(9 years, 10 months ago)
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The Lord Bishop of St Albans
To ask Her Majesty’s Government what is their assessment of the pressures facing accident and emergency services.
The Lord Bishop of St Albans
My Lords, I come to this debate not as a doctor with specialist medical knowledge nor with any special insights into the complex processes which hospital managers have to manage. I approach it as someone from an institution, the church, which has been concerned for healing, in its broadest sense, from its very foundation and I live opposite what is left of the great medieval monastery of St Albans, which for centuries was a centre of healing, with its infirmary and herbarium. In my present role, I have regular contact with the hospitals across Hertfordshire, Bedfordshire, Luton and Barnet, which make up the diocese of St Albans.
I also come as someone who has received the benefits of A&E departments in my own family. Not many years ago, my eldest nephew was diagnosed with a brain tumour and had to have serious surgery on several occasions. Sadly, he has since died from the tumour. About five years ago, he and all the extended family were staying with me for Christmas and, in the early hours of Boxing Day, he had a fit. I remember vividly the intense panic as we were all roused out of sleep to find what was going on; as we waited anxiously for the ambulance, willing it to come because we all felt so helpless; as he was rushed into Watford General Hospital A&E department. What a relief it was, in that terrible time, to feel there were people around who knew what they were doing. I am well aware from talking to doctors and nurses and visiting hospitals that the widespread coverage in the media about A&E departments has not only been frustrating for many of those front-line people but profoundly demoralising. I pay tribute to all who work in such departments and thank them for their tireless service, not least those in Watford General Hospital.
The House will be aware that pressures on A&E services have been mounting over a number of years. While the NHS always faces pressures in the winter, these have been compounded by our ageing population. We now have 350,000 more over-75s than four years ago. This rise has occurred simultaneously with a significant increase in A&E attendances and a greater level of sickness among those who arrive, leading to an increase in emergency admissions of nearly 6% on last year. In my own diocese, the A&E departments are facing these challenges with varying degrees of success. For the week of 5 January, Watford General Hospital fell below the Government’s target of 95% of patients seen in four hours, while Luton and Dunstable University Hospital exceeded this target, in line with its track record as one of the top 10 trusts in the country.
What is causing this? Attendances are up, but the problems go much deeper. Reports have emerged of people in some places having difficulty getting appointments with their GPs. There have been discussions about changes in social care leaving some elderly and frail people without the necessary support. There are staff shortages and recruitment difficulties in A&E units. Many in your Lordships’ House will be aware of A&E’s three main areas of activity: triage, treatment and referral. Problems tend to arise in bottlenecks at the triage and referral stages. Effective triage is compromised by the presence of patients whose needs do not fit the current services offered in A&E departments. Until quite recently, these individuals were often referred to as “inappropriate attenders”, but current research suggests that it is not the patients who are inappropriate, but the services that emergency departments provide. Estimates vary that between 15% and 40% of patients require services other than those offered by an emergency department and it is the presence of these patients that creates part of the bottleneck at the triage stage.
At the other end, efficient referral after treatment is compromised by problems in bed allocation in acute medical and surgical wards as well as by accessing appropriate services. In many cases, A&E doctors admit patients for further diagnostic tests or when the additional expertise of medical or surgical staff is required. Around 20% of referrals from A&E to acute wards involve patients whose conditions could be treated appropriately by their GPs or in the community. Up to 40% of patients referred to acute wards are discharged within a few hours of admission. The Department of Health says that the effective management of the flow of patients through the health system is at the heart of reducing unnecessary emergency admissions and managing those patients who are admitted. The problem is how to identify how this can best be done.
Much of the debate in the other place has, not surprisingly, been highly politicised because we are approaching an election. I hope that, in this debate, this House can stand back and take a more dispassionate view, drawing especially on the huge knowledge and experience of some noble Lords who have intimate, personal working experience in the National Health Service. I hope that we can set this debate in a slightly wider and longer term context. Certainly, it needs to be set against the background that A&E services across Europe are facing similar challenges.
