'.

Mr John Maxton (Glasgow, Cathcart, Labour)

With this it will be convenient to take amendment No. 169, in page 14, line 26, at end insert

`, including requirements as to the provision of information on services provided to the principal'.

Mr Desmond Swayne (New Forest West, Conservative)

In view of what the Minister has told us about the disagreeable consequences of reconvening the dreaded Programming Sub-Committee, it may be for the convenience and relief of the Committee if I kept my remarks as focused as possible. That will be my endeavour.

Amendment No. 168 attempts to remedy the lack of clarity in the clause. What was meant was not entirely clear to us. The explanatory notes state:

The body to be regulated is any body or organisation providing out-of-hours cover to GPs that will have to be accredited by a Health Authority.

Does that mean that the body will have to be accredited by any health authority, not necessarily by every health authority, to which it provides an out-of-hours service? That is our understanding of what the clause means, so we are trying to make it more explicit. After all, we are here to help. The spirit of the amendment follows Oliver Cromwell when he said that no real reform could be achieved unless the whole law was reduced to the bigness of a pocket book, intelligible to all men.

Having said that, and believing that the clause has precisely that meaning, I understand the attractions of its having an interpretation under which a provider would have to be accredited and be on the list of every health authority to which it provided a service. If a complaint were to arise against such a provider, the health authority that received the complaint might be unable to seek redress by taking proceedings against that provider, with a view to removing it from its list. The health authority would have to initiate those proceedings with another health authority that had the provider on its list.

It may be administratively convenient for a provider to be on every health authority's list to which it makes provision. However, that administrative convenience must be set against the huge bureaucratic burden that would be placed on the provider of having to register to be accredited by every health authority to which it provided a service. We tabled the amendment in the understanding that the clause means that once a provider has secured access to the system by gaining accreditation from a health authority, that body can provide those services to all health authorities. We seek to make that explicit in the Bill.

Amendment No. 169 is intended to make one of our principal concerns explicit. We fear that access to NHS services may be becoming fragmented. That concern for continuity of care is not restricted to Conservative Members, but is also a concern among medical professionals. In an article in Doctor on 21 January 2000, Dr. Gillam, the Luton general practitioner who is also a director of the primary care programme at the King's Fund, commented that NHS Direct was part of what he saw as an agenda of fragmenting access to the national health service and that it could destroy continuity of care.

That fear has been echoed in a survey of doctors published in GP Magazine on 25 February 2000, which revealed that 81 per cent. of doctors questioned felt that continuity of care was being jeopardised by NHS Direct and walk-in centres. That concern for continuity of care was expressed in the independent report that was commissioned by the Department of Health ``Raising New Standards for Patients—New Partnerships in Out-of-Hours Care.'' I draw the Committee's attention specifically to recommendation 4 of that report, which states that

all providers should report all out-of-hours consultations to GPs by 9.00 am the next normal working day.

Clearly, the authors of the report share the concern that there should be continuity of care and that that information should be provided. However, even that was only an interim measure and very much a second best, because the ideal solution is the provision of electronic systems. The electronic health record will provide a three-way exchange of data between NHS Direct, the out-of-hours providers and general practitioners. It would assist us if the Minister could say precisely what stage has been reached in the provision of the electronic record and what prospect there is of its delivery in the medium term.

I have a wider concern about the clause, which is not germane to these two rather focused amendments. I am inclined to leave that matter to a stand part debate, but if you decide that there will not be a stand part debate, Mr. Maxton, I shall seek to catch your eye a second time.

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

The hon. Member for New Forest, West (Mr. Swayne) has raised some useful points and I hope that I can deal clearly with our policy intentions. We shall address these matters in regulations made under the clause, but what we intend to do on health authority accreditation goes some way towards meeting the hon. Gentleman's concerns, although not entirely.

If a GP co-op provides out-of-hours services covering two or three health authority areas, it is obviously sensible for the health authorities to agree that one health authority should take responsibility for accrediting the service for all of the others, to avoid repetition of a bureaucratic process, and regulations will provide for that. However, we do not think it appropriate that an out-of-hours provider who is on the list of one health authority should automatically have that accreditation accepted by all other health authorities. The reason is that some out-of-hours providers are very large--some are large commercial organisations. Although legally they are single bodies, they have a fairly loose federal structure, and the quality of service can vary from one part of the country to another, even though the umbrella organisation is the same.

