Stunell, Hunter and Lamb on NHS Appointments

• [Feb 04]: ' . . WE need to learn the lesson that grandiose, centrally imposed systems that are ill-thought through and do not get buy-in from clinicians are doomed to failure.'

Andrew Stunell (Hazel Grove, Liberal Democrat): I AM pleased to have the opportunity to bring this important issue to the House and look forward to the Minister's response. It has affected the medical histories of many of my constituents.

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

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

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

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

"Me, I'm giving up but if you wish to carry on the saga be my guest!!!"

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

• Norman Lamb (North Norfolk, Liberal Democrat): Does my hon. Friend agree that if a particular hospital or clinic disappears from the list because the waiting time is more than 18 weeks, that restricts choice rather than enhancing it?

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

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

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

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

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

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

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

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

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

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

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

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

that is, my constituent-

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

"one of the great success stories of the national programme for IT."-[Hansard, 4 November 2008; Vol. 482, c. 102.]

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

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

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

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

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

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

• Norman Lamb (North Norfolk, Liberal Democrat): Let me start by congratulating my hon. Friend Andrew Stunell on securing this important debate. I congratulate also my hon. Friend Mark Hunter on his contribution, which was also important to the debate.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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