Until recently, some emphasis has been placed on attempts to demagnetise emergency departments, even though it has long been established that this tactic meets with little success. Both self-referrals and referrals from GPs willing to short cut protocols have resulted in increased numbers of patients presenting for treatment. Some 20% of A&E patients decide to attend a day in advance, the majority do not consider going first to their GPs, and 80% fail to make use of advice services such as NHS Direct. While there has been a change in people’s expectations and preparedness to wait for an appointment with their GP, we must not overstate the extent to which A&E services are being clogged up by misuse. The vast majority of A&E users are not inappropriate attenders; that is to say, they should be within the health service.
Recently, some pilot projects have begun to change the range of services available in A&E departments. For example, some GPs co-locate in emergency departments as primary care physicians while others locate out-of-hours GP services adjacent to A&E departments. Other GP practices have supplemented NHS Direct with their own telephone consultation services, enabling patients to speak with their own doctors. There is growing evidence over the past decade that these approaches relieve pressure on A&E staff and enable efficient triaging at the front door. Similarly, pilot projects that locate acute medical and surgical staff in or approximate to A&E departments at peak times have enabled improved patient flow as additional diagnostic expertise has resulted in inappropriate admissions to acute wards being minimised. Co-location of acute assessment units has also enabled patients to be monitored and assessed without them either remaining in A&E or by being admitted to acute wards. These approaches require strong leadership, close co-operation among health professionals, focus on patient care and strategic implementation. What more can be done to enable every hospital to have its own 24-hour GP practice?
Ultimately, resolving the current and on-going A&E crisis involves a systematic change to the ways in which health and social care are organised. Access to good social and community care can relieve pressure on GPs, enabling them to play a greater, proactive role in emergency medicine. Allied with a willingness to break down barriers within hospitals between emergency departments and acute wards, strain on A&E staff can be alleviated and patient experience improved. I hope that this debate will play a small part in exploring the complex reasons for the current problems and help us in addressing the challenges facing A&E departments today.
Lord McColl of Dulwich (Con)
My Lords, I thank the right reverend Prelate for initiating this important debate. He has set exactly the right tone—let us keep petty party politics out of this and concentrate on the patients. It is important to stress that the staff in A&E departments—nurses, doctors and administrators—are doing a very good job indeed under difficult circumstances. Having worked a lot myself in accident and emergency departments, I know only too well how difficult it is. Patients come in, one is not sure what is going wrong with them, and it takes a little while to sort them out.
There were some political shenanigans some years ago when there were complaints about people waiting on trolleys far too long in casualty. I produced a paper when I worked in No. 10 entitled Off Your Trolley. The answer was that if you are really ill and they do not know what is wrong with you, stay in the casualty department where all the expertise is—the expert equipment and the doctors and nurses—until an accurate diagnosis has been made. If it worries people that they are on trolleys, they should take the wheels off after 20 minutes and the trolleys will then constitute a bed, so people will not fuss about it.
Things have improved enormously in this service from the days when I first worked in casualty. I remember once going through the accident and emergency department of a hospital that shall be nameless, where there was a man groaning on a trolley. I went up to him and asked how he was, and he said, “I’m in terrible pain in my shoulder, it’s dislocated, I’ve been here for three hours and I have not seen anyone”. I said, “I could put you in a very comfortable position where you’d be free of pain. Would you like that? I’m not working in the department, but we can get on and do it”. So I put him on his face with his arm hanging over the side of the trolley and the moment when he was in that position he said, “Ah, I’m free of pain”. I said, “Now you’re free of pain, the muscles will relax and the thing may go back on its own, without any anaesthetic—so you go off to sleep and I’ll come back in half an hour and see how things are”. When I came back, he was sound asleep and snoring, so I crept up on him and very gently manipulated the arm. Suddenly, clunk, it went back—and he woke up and said, “Oh, it’s gone back”. I said, “Yes, you can go home now, but perhaps we ought to tell somebody what we’ve been doing”. Things are much better than that now, because we have rapid assessment. Somebody senior goes around the A&E departments, assessing things quickly, so that sort of thing no longer happens.
There has been an enormous increase in the number of people attending, and we do not know why. As we do not know why, it is quite wrong to start blaming any group of people. It is very demoralising if you are a doctor, nurse or administrator working for the NHS and people start attacking and accusing you of this and that when they really do not know the cause of the increase in the work. What is true is that more resources are being put in and more staff are being recruited, which is good news. But we must stop blaming people and pointing the finger. The blame culture has to go, and we have to be more constructive.