Thus we feel it necessary to allow a health authority, if it wishes, to choose to accredit the organisation that offers the service to patients in its area. We believe that to be the right compromise. Under these arrangements, part of a large organisation—I do not want to single out the commercial deputising organisations—would not receive an automatic right to accreditation everywhere simply because it offered a perfectly satisfactory service in one place, as quality of service varies.

Mr Philip Hammond (Runnymede & Weybridge, Conservative)

I understand what the Minister says, but as the clause is phrased, it is the person providing the service—that is, the company—that is being accredited. The health authority would therefore be unable to determine who was providing the services. It could be a national company based in London that provided services all over the country.

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

The health authority would be able to look at the arrangements being implemented in that particular area—for example, to satisfy itself that the information technology requirements or the arrangements for clinical audit were in place for patients in its area.

Dr Peter Brand (Isle of Wight, Liberal Democrat)

Has the Minister considered an alternative way of tackling this problem? If approval in one health authority qualified a large company to practise in any other, it could lose that approval in all health authorities if its performance was unsatisfactory in any one of them. In some franchising operations, those who trade on well-known national images may not be diligent in ensuring that that national package is being delivered locally. That would make the larger organisations more accountable.

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

The hon. Gentleman is right about accountability. Our solution allows the individual health authority to carry out the accreditation process itself. That will provide a stronger safeguard than the health authority having to accept the accreditation of other authorities and being able to object only once problems came to light. I think that we are at one on the level of accountability required.

We entirely accept the principle behind amendment No. 169, but it should be dealt with in regulations. It is important that a patient's GP or a person providing personal medical services has full and up-to-date information when one of his patients has been seen out-of-hours—information on who saw the patient, the diagnosis, what was prescribed and so on. The out-of-hours review recognised that. The Government intend to specify that out-of-hours service providers must supply full clinical details of consultations to practices by the start of the next working day. We will make regulations to ensure that GMS principals and other providers of primary care receive the necessary information.

Mr Philip Hammond (Runnymede & Weybridge, Conservative)

If the Minister is committed to ensuring continuity of care and that information is passed back to the principal practitioner, what arrangements will he put in place to ensure that the details of a patient's walk-in consultation is reported back to his GP?

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

It is a consistent part of the walk-in centre programme to develop and improve those links. That relates to the electronic patient record, which the hon. Member for New Forest, West mentioned. Paragraph 4.21 of the NHS plan states that there should be

access to electronic personal medical records for patients by 2004.

By that time, we expect that

75 per cent. of hospitals and 50 per cent. of primary and community trusts will have implemented electronic patient record systems.

That is the extent of the progress that the Government hope to have made by 2004.

In the interim, it is not sufficient for walk-in centres to wait for electronic patient records to come along at some time in the future. Depending on the local infrastructure, local protocols are being developed with primary care groups to use electronic communications, fax or telephone, as appropriate.

Mr Philip Hammond (Runnymede & Weybridge, Conservative)

What would happen if a patient walked into a walk-in centre and refused to disclose his identity? My understanding is that the patient would receive a consultation like any other patient, although it would not be possible to report back, whether or not there is an electronic data system. That would be a serious disruption to continuity of care. If the Minister is concerned about the issue in relation to out-of-hours treatment, is he not also concerned about the proliferation of walk-in centres leading to patients being able to opt part of their medical history out of their records? That is happening in some walk-in centres.

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

Every effort is made not only to encourage patients to identify themselves at walk-in centres, but proactively to encourage patients who are not registered with a GP to do so. I am not entirely sure whether the hon. Gentleman was suggesting that those who, for whatever reason, do not want to disclose their medical histories should be turned away from NHS treatment. However, we are working hard to ensure that continuity of care is maintained. That is a key objective in our development of this new and convenient method of access to the NHS.

Dr Peter Brand (Isle of Wight, Liberal Democrat)

I am sure that we have a long way to go on information exchange, as a recent Which report pointed out. Would the Minister answer the question asked by the hon. Member for Runnymede and Weybridge slightly differently? If a patient registers normally at a walk-in centre but specifies that certain aspects of the consultation should not be shared, does that patient have the right to have those details withheld? The answer to that question will clearly be relevant to later debates.

