Urgent and Emergency Care

Lord Kamall Excerpts

Tuesday 6th September 2022 Lords Chamber

[Noble Lords]

Oh!

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)]

I thank both noble Baronesses for their welcome that I am still in post; let us see for how long.

I pay tribute to my right honourable friend the former Secretary of State for Health, Stephen Barclay. When he came into office, he was quite clear that he saw the headlines, the issues about access to GPs and primary care and the ambulance waiting times. He said, “Look, I don’t know how long I’m going to be in office, but I’m determined to work on this over the summer”. This Statement is the result of that. Had he stayed in post, no doubt some of the questions that the noble Baronesses, Lady Brinton and Lady Merron, raised would have been answered with other Statements. Hopefully he has set in place the process to enable his successor to deal with some of these issues.

When he came into position, he was quite clear. In fact, he was so clear that he said, “I want the latest numbers on my wall”. He also asked, “Who do I need to talk to?”. He got the NHS England leadership in, contacted the most challenged trusts and the ambulance services and asked, “What can we do to help and how do we understand about discharge?” As the noble Baronesses rightly said, it is about not just ambulances but the whole system of discharge, making sure that there is somewhere in the community for patients to go from hospital. Are there sufficient beds? He has tried to work on this. Clearly, some of this will take time to work through.

Both noble Baronesses referred to the fact that we have contracted St John Ambulance to deliver auxiliary ambulance services. My understanding from when I checked is that this is immediate, but I will have to clarify that to make sure I have given an accurate answer to the question. Because ambulance trusts receive central monitoring and support from the NHS England-funded ambulance co-ordination centre, the Secretary of State worked closely with NHS leadership to look at how to put money into the system and to make sure it gets spent and gets through the system. It is all very well talking about inputs, but how about that? We have provided £150 million extra to improve response times, additional call handler recruitment and investment in the workforce. We have seen an increase of about 12% in ambulance staff and support staff since 2019.

On the handling numbers, it is really important that it is not just about signposting individuals. There are health professionals on the line who can deal with the patients when they ring up for advice. When I had to call 111 just before the summer break, I spoke to the call handler, who then arranged for a GP to ring me back to have a further, detailed conversation. As a result, the GP then made an appointment for me at the local A&E, so I just had to turn up at an allotted slot. That is what they are looking to do to ease pressure on A&E. Can they deal with it without having to go to A&E in the first place? For the less urgent but immediate cases, can they allocate a time slot?

So we are boosting the 999 and 111 call handler numbers and providing targeted support to some of the hospitals facing the greatest delays. The former Secretary of State was quite clear about looking at the areas where we have the most trouble, seeing what we can do about it and getting all the system leaders together. I am afraid it will not be resolved overnight—I am sure that noble Lords recognise that—but trusts are now closing 12.5% of incidents over the phone, which is nearly twice the pre-pandemic rate. We are also providing investment to upgrade the accident and emergency facilities at more than 120 separate trusts.

There is also the national discharge task force, which is focusing on how we address the discharge problems in particular areas and work with local system leaders to understand those problems. The former Secretary of State has been having those conversations and diving into real detail, either convening people or bashing heads together to make sure that we tackle this. He has put in a place a number of processes, which my right honourable friend the new Secretary of State for Health, Thérèse Coffey, will have to deal with. He has at least put that process in place so she can hit the ground running. As I said, he has taken a close interest in the most difficult and challenged areas.

I will try to deal with some of the specific issues. First, the former Secretary of State was quite clear that we need to think about the winter plan now and not wait until we hit winter. That means preparing for variants of Covid-19, and increasing capacity outside of acute trusts and resilience in 111 and 999 services, as we have mentioned; it means looking at target category 2 response times and ambulance handover delays, at how we reduce crowding in particular A&E departments, and at how we reduce hospital occupancy.

In response to the question from the noble Baroness, Lady Brinton, about the breakdown between virtual beds and hospital beds, I cannot give that data at this point; it might be a dynamic situation, as and when, and will depend on whether individual patients’ homes are suitable to accommodate a virtual bed. They will have to meet certain standards; it is not just a word but a proper virtual bed. We also need to look at how we can ensure timely discharge and provide better support for people at home.

On mortality rates, we see the headlines and, clearly, we have conversations with our officials within the NHS. They do not believe that it is correct to link those performance figures directly to current excess mortality rates but they recognise that there are, sadly, far too many cases of people who should have been seen. There have been deaths but I do not have exact numbers. I will try to get more details for the noble Baroness.

On the overall workforce, as I have said a number of times, I would disagree with noble Lords who say that there is no plan; that is not correct. We have already commissioned Health Education England to work with partners. The department has also commissioned NHS England on long-term workforce planning. As noble Lords will know, the Health and Care Act makes it incumbent on the Secretary of State to publish a report on the workforce and the challenges ahead.

I will stop there for now. I apologise to the noble Baronesses; I will try to answer in writing the questions that I have not answered here this evening.