What is the answer? Preventive medicine is one of the great emphases in the Department of Health, and it certainly helps. We have the worst epidemic that we have had for 95 years in this country—the obesity epidemic—and we need to get people thinned down. They have to eat less and take more exercise. We have to improve people’s health, which will tend to reduce the problem. But we also have to have an alternative way of funding the NHS.
Baroness Gale (Lab)
My Lords, I, too, thank the right reverend Prelate for bringing this important debate before us today. I may take a slightly different angle from other noble Lords. We are all aware of the problems facing accident and emergency services, but the current pressures on them are exacerbated by a consistent failure to properly support people with long-term conditions such as Parkinson’s, both before and after hospital admission.
In 2012-13, people with Parkinson’s had more than 65,000 unplanned or emergency admissions to hospital, often due to falls, infections or cognitive issues. In England, those over 65 with Parkinson’s are three times more likely to have an unplanned admission to hospital than other people of the same age. In addition to creating serious pressures on already overstretched hospitals, this costs the NHS around £177 million each year. However, with proper support at an early stage, many of these admissions could be avoided.
Giving people with Parkinson’s the right information and equipment can often help them to manage their condition, rather than relying on accident and emergency services once they reach crisis point. Services such as physiotherapy, dietician support or falls prevention are also a great help in averting health crises, yet access to these services remains inconsistent. Good quality early intervention would significantly reduce the high number of people with Parkinson’s coming into accident and emergency departments in the first place, thereby relieving some of the pressures that hospitals are now facing.
There is also an urgent need to improve care for people with Parkinson’s once they are admitted to hospital, in order to reduce both avoidable harm and the length of time they are required to stay. Patients with this condition currently spend around 75% longer in hospitals than others of a similar age, equating to more than 128,000 excess bed-days a year. In 2012-13, these excess days cost the NHS more than £20 million. A key reason for this is that many people with Parkinson’s who are admitted to hospital often experience serious disruption to their medication. Parkinson’s medication regimes are often complex, sometimes requiring up to 30 doses at specific points throughout the day. It is vital that people receive their medication on time, because delays can rapidly worsen their symptoms. We have discussed many times in your Lordships’ House the need for these patients to get their medication on time, every time. Anyone with Parkinson’s who does not receive their medication on time is put at risk, and these incidents can create a vicious cycle of escalating care needs for patients with Parkinson’s and overwhelming pressures on hospital staff.
However, there are a number of straightforward and cost-effective steps that hospitals can take to reduce medication errors and excess bed-days for people with the condition. They include giving patients the option to administer their own medication, as recommended under existing guidelines; taking up Parkinson’s UK’s training opportunities on the importance of medication timing; and making sure that there is always a supply of Parkinson’s drugs in emergency medication cupboards so that they are easily accessible when someone with the condition is admitted.
I am sure the Minister recognises that there is a clear link between the lack of adequate support for people with long-term conditions like Parkinson’s, and the serious pressures being experienced by accident and emergency services. Taking steps to reduce both avoidable admissions and avoidable harm will protect individuals, alleviate the strain on hospitals, and benefit our health service as a whole. I hope that the Minister will take the opportunity to outline how these problems can be addressed as part of the Government’s wider response to the current situation.
Lord Jones of Cheltenham (LD)
My Lords, I, too, congratulate the right reverend Prelate on securing this timely and important debate. I should like to focus my remarks on the situation at the Gloucestershire Hospitals NHS Foundation Trust and the critical incidents at A&E at Gloucestershire Royal and Cheltenham General Hospitals. The latest critical incident lasted for more than a week and was lifted only yesterday. Presumably in that time, hundreds of routine operations and admissions were cancelled and have stacked up. This was the second such critical incident at GHT in a month and went on longer than those at other trusts in the country. We need to understand why.
It is complicated and not simply to do with money. We know that the coalition Government have increased NHS spending overall from £95 billion in 2010 to £115 billion this year, giving GHT £3.6 million for winter pressure this year; so what are the problems? Are too many 111 calls going into A&E? Anecdotal evidence from local doctors says that they are, and certainly the non-medical call-handlers have a naturally risk-averse system that will direct people to a doctor when in doubt. The Prime Minister, in response to a Question from my honourable friend Martin Horwood, said that only 7% of 111 calls ended in A&E. I believe that that was a statistic from October; it would be helpful if the Minister could tell us whether that is increasing and what it has been in the last month or two.