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

I should like to take advice on that, as that is slightly outside the scope of the amendments, which are about out-of-hours services provided by GPs or walk-in centres if they are part of an accredited system of out-of-hours services. I am not entirely sure of the precise legal rights that patients may have, in any part of the NHS, not to disclose their full medical history if they prefer not to do so. I would like to be sure before saying how that would apply to walk-in centres or out-of-hours services.

Dr Peter Brand (Isle of Wight, Liberal Democrat)

It would help if that advice was made available in time for our later debates. It is not uncommon for a patient to share all sorts of information, and a core of information certainly needs to be shared, but a patient may not want to share certain aspects of a consultation. For instance, a pregnant under-age girl may not want a family friend who happens to be the GP to have that information shared. It is important, when we reach the information-sharing provisions, that we recognise that there are real ethical problems as well as administrative problems.

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

I am grateful to the hon. Gentleman for that early indication. I hope that the Committee accepts that it is better for me not to risk misleading the Committee on those legal issues, but I shall ensure that we can return to them in due course.

Mr Philip Hammond (Runnymede & Weybridge, Conservative)

I am grateful to the Minister for his indulgence in allowing me to make one final point in this rally.

He asked a few moments ago whether I thought that patients should not be seen at walk-in centres if they did not want to disclose their identities. I was not suggesting that; I was asking the Minister to acknowledge an inconsistency. We all believe that, in principle, continuity of care is a positive thing, and the amendment seeks to achieve that for out-of-hours services. Does the Minister accept that, by creating walk-in centres, with all their convenience, the Government have for the first time allowed patients access to the NHS free at the point of use without that consultation having to be entered in their medical records?

For the first time in the family practitioner service, we will allow patients selectively to edit their on-going definitive medical history. As in the example given by the hon. Member for Isle of Wight (Dr. Brand), patients already do that to ensure that information that may be embarrassing or inconvenient or that may affect their insurance ratings is excluded from their medical history.

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

I am not sure that that is the case. For example, those who go to accident and emergency departments and do not reveal their real identity are not turned away. There are many ways in which patients can do that. It is generally undesirable, although the hon. Gentleman mentioned circumstances in which it might be necessary. For example, in the tradition of genito-urinary medicine clinics, confidentiality is respected. It has always been possible to gain access to the NHS without identifying oneself. Perhaps we can return to that matter later.

Mr Desmond Swayne (New Forest West, Conservative)

My hon. Friend the Member for Runnymede and Weybridge has drawn our attention to a key point that goes to the heart of our concern about the fragmentation of access to the NHS.

Mr Hilton Dawson (Lancaster & Wyre, Labour)

Does the hon. Gentleman recognise that in drawing attention to what he calls fragmentation, he overlooks the excellence of NHS Direct? He should note the comments of Mrs. Jean Jones of Pickthorn close, Lancaster, who spoke of the tremendous benefit that she derived from NHS Direct on new year's day 2001. It gave her excellent, comforting, reassuring advice when medical services were not available to her husband.

Mr Desmond Swayne (New Forest West, Conservative)

I could detain the Committee for some time, Mr. Maxton, but you have informed me in a note that there will be a stand part debate, so I shall confine myself to the narrow subject of the amendment on out-of-hours access. I am reassured to learn from the Minister that what we would like included in the Bill, by way of amendment No. 169, will be dealt with in regulations.

I am not entirely sure that I understood the compromise that the Minister was outlining with respect to amendment No. 168. Am I right in thinking that he was suggesting a regional structure?

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

To use an example from my locality, Southampton and South West Hampshire health authority might decide to accept the judgment of Portsmouth and South East Hampshire health authority in accrediting a service that was offered across both health authority areas. However, there would not be a requirement on the Southampton and South West Hampshire health authority to accept another health authority's judgment. That allows for cases in which it is thought that the quality of service might vary between areas.

Mr Desmond Swayne (New Forest West, Conservative)

I now understand the Minister. That leaves us with reservations about the bureaucratic hurdles that a provider might have to negotiate if the health authorities were not minded to accept one another's accreditations. However, seeing the clock, I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Mr John Maxton (Glasgow, Cathcart, Labour)

Order. I wonder whether it would be for the convenience of the Committee if I mentioned that while, as Chairman, I am reasonably tolerant of amendments if they help the debate, in the previous debate my tolerance was stretched a little.

