Emergency Healthcare (Public Services Committee Report)

Baroness Morris of Yardley Excerpts

Thursday 20th July 2023 Grand Committee

[Baroness Morris of Yardley (Lab)]

My Lords, I am also pleased to be able to contribute to this debate as a member of the committee. I pay tribute to my noble friend Lady Armstrong, who was the inaugural chair of the Public Services Committee and has led it through its first years. Indeed, this report was the last from the committee under her chairmanship. I overlapped with her only on this one report, but I could tell from the time I spent on the committee how much she had done to establish it as a very important committee in our House. I know that there have been a whole series of reports which will add to our debate and our consideration of some crucial issues facing society at the moment. On behalf of all committee members, I place on record our appreciation for the contribution she has made.

I am sorry that this debate is taking place seven months after the report was published. There was never going to be a queue at the door waiting to get in as the debate started, but I hope the appropriate authorities can take note of this.

Governments are always reluctant to use the word “crisis”, as lots of things flow from that. Our committee found that there was a crisis in emergency care, and we used that word. I think we produced sufficient evidence to say that there was a crisis.

Even if you do not take that point, it is interesting to look at the document published by the Government since then, the Delivery plan for recovering urgent and emergency care services, in which they describe what happened last winter and the state we are in. They said it was

“the most testing time in NHS history”,

that there were

“problems discharging patients to the most appropriate care settings”,

and that hospitals reached record occupancy levels. The document also says that patients were spending longer in accident and emergency departments and waited longer for ambulances, and that that has taken its

“toll on staff, who … work in an increasingly tough environment”.

The committee could not match the description the Government themselves gave of the state of the ambulance service and emergency services at key points during last winter. So, whether you want to use the term “crisis” or not, our joint starting point is that things were intolerable last winter and have been intolerable for quite a while. We are not confident that they are going to be any better this winter. To some extent, the challenge for this debate and for the Government now is whether they can use those experiences and the evidence we gave in the report to make sure that things are not as bad next winter and that we can move on.

Lots of things have happened since our report was published, and I want to refer to some of them. It is very difficult, given the time of year and the way the public debate moves on, to know exactly what progress has been made since our report was published in January. I know that some of the figures on waiting times for ambulances have got better. I do not know if that is because of the time of year or because of action the Government have taken. However, I noted with some concern the National Audit Office’s report from June this year. When it looked at recent performance, it concluded that patient access to services for unplanned or urgent care has worsened; that there is too great a variation in service throughout the country; that the NHS has not met operational standards; and that performance has worsened in terms of delays in transferring patients from one service to another.

That is where I think we are. There is joint knowledge and a shared platform of debate that there was a crisis last time, and some of the statistics were very worrying. The one bit of evidence we have from a third party—the NAO report—does not indicate that things are getting any better. The effect this has had on the public, communities and their confidence is well known. It is no exaggeration to say that people lost their lives because this service was not performing at a higher level.

I want to take six points from our committee which struck me, on reflection, go through them and invite a response from the Minister. These are the six areas that stuck most in my mind, and I would like some reassurance that progress is being made on them. First is the immense complexity and connectedness of all the different parts of the system. We talk a lot about the health service and social care and how they do not work together. However, when you look at the emergency services, it is not just those two that have to work together: it is the police and the fire service, and the attitude of the public.

That leads to the second point: it is very difficult to work out who has the ability to effect change. People want to change things. They want to change their bit of the service, but they cannot change other bits. What became evident during the committee’s deliberations is that there is no one leader who can solve the difficulty. That is a problem, but the system itself does not allow people to make changes that have to be made if they are to improve their bit of the service. There has been a really good example of that since our committee’s report was published: the decision of the Metropolitan Police not to attend mental health cases.

I know why the police have done that, because in the committee you would hear somebody tell you that some police officers are spending the whole of their shift sitting in A&E with a person who has mental health problems, whom they have been called to assist. I can absolutely understand why they have said that that cannot happen any longer. I do not believe for one minute that the head of the Metropolitan Police has not tried to solve the problem as well, but I suspect that he has concluded that he cannot get other bits of the system to shift or make the changes in social care, the local authority or the health service—he has to act unilaterally to protect the service that he is absolutely accountable for and responsible for delivering. That is just one example, but that has happened in the last few months. We find so many cases of that, where people knew what they wanted to do to make their bit of the service better but were powerless, because changes needed to be made elsewhere, and the structure that could have brought everyone together to make the changes just does not seem to be there.

My third point, and the point that the noble Baroness, Lady Armstrong, made, was that people are risk averse, and there is very little approach to shared risk. I was pretty appalled to find that some schools, as a matter of policy, called an ambulance every time a child had a head knock, even if the parents were there and were prepared to take their child to accident and emergency. I do not want to belittle the difficulty of taking decisions like that if you are a headteacher or a teacher, but something is wrong there, if mum and dad say that they will take their child to accident and emergency, and the school says that no, the policy is that they have to call an ambulance for every child who bangs their head. We heard similar stories in care homes with patients who had fallen. The public are risk averse to making decisions which on reflection, might perhaps be more sensible.

We see that with 111 services as well. The statistics show that the 111 person is more likely to say to go to the accident and emergency than they are anything else, because there is a risk-averse attitude there. With some of the targets, the attitude to risk is problematic. For those responsible for making sure that ambulances do not wait in the car park at the entrance to the hospital, the best thing to do is to get the patient into the A&E waiting room, because they have then met the target—but it has not solved the problem for the patient, who is now in the waiting room. Others want to get them out the other end, because their target is to get the accident and emergency casualty waiting room down to as few people in it as possible. So they push the patients out to somewhere else, where they wait to go into care or back into the community, and they have met their target.

There are so many instances where people behave in a way that shows that they are not connected to other bits of the service, and they are risk averse. They want to solve their bit of the problem and make sure they can show that their service is performing better with regard to targets. No one actually says, “Let’s put our risks together—let’s put it all together and let’s have some sort of target, which means that I in my bit of the system act in a way that helps you as well as me”.

The fourth point is that one thing that frustrated me, time after time, was that I sat and listened in the committee to the most wonderful pilots going on in different parts of the country. I thought, “Why have we got a problem? Why is anything wrong, because I have just heard the most wonderful example of what is happening?” Nobody knew why it did not happen elsewhere as well. Nobody knew who was evaluating it or who had the power to say that it should happen elsewhere, and that is a problem. So I say to the Government that, while I welcome some of the initiatives that they have announced in recent months—full service virtual wards, transfer of care hubs, and greater flexibility for clinicians—the key thing remains that they are all relatively confined things that are likely to bring about some success.

The key problem for me—and this is where I finish—is that, with the integrated care boards, who is going to make sure that someone can implement the plan that they have been charged with writing up? Could we do more so that the regulators actually make a judgment as to whether services are working together, as well as whether they are working for their own interests? Can the Minister perhaps reflect about whether he is absolutely confident that the people who need to make changes have the power to do so?