GHT has implemented what is called the UTOPIA system of routing all unplanned admissions through A&E. Has this made things worse? The theory is that people see a doctor sooner than in direct admission, when they have to wait for the next ward round, but in practice you need enough capacity in the emergency department to handle cases, which GHT pretty obviously does not have. I wonder whether the June 2013 decision to remove doctor cover from Cheltenham A&E at night and route blue-light admissions to Gloucestershire made matters worse. I understand that these decisions were made not due to a lack of money, but simply to the failure to recruit sufficient staff. Is there something wrong with the salary structure within the NHS that particularly affects Gloucestershire? At night, Cheltenham General Hospital is now really a minor injuries unit, although I understand that it still gets help from GPs in the out-of-hours service based at CGH .
I have spent more time than I care to remember as a patient in Cheltenham A&E. In January 2000, I was there following a sword attack in my constituency office which left my assistant dead and my hands in need of repair with 57 stitches. Then, in 2002, 2003 and 2006 I had three events of flash pulmonary oedema, all at night. This is a deeply unpleasant experience in which the heart goes into a ridiculous non-rhythm and stops pumping and one’s lungs quickly fill up with fluid. Fortunately, I was at home when these events occurred; I am grateful for the prompt response of the ambulance paramedics who rushed me to Cheltenham A&E. On two of these occasions my wife was called out of the family room and told to prepare herself for the worst; but thanks to the skill of the truly wonderful doctors and nurses—and, no doubt, a lot of praying in the family room—I survived. I do not know what the doctors did: I was out at the time, but I understand that a super-dose of frusemide was involved. If the recent downgrade of Cheltenham A&E had been in operation then, it would have taken an extra 15 minutes to get me to Gloucestershire Royal. I would probably not have survived and would not be here now addressing your Lordships’ House. Therefore, will the Minister ask the regulators and the Care Quality Commission to look into the difficulties in Gloucestershire to give answers as to why we have experienced these critical incident periods? Will he please ask the Gloucestershire Hospitals Trust to reinstate round-the-clock A&E services at Cheltenham General Hospital and ensure that it has the capability to recruit sufficient doctors, nurses and technicians?
The Lord Bishop of Ely
My Lords, I am very grateful to the noble Lord, Lord McColl, for reminding me how pleased I was to be off my trolley in February 2013, when I was admitted as an emergency patient to Addenbrooke’s Hospital in Cambridge. Were it not for the skill and dedication of the surgeons and nurses—and the grace of God—I would not be here now. Like the right reverend Prelate the Bishop of St Albans, I pay tribute to the dedication of staff in our hospitals, not least Addenbrooke’s, from which no one needing emergency treatment is turned away.
I support the thrust of what the right reverend Prelate has already said. The immediate problem for Addenbrooke’s recently, in its critical incident over accident and emergency, was the high intake of unusually frail elderly patients in December. They took up more than 300 of the 700 adult beds available. The number of elderly admissions is bound to double—so the chief executive tells me—in the next 20 years. The only immediate resolution was provided by a release of funding and access to beds in social care by the county council.
I am pleased to commend the even closer co-operation of trusts and social care providers to ease the pressure on A&E and to provide even more joined-up care for the frail and elderly, both in their homes and in nursing environments. The new frailty assessment unit at Addenbrooke’s seems to me a way ahead in offering an overhaul of how hospitals care for the physically and mentally frail patients, and how to keep patients in hospital for the shortest possible time by having such units next to A&E with a resident multidisciplinary team.
I am also very concerned about the CQC’s report on Hinchingbrooke Hospital in Huntingdon. Without wanting to support poor performance, Hinchingbrooke’s best asset is its dedicated staff. The chaplaincy was one department that was praised in the report. I shall visit staff at the weekend with the chaplain. I mention the Hinchingbrooke situation because a longer-term response to this debate needs to be an urgent approach to even closer synchronicity between regional hubs and district hospitals. This will be one such opportunity.