Question proposed, That the clause stand part of the Bill.

Mr. Swayne: We welcome the principle of the clause. It is appropriate and desirable that a high standard of out-of-hours care should be available throughout the country. I am sure that all hon. Members will be aware of the need for that from their postbags and constituency case work. The health service ombudsman has drawn attention to existing problems.

Some concerns remain, however. The first is that the clause has resource implications for the administration and scrutiny of the accreditation process. What is the Minister's estimate of the effort and cost that health authorities will have to face with the new duty?

I received a brief from the Royal College of Nursing that detailed a concern pertinent to the clause, although it also affects a number of others. It sought assurances that the new accreditation conditions will not exclude nurse-led practices under the new personal medical services dispensation. Some nurse-led practices employ GPs, but the RCN fears that, because nurses cannot act as principals, they will be excluded from acquiring accreditation under the clause. Will the Minister deal with that concern?

We understand that, by 2004, a single phone call to NHS Direct will be a one-stop gateway for out-of-hours access to health care, with NHS Direct passing on the calls to the GP or the out-of-hours provider. Our concern is that that should not be the only gateway; it should be a one-stop shop or gateway but not the only one.

The independent report ``Raising New Standards for Patients -New Partnerships in Out-of-Hours Care'' proposes, in recommendation 7:

Service level agreements incorporating all the Quality Standards should be established, between NHS Direct and all providers of out-of-hours services.

We are concerned that these regulations will be used to push all out-of-hours providers into accepting NHS Direct as the only gateway to their services.

Mr Simon Burns (West Chelmsford, Conservative)

Has my hon. Friend ever rung NHS Direct? Unlike the hon. Member for Lancaster and Wyre (Mr. Dawson), I phoned on new year's day 2001 to get some advice on a child's health but, after 25 minutes of waiting to get through, I had to give up.

Mr Desmond Swayne (New Forest West, Conservative)

I have only rung NHS Direct when I have been prompted to do so by constituents who have complained to me about the service. I always use pharmacists rather than the assistance that can be had over the phone from medical professionals, for precisely the reasons to which my hon. Friend drew attention.

We fear that these regulations will push us towards a situation in which someone wanting to access any out-of-hours provision must do so via NHS Direct.

Mr Philip Hammond (Runnymede & Weybridge, Conservative)

Although my hon. Friend has not stated this explicitly, he knows well that pilots are being considered in which access to the 999 ambulance service is also obtained via NHS Direct. The experience of my hon. Friend the Member for West Chelmsford (Mr. Burns) could be alarming in that context.

Mr Desmond Swayne (New Forest West, Conservative)

I am aware of that, and the prospect is most alarming. We have the same concern with those pilots as we have with these regulations: that they will be used as a means of enforcing the provider to allow access to his service only through NHS Direct.

Ms Lorna Fitzsimons (Rochdale, Labour)

Whatever the experiences of the hon. Gentleman and his colleagues, will he also accept that I am deluged with complaints about surgeries that leave inadequate answer phone messages? In some cases, the contact number for an emergency doctor is cut off halfway through, and no information is given about when the surgery will next be open or about any service alternatives. That leaves the person no choice but to go to an accident and emergency department or to contact NHS Direct.

We are lucky enough in my area to be able to access NHS Direct. It is a safeguard for many people who find themselves in the same situation as the hon. Member for West Chelmsford when he had to phone to get advice about a sick child. I have used the service and found it invaluable when the ordinary surgery has let me down.

Mr Desmond Swayne (New Forest West, Conservative)

I should be interested to know how long the hon. Lady waited to get through. She draws attention to a legitimate concern in saying that there needs to be a safety valve. The problems that she has highlighted should be rectified by the regulations that we have discussed, so that a high quality standard of provision is assured. Our fear is that NHS Direct will become the only means by which out-of-hours services can be accessed. We do not believe that it is proper to move to such a situation until the case for NHS Direct has become much sounder than it is at the moment. The jury is still out.

My hon. Friends have already drawn attention to the problems that many people perceive with NHS Direct. Only last year, the conference of the British Medical Association voted that the £80 million currently being spent on NHS Direct would be better spent on renovating their surgeries [Laughter.] I can understand there being a measure of self-interest among general practitioners, but those are the very people who must have confidence in that service. It would be improper of us to use these regulations to require them to make their out-of-hours services available only through NHS Direct before there is sufficient confidence in NHS Direct to bear the weight of that requirement.