Very importantly, alongside having GP services available in hospitals, we need to rethink how we recruit younger GPs to market towns and semi-rural settings, such as most of my diocese. In Ely itself, an older profile of GP practice is desperately seeking younger colleagues to take on the profoundly important and complex care needs of the very elderly. The experience of Ely is that recruits are not easy to find. When they are found, they do not often stay, because they are not prepared for the multiple and heavy demands placed on GPs providing clinical, social and pastoral care for elderly patients who are desperate to stay in their own homes, which is much to be commended. We need to support our GPs, as I know Simon Stevens plans to do in his proposed strategy for the future of the NHS. However, this needs to be rooted on the ground in how younger people are formed and prepared for the reality of GP ministry among the elderly in our communities.
In December, the chief executive of Addenbrooke’s, the clinical commissioning groups and the county council presented improvement plans to Simon Stevens and the chief executive of Monitor. Here was an opportunity to pool together the most effective joint services and investment in a lively, real and continuous approach, beyond any change of government, to how we unite our health services properly to get beyond immediate crises to a careful and thoughtful response, particularly for the most elderly members of our communities.
Viscount Simon (Lab)
My Lords, in opening the debate the right reverend Prelate mentioned people having to wait in ambulances outside A&E departments, in addition to which some patients have to wait at home for ambulances to arrive because ambulances are not available. I wonder how many patients’ conditions, when they arrive seriously ill at hospital, have worsened due to the delay.
Until recently St John Ambulance could provide a rapid response to patients where and when required, thus keeping conventional ambulances free for other work. It could also provide immediate life-saving intervention in more serious incidents where ambulances were delayed in reaching the patient and when it was nearer. It was able to use blue lights and sirens. It could also use motorcycle units when required, in addition to which motorcycles were used to transport emergency equipment, medicines or other parts very urgently.
However, following a judgment handed down in the Court of Appeal last March, all response services not involving a conventional ambulance have ceased. The judgment has also applied to many other operating response cars, support vehicles, emergency equipment tenders and the like. Consequently, they can no longer exceed speed limits, go through red lights or do anything else that they used to do under an exemption. A special order under Section 44 of the Road Traffic Act 1988 refers to the use of sirens and lights. It runs from 6 June 2014 until 5 June 2016 and permits vehicles constructed for medical response emergencies that are not emergency vehicles to operate within the meaning of the various vehicle lighting and construction regulations. A list has been provided of the ambulance services covered that are associated with NHS trusts.
As St John Ambulance vehicles are appropriately constructed, I wonder why they have not been included in the list. Is there any possibility of this being amended? It also has very robust driver training standards and compliance. St John Ambulance used to be very useful and very helpful to the accident and emergency services and it still could be if the exemptions that it and other like-minded organisations used to have for vehicles used “for ambulance purposes” were restored.
Lord Greaves (LD)
My Lords, I will follow up the remarks that have just been made by the noble Viscount, Lord Simon, on ambulance response times.
Pendle Borough Council in Lancashire—I declare an interest and remind the House that I am a member of it—has made full use of its new statutory scrutiny powers concerning the health service as laid down in the Health and Social Care Act. A meeting of its health scrutiny panel this week received evidence from councillors and members of the public. For Pendle as a whole, in the three months at the end of last year the number of ambulances arriving within eight minutes was only just over half, at 55.7%. However, in the West Craven area of Pendle—the towns of Barnoldswick and Earby and surrounding villages on what might be called the Lancashire-Yorkshire border country—it was 10.7%, which is clearly not satisfactory.
Evidence was also received from members of the public on 999 calls that on at least two occasions, on 17 November and 14 December, 999 calls were put through to the ambulance service, but then went on to an answering machine. Clearly that is totally unsatisfactory. I wonder whether the Minister will have a quiet word and find out whether something is seriously wrong in this part of the North West Ambulance Service.
The rest of what I want to say comes from a hands-on account by a worker at a Greater Manchester hospital who works nights in A&E, which I have very kindly been supplied by UNISON North West. I would like to read out the account that this worker has provided, which shows the pressure that workers such as this are under. The account says:
“We work as a team—there are doctors, nurses, mental health specialists, radiologists. It’s challenging and rewarding work. Staff work 12 hour shifts and rarely get to take their scheduled breaks. I just have to grab something to eat and keep going.