Mr Hilton Dawson (Lancaster & Wyre, Labour)

Does the hon. Gentleman accept that the experience of the present pilot project for NHS Direct is that, despite some initial scepticism from GPs, the project has been successful and has developed largely because of the co-operative attitudes of GPs and the medical profession?

Mr Desmond Swayne (New Forest West, Conservative)

Experiences differ as, no doubt, the National Audit Office report will tell us. However, at the moment the jury is very much out. A snapshot survey of 500 calls to NHS Direct from 5 to 11 January last year showed that 33 per cent. of patients were advised to take care of themselves, 23 per cent. were told to go to their GP immediately, 18 per cent. were advised to see their GP as a routine visit and 6 per cent. were told to go to their hospital accident and emergency department, of which 2 per cent. were to be as emergencies. In addition, 18 per cent. were told to seek advice from another health professional or to get more information. Most of the calls involved young children and young women, with a low rate for older adults.

The survey showed that almost half those who ring NHS Direct go to their GP as well. A call to the service costs the NHS £8. A visit to the GP costs £10.55, and one to an accident and emergency department £42. When a patient talks to NHS Direct and then goes to the doctor—as so many do—it costs a total of £18.55, so we are increasing the cost to the national health service by sending so many of the people who have rung NHS Direct to their doctors. They may as well have gone straight to the doctor and saved the additional cost.

Mr Adrian Bailey (West Bromwich West, Labour/Co-operative)

Does the hon. Gentleman acknowledge that many people phone NHS Direct for advice about whether they should go to the GP? When the advice is that there is no need to go to the GP, there is a potential saving to the NHS that should be incorporated in the figures.

Mr Desmond Swayne (New Forest West, Conservative)

The answer to the hon. Gentleman is that very few of those who ring NHS Direct are saved that trouble, because so many subsequently visit their GP.

Mr Philip Hammond (Runnymede & Weybridge, Conservative)

Labour Members are jumping up and down like Jack-in-the-boxes to extol the virtues of NHS Direct. The fact is that the Government have rolled out the programme without a robust evaluation of its success and cost effectiveness. Now, our best hope is that the National Audit Office will undertake a full investigation into NHS Direct and its cost effectiveness, and only after that will sensible decisions about its role be taken. Until then, neither Labour Members nor anyone else can make an effective evaluation of the part that NHS Direct plays in our health system.

Mr Desmond Swayne (New Forest West, Conservative)

My hon. Friend is right and we are awaiting that investigation. It would not be acceptable if the regulations could create a situation in which the only out-of-hours access to the NHS was via NHS Direct, given that we are doubtful about the robustness of that organisation to deliver the service. My hon. Friend's point that there has been no evaluation of NHS Direct is accurate, although the figures that I quoted come from Sheffield university's evaluation of NHS Direct's first-wave sites, contained in the second interim report to the Department of Health, produced in February last year.

Mr Philip Hammond (Runnymede & Weybridge, Conservative)

It was not robust.

Mr Desmond Swayne (New Forest West, Conservative)

It may not have been robust, but it nevertheless drew attention to a significant number of problems. My hon. Friend is correct that we must await a more thorough examination. The medical profession is deeply concerned about the way in which NHS Direct has been rolled out without any proper evaluation hitherto. It is time that that evaluation was made. We should not accept regulations that create a situation in which all out-of-hours access is through NHS Direct when so many questions still pertain to that organisation.

Dr Peter Brand (Isle of Wight, Liberal Democrat)

I do not want discussion on the clause to focus solely on NHS Direct. However, it is clearly an evolving service that is having problems during its evolution. Not only has it found it difficult to cope with capacity, but there have also been significant problems with the computer programmes on which the advice is based. It can take a long time to get hold of someone, and the assessment process by an NHS Direct assessor is very time consuming. Sometimes advice is also a little too direct. One of my wife's patients told her that NHS Direct had told the mother that the child had to be seen by a doctor within an hour. It is not the role of NHS Direct to dictate how a patient should be seen, or at least I do not believe that it should be. Those issues must be resolved in time.

I worry that NHS Direct is a free service to GPs. In effect, GPs are being bribed into using NHS Direct because they are pragmatic people who will use a free service. However, it is not a free good and we must recognise that public money is spent on that service. Let us hope that it works out well.