We never know what we’re going to encounter … but some things are predictable … a lot of alcohol-related cases up until about 3am. From 5am we begin to get broken hip or fractured neck cases where elderly people have had a fall. These are often people in care homes who are having ‘unwitnessed falls’ when they get up. I think that if there were enough staff in care homes some of these accidents would never happen.
Sometimes people come in with minor ailments like colds because they can’t get a GP appointment … But our main problem is that we don’t have enough capacity for people who really need to be admitted.
We see most patients within 4 hours. If they need to be admitted they should then go to the MAU (Medical Assessment Unit) for the first 24 hours, but sometimes there isn’t space … We have some bays on A&E where people can wait on trolley beds, but if we have too many then patients can have to wait for 2 or 3 hours on corridors. Ambulance paramedics help to provide the care that patients need while they wait, but it is a frustration to us that they are not being treated in the right environment. Detaining the paramedics also has a knock-on effect for the time it takes to respond to new emergency calls.
When MAU is full, the registrar will come to A&E and discharge people when they can. This can be a problem and we can sometimes see the same people in A&E the next night and even the night after that.
If they need to be admitted and there is no room in MAU, patients might be moved out of MAU after less than 24 hours. Other patients who are sleeping on wards can be moved during the night to make space for them to be accommodated. It can be that people end up on a ward that is not best placed to meet their needs.
We are struggling to provide the level of care that we want to because we don’t have enough capacity. We want to provide the best but the service is always stretched … We feel that we have to work flat out all the time just to keep things going … I sometimes can see that staff are so stressed that they should really be off work, but they won’t take time off as they know that will make things even worse for their colleagues”.
In a sense, that shows the strength of what is traditionally known as the public service ethos but really it indicates that it is not just when the four hour target is being breached that these kinds of stressful situations and pressures exist, but week-in, week-out through the year, as many of us know from the experience of the people we speak to.
Lord Hunt of Kings Heath (Lab)
My Lords, this has been an excellent debate. I congratulate the right reverend Prelate on his very penetrating analysis of the challenges facing the NHS at the moment.
Like other noble Lords, I pay tribute to staff in the emergency services, indeed in the whole of the health and social care system, for the way that they are responding to the enormous pressure. The noble Lord, Lord Greaves, really put his finger on it when he talked about some of the pressures. We know that junior hospital doctors are at the moment not being attracted into emergency departments. Can the noble Earl tell me whether the Government have a strategy for finding ways in which we can both encourage new doctors into emergency departments and also relieve some of the pressure on them so that they do not burn out and find it overwhelming when they face situations as they do today? Will he also respond to my noble friend Lord Simon on the contribution of St John Ambulance and other services like it?
On the actual pressures, my noble friend Lady Gale spoke very eloquently about the pressures in relation to people with Parkinson’s. The right reverend Prelate the Bishop of Ely talked about the doubling of admissions over 20 years. Can the noble Earl say what the Government expect in relation to flows of patients through hospitals through A&E? He will know that the five year plans of NHS trusts and foundation trusts are all predicated on reducing capacity on the basis that something will happen elsewhere so that patients no longer need to go to hospital. There is very little sign that that is going to happen, and I would like to hear what the noble Earl has to say about that.
I understand the point about politics. I gently point out to the House that this yearly increase is nothing new. In the previous Government we managed to cope with it and keep within our targets. There is no doubt that something has happened. I have no doubt that the restructuring has had an impact. The one thing that is missing above all else at the moment is someone being in charge locally. There is no one single person in a health and care system you can go to and say, “You are in charge. You are responsible”. We desperately need to get that local leadership back.
On the 111 issue, which the noble Lord, Lord Jones, raised, are the Government going to undertake a review of it? Has the noble Earl seen the evidence given yesterday by Cliff Mann, the president of the College of Emergency Medicine, when he said that the “absurd” 111 helpline is to blame for overloading A&E with patients?
I also pull up the point made by the noble Lord, Lord Greaves, about the ambulance service. Is the Minister as alarmed as I am by reports today of ambulance staff from the East of England Ambulance Service leaving the dead body of a man on the floor so they could finish their shift on time and indeed the report yesterday of staff there on their own volition apparently not following procedures in relation to the maximum call-out times? What is going on in the East of England Ambulance Service? We need an external review of it. On ambulance services I also ask the Minister about the policy of some services very insensitively called “drop and run” where patients are left at the door of A&E without a proper handing over to A&E staff after a certain time limit of 30 to 45 minutes.
On the weekly A&E data, one trust last week hit only 53.7% against the 95% target. What impact does the noble Earl think that will have on mortality rates? Is monitoring going on to see what impact that is having on safety and quality?
Finally, does the noble Earl agree that there are all sorts of issues such as 111, primary care and people’s predilection to come through the door more often because A&E is a place where they are going to get high-quality care from a lot of staff which is not available out of hours elsewhere? However, when it comes down to it one single issue is clearly responsible for most of our problems—the swingeing cuts made by the Government to local authorities and the impact on social care. The real issue is that patients cannot be discharged into the community because the community facilities have gone. What is the noble Earl going to do about that?
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I very much welcome the opportunity to debate this important issue and I pay tribute to the right reverend Prelate the Bishop of St Albans for introducing it so admirably. The NHS is facing unprecedented demand with record numbers of people attending A&E and the ambulance services providing record numbers of emergency journeys. Despite this, the NHS is still providing high-quality care, and alongside the right reverend Prelate the Bishop of St Albans and other noble Lords, I place on the record my thanks to all NHS staff for their hard work in responding to this challenging time.
Winter is always challenging and this year it comes on top of a general increase in A&E attendances. In 2013-14 these were up one-third on 2003-04. So far this year, A&E attendances have been higher than in any year since 2010 with, on average, almost 3,500 more people a day attending. This has led to an increase in emergency admissions of nearly 6% on last year. The noble Lord, Lord Hunt, said that this was nothing new. I have to tell him that it is. It is about double the trend of increase that we have seen in recent years.
There is no single cause of the increase in A&E attendances. Healthcare is a system and problems that arise in one part of the system will impact elsewhere. Commissioners and providers need to look at what is happening not just in hospitals but more widely, and address the issues that are most salient in the particular area. That is what they have done in drawing up local plans to spend the £700 million of additional support mentioned by my noble friend Lord McColl that the Government have made available to the NHS so it can ensure urgent and emergency care services are sustainable year round and ready for the pressures of winter. In addition to providing more staff and beds, the money has funded local initiatives including: local information campaigns so people are better informed on where and how to access the services they need; seven-day pharmacy services; enhanced NHS 111 and GP out-of-hours services; and schemes to help people recover in the comfort of their own home after surgery. Some £50 million of the winter money was specifically to support ambulance trusts.
I have set out what the Government have done in response to the immediate winter pressures. However, we recognise fully that we require system-level change to ensure that services can be delivered on a long-term sustainable basis. I will now set out our longer-term plans to achieve this goal. The right reverend Prelate the Bishop of St Albans called for a systematic review and that is already under way. NHS England’s urgent and emergency care review should improve access to, and the availability of, services outside hospitals. This will involve providing consistent and same-day access to primary and community services.
The vision for the review is simple. For people with urgent but non-life-threatening needs, the NHS must provide highly responsive, effective and personalised services outside hospital and deliver care in or as close to people’s homes as possible, minimising disruption and inconvenience for patients and their families. For people with more serious or life-threatening emergency needs, the NHS should ensure that they are treated in centres with the very best expertise and facilities in order to maximise their chances of survival and a good recovery. If the NHS gets the first part right, it will relieve pressure on hospital-based emergency services, so that the focus can be on delivering excellent care.
NHS 111 plays an important role in ensuring that people get access to the right care when they need it. Only around 8% of calls handled by NHS 111 result in advice to attend A&E. In November the figure was in fact 6%. Moreover, 30% of callers say that they would have attended A&E if NHS 111 had not been available. That indicates that NHS 111 is instrumental in diverting people from A&E rather than adding to those attending. It is a myth that NHS 111 makes matters worse.
Implementation of the urgent and emergency care review will include enhancing NHS 111 so that it becomes the smart call to make, offering a 24-hour, personalised priority contact service. The service will have access to people’s medical history and allow them to speak directly to a nurse, doctor or other healthcare professional if that is the help and advice that they need. NHS 111 will also be able to directly book a telephone call-back service.