My concern about the clause is that a health authority may be reluctant to sanction any other other-of-hours services as out-of-hours first-line-of-call access is free through NHS Direct. Would arrangements made by individual contractors—to have internal rotas, for example—also have to be approved by the health authority, or could those contractors retain their individual 24-hours-a-day responsibility? I was in a single-handed practice for about 15 years, and I was on call every night apart from Thursday, through a rota with colleagues. That worked well, except that one of my colleagues, who was not terribly reliable, put a message on the answer phone saying, ``If there are any problems, ring me at home''.

Such methods are no longer acceptable to most practitioners, and would not be to me now, because patients' attitudes have changed. That is perhaps part of increasing consumerism, which the Government have fuelled by raising patients' expectations that there should be access to just about anything, 24 hours a day. That issue needs to be addressed, but not in this debate.

Mr Philip Hammond (Runnymede & Weybridge, Conservative)

The hon. Gentleman pursues an interesting line and might further ask the Minister whether the purpose of the clause is to approve providers of out-of-hours services, or whether the regulations under it are to be used to define the routes of access to those services by making it a condition of approval that a person's service is accessed in a certain way. That would run some of the risks that the hon. Gentleman has outlined.

Dr Peter Brand (Isle of Wight, Liberal Democrat)

I am grateful for that intervention, which clarifies what I was intending to say. The clause gives the Secretary of State the power, through regulations, to determine how access is provided, irrespective of local traditions or of what has worked in the past.

I do not oppose the clause, because I am a realist and I know that the world has moved on during the past 20 years. However, I would like an assurance from the Minister that the clause gives neither the Secretary of State nor health authorities powers of direction that could become unreasonable, such as the power to direct not in the interests of patient care but in the interests of administrative convenience, or even the power to shuffle responsibilities among different budgets.

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

I shall start on that final point. The clear intention of the clause is to enable the setting of standards that providers will have to meet. The focus is on those standards; that should be a considerable reassurance to the Committee. Those standards will have to be met by all accredited providers, however their services may be organised. I do not find it acceptable to require a higher standard from one provider than from another. For example, the out-of-hours review proposed that 1 per cent. of clinical records should be continuously audited by a sampling method that would measure the standard of record keeping for each provider of out-of-hours services. We would not want the out-of-hours services of some patients to be subject to that regime, but not those of others. The out-of-hours review suggested the imposition of standards on aspects of telephone access, such as the percentage of calls engaged or abandoned and the time taken to answer, and on the way in which the triage system operates.

Such standards should be available to patients in all parts of the country, irrespective of the way in which the service is provided. Our focus is on those standards. The out-of-hours review suggests measures that are directly related to patient services and patient outcomes rather than to particular organisational models. For example, time limits for home visits in the case of an emergency should be subject to quality standards.

It is important that record keeping and auditing should be of a consistent standard throughout the country, however the provider organises its service.

Mr Philip Hammond (Runnymede & Weybridge, Conservative)

Is the Minister saying that he will not use the regulations under the clause to define certain methods of access only to out-of-hours providers?

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

We have no intention of using the regulations to require every patient to follow a particular procedure—as they are currently drafted, I am unsure whether we could use them in that way. However, I believe that patients will find it convenient to have to ring only one number to access advice and out-of-hours services. That service is already offered to between 2 and 3 million patients in England, as a result of the integration of NHS Direct with GP co-ops. Therefore, it is not just a fanciful concept. It already exists in large areas of west London, where the Harmoni co-op is integrated with NHS Direct. An increasing number of co-ops are integrating their services with NHS Direct. The situation will further improve as the latest triage software becomes available to the whole of NHS Direct and is integrated with out-of-hours services.

An existing telephone line may be retained because, for example, a co-op may wish to offer that service to its patients; but I believe that most patients will prefer to have to remember only one number to access a wide range of services.

I assume that the Committee has not discussed in detail the principle of accreditation because it generally welcomes the proposals that underlie the clause, and that are described, in particular, in the out-of-hours review. Therefore, although I could discuss the clause in more detail, it might be satisfactory to deal only with the issues raised in the debate.

I am unsure whether the hon. Member for New Forest, West was objecting to the concept of NHS Direct or to the idea that there should be accreditation and standards. I assume that he accepts the idea but does not like NHS Direct.

When we began to develop NHS Direct, the official Opposition used to jump up and down and say, ``We thought of it first.'' Now, just as its success is becoming apparent, they seem to have changed their tune. That is typical of their political judgment at the moment.

Mr Philip Hammond (Runnymede & Weybridge, Conservative)

The Minister has rattled my cage. I reassert that my party thought of NHS Direct first; I think that our pilot scheme was in Wiltshire. We have consistently said that NHS Direct could play an important role in the overall delivery of health care services, but it must be properly evaluated before it is rolled out. Our objection is that the Government rolled out the pilot schemes nationwide without any robust study of the value for money and cost-effectiveness provided by the service. As the NHS budget is limited, that is an irresponsible way to proceed.

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

I disagree. NHS Direct—which is clearly linked with the provision of out-of-hours services—is subject to continuous evaluation, and that evaluation is published. NHS Direct is also subject to a degree of clinical governance that is not practised in every part of the NHS. That is one of the great strengths of NHS Direct. Consultations are tape recorded, although the information contained on those recordings is confidential. Therefore, if a patient complains that he or she was told to do X, that can be checked. That would not be the case in almost any other consultation that may take place elsewhere in the health service, and it has enabled previous allegations to be substantiated.

I want progress to be made with out-of-hours services, so that it becomes possible in every part of the country to access accredited out-of-hours services by ringing the NHS Direct number. At present, millions of patients already have that service. Other GP co-operatives would like to work with NHS Direct because they recognise the advantage of having NHS Direct provide a triage service. People working in other parts of the service want to see how it works in practice. That is why the implementation of the out-of-hours review is based on the development of exemplar projects over the coming years.

Those projects will demonstrate to GPs who may be uncertain about which course to take that the service is a cost-effective, patient-friendly and doctor-friendly way of proceeding. That will enable those services to achieve the necessary standards of accreditation and to offer a better service to patients. When we responded to the out-of-hours review, I made it clear that we wanted to proceed on that basis. By working with those who want to move in this direction at an early stage, we will be able to demonstrate to those who have doubts that this is the right direction.

Mr Desmond Swayne (New Forest West, Conservative)

The Minister asked if I was opposed in principle to accreditation. In my opening remarks, I sought to make it absolutely clear that we are in favour of that. We support the principle behind the clause. Our concern is that the regulations might be used to enforce access to all out-of-hours services via NHS Direct, which we do not believe is yet sufficiently robust to bear that burden.

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

I have dealt briefly with the strategy that we would prefer to follow in order to convince people, and I believe that we will achieve our objective.

The resolution of practitioners at the BMA last year about investing £80 million in their premises provoked some amusement. At our last sitting, we discussed the investment of £8,000 million in the premises of GPs, so clearly we are meeting that aspiration of the medical profession.

Regarding nurse-led practices, the responsibility for out-of-hours provision clearly lies with the GP, as does the rest of the service. However, there is no bar to nurse-led practices—PMS practices—becoming accredited providers, provided that they meet the standards set out in the regulations.

Dr Peter Brand (Isle of Wight, Liberal Democrat)

The Minister did not respond to my specific question about whether rotas for GPs who intend to retain 24-hour responsibility will be caught by the regulatory mechanism.

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

I had intended to answer the hon. Gentleman's question. It does not matter whether the service is provided by rotas. If it is an out-of-hours service, it has to be accredited under the regulations. The quality of the service offered to the patient must be consistent.

Dr Peter Brand (Isle of Wight, Liberal Democrat)

If a husband and wife team look after a practice population 90 per cent. of the time, will they have to apply for accreditation in order to have an arrangement about who gets up at night?

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

The issue is whether someone delegates responsibility to another provider. If that is unclear, I will write to the hon. Gentleman.

We must ensure that we have consistent standards across the service. That should be a part of any arrangements that are put into place. There will be some challenges to the traditional provider or practice, but if there is no delegation—the individual is offering a 24-hour service as stated in his or her contract—there will be no accreditation requirement.

Question put and agreed to.

Clause 21 ordered to stand part of the Bill.

Further consideration adjourned.—[Mr. Jamieson.]

Adjourned accordingly at twenty-four minutes past Eleven o'clock till this day at half-past Two o'clock.