Another key aspect of improving services outside hospitals is providing seven-day access as a matter of course. Currently, not all services are delivered at weekends, and sometimes staff cannot get the advice and decisions that they need from more senior colleagues on Saturdays or Sundays. Delivering the vision of seven-day services could improve the clinical outcome for patients. NHS England is therefore working with NHS employers and staff to develop plans on how seven-day services can be delivered. This should improve outcomes and experiences for patients as well.
I should like to move on to the better care fund. For the first time, this Government will join up health and social care services through the £5.3 billion better care fund. I can say to the noble Baroness, Lady Gale, in particular, and to the right reverend Prelate the Bishop of Ely that the vast majority of this money is being spent on social care and out-of-hospital community health services. These aim to keep people—especially the frail elderly—out of hospital and, if they have to be admitted to hospital, support them to leave safely as soon as they are well enough to do so.
Underlying the new approach are improvements in seven-day working across health and social care to help quicker, more appropriate discharge from hospital. One of the metrics for the fund is the number of people supported to remain at home at least three months after discharge from hospital. Plans project that over two years, the number of older people supported to remain at home at least three months after discharge from hospital will increase by 33.7%. That will be good for those patients but it will also save a great deal of money. Schemes in plans typically focus on things such as increasing capacity in reablement or intermediate care services, or multidisciplinary emergency response teams, which focus on avoiding unnecessary admissions to hospital.
I now turn to our plans for access to primary care. We are offering 7.5 million more people extra evening and weekend appointments, as well as e-mail and Skype consultations, through the Prime Minister’s Challenge Fund, and by 2020 we will offer seven-day GP services to everyone in England. We have announced a £1 billion primary and community care infrastructure fund, which will improve access for millions more people through introducing new models of care and improving estates and infrastructure—including, I am sure, GPs’ surgeries. There are now more than 1,000 more GPs working and training in the NHS compared with the position in September 2010, and there are 40 million more appointments every year than there were in 2008-09.
I turn to some of the questions that were asked during the debate and, as usual, I shall write to noble Lords whose questions I cannot answer today. The noble Lord, Lord Hunt, made me prick up my ears when he said that the problem is that no one is actually in charge of the system. I contend that the system is now more co-ordinated than it has ever been with the system resilience groups that we see in every single area of the health service. These groups comprise commissioners, acute providers, social care and all the players in the system so that they can genuinely co-ordinate their actions and assess the risks and priorities that they need to address.
The right reverend Prelate the Bishop of St Albans said that people are turning up at A&E when they could go elsewhere, and he is absolutely right about that. The urgent and emergency care review that I referred to noted that it had been estimated that about one-quarter of A&E attendees could have been treated elsewhere. A number of local areas are taking action to make people aware of the range of different urgent and emergency care services that are available and the circumstances in which they should be used, as well as the alternatives, such as pharmacies, that are open to people.
The right reverend Prelate also asked about staffing, especially doctors—a point also raised by the noble Lord, Lord Hunt. Compared with last year, more than 260 more new doctors will be available in A&E. That is good news. It includes British trainees but also senior staff from other countries, including India, the UAE, Egypt and Malaysia.
A number of noble Lords, including the right reverend Prelate the Bishop of St Albans, called for more collocation of services. I fully agree with the wisdom of that suggestion. As part of the urgent and emergency care review, NHS England is supporting the collocation of community-based urgent care services in co-ordinated urgent care centres. He may like to know that 112 out of 143 NHS hospitals already have GPs working in, or collocated with, A&E departments.
My time is nearly up but I want to touch briefly on ambulances. The department is working closely with NHS England, Monitor and the NHS Trust Development Authority to improve performance, and the Government have provided an extra £50 million of funding to ambulance services. However, these services are facing unprecedented levels of demand, with an additional 2,000 emergency journeys a day. Despite that, they are still providing high-quality care. We have introduced the ability to fine providers where handover delays at hospitals are unacceptable. Since then, those delays have gone down markedly.
I will respond to my noble friend Lord Greaves about the North West Ambulance Service, and I will also respond on the incident of the dead body, which the noble Lord, Lord Hunt, mentioned in relation to the East of England Ambulance Service.
My time is up but I hope that noble Lords have been able to glean from what I have said that there is a great deal going on. We are gripping the issue. There is no one cause of the increasing pressure on A&E, but we have comprehensive plans, which I have just covered in some detail, to relieve the pressure that we are currently seeing on our A&E services.