[Viscount Hailsham (Con)]

My Lords, would my noble friend agree that the problems in the ambulance service are essentially reflective of the problems in the National Health Service more generally? Would he also agree that there is a widespread feeling that the National Health Service as presently constituted is no longer fit for purpose? Given that, and bearing in mind that proposals coming from individual parties or Governments are unlikely to command general consent, has the time not come for the Government to appoint a royal commission to consider how best health services in this country should be provided and funded? Such a way forward might provide the basis for a proper, agreed change.

[Lord Kamall (Con)]

I thank my noble friend for his question. We have a debate this week tabled by the noble Lord, Lord Patel, on reform of the health system. One thing the noble Lord believes, as do a number of other practitioners and noble Lords who have worked in the health service, is that it is time to reform the old model of seeing your GP, getting five or 10 minutes if you are lucky, and then being referred to secondary care elsewhere. In this day and age, we need such reform. We need to take advantage of data and new technology but also to look at work processes. Some of the stuff that was being done in secondary care until recently can now be done at primary care level. Even in primary care, it does not always have to be the doctor who sees the patient; it can be a practice nurse, a physiotherapist or a local civil society group.

Clearly, there is a need to look at the model of the NHS and how services are provided; all parties recognise that there are areas for reform. It would be great if we could get consensus but, sadly, this issue is too much of a political football. When I speak with my friends from other parties, we say candidly that something has to change and that there has to be reform, but it is clearly too tempting to bash any Government. I know that, when we were in opposition, we would have bashed the Government of the day on health. It is, sadly, too tempting a political football.

[Baroness Bennett of Manor Castle (GP)]

My Lords, I follow on from a point raised by the noble Baroness, Lady Merron. The Statement refers to the new contract with St John Ambulance—I join others in welcoming that—and to recruiting call handlers, paramedics and social carers. There is no reference to the acute crisis we have regarding doctors, nurses, midwives and associated health professionals.

To pick up on the question of whether we need a royal commission and systems change, the underlying situation is that the UK has 2.8 doctors per 1,000 people and 7.9 nurses, which is the second lowest in the OECD. Our number of hospital beds per head of population is on average lower than everywhere in the OECD but Denmark and Sweden. We simply have an acute lack of resources, which is independent of systems and is putting enormous pressure on services. We are now seeing huge pressure being put on medical professionals. Being a specialist in A&E is an acutely difficult and challenging task. The issues of ambulance response times and the queues of ambulances outside A&E are clearly putting huge pressure on people.

The Minister referred to the fact that, as we speak, we have a new Secretary of State. Surely it is time to acknowledge the contribution that those doctors, nurses and other medical professionals are making, through some kind of new, big gesture from the new Secretary of State to say, “We have to keep you. We really value you.” We are recruiting new people but others are walking out of the door as quickly or more so. This has to change. Surely a recognition of the care and service that has been given and continues to be given would help.

[Lord Kamall (Con)]

The noble Baroness makes a very important point which noble Lords across the House will agree. We should pay tribute to the hard work of medical staff in our system of care; there is no doubt about that. I take the point that this is about not just the ambulance service but other parts of the health service. In fact, had my right honourable friend the former Secretary of State stayed in post, he would have issued subsequent Statements on what we are doing about the GP workforce and some of the other issues that noble Lords have raised.

It is clear that one of the issues is retention. The NHS has its people plan, published in July 2020. We understand that people are leaving and, yes, there are newspaper headlines, but what are the issues behind those headlines? There is a very difficult issue around pensions and, particularly for some of the wealthier GPs, whether it is worth their while, having built up a massive pension over the years. There has been a bit of discussion and to and fro with the Treasury over that. However, it is quite clear at trust and workplace level that we have to make sure there are well-being courses and that we are looking after staff. We also have to look at the individual decisions as to why people may want to leave.

No doubt many staff are exhausted after the last couple of years. An amazing amount of pressure has been put on them and, as the noble Baroness says, it is right that we find ways to send a strong message that we value them and want to keep them as well as recruit new staff. We also have to look at this against the wider picture. We have more doctors and nurses than ever before. The question is: why, despite that, do we have this pressure? It is because the demand is outstripping supply.

We are now aware of far more health conditions than we were, say, five, 10 or 20 years ago. When preparing for a debate on neurological conditions the other day, I asked my officials to list them all. They said, “We can’t do that, Minister—there are 600.” Let us think about that. We were not even aware before of all those conditions. How many staff does that require? Or let us think about mental health: 30 or 40 years ago, it was not taken seriously; it was all about a stiff upper lip and pulling yourself together. Now we take it all seriously, and have mental health parity in the health Bill, which will need more staff. We will have more staff—more doctors and nurses—but the demand will outstrip supply. That is why a proper debate is needed across parties.

[Lord Colgrain (Con)]

My Lords, I apologise for leaping rather prematurely to my feet before my noble friend the Minister just now.

It is often the case that you read things in the newspaper and either you doubt the veracity of the information or you feel it is apocryphal, and you have to wait until such time as something occurs to you personally before you understand how vital it is. Last week I visited my 97 year-old mother, and I was there when she suffered a fall as a result of which she broke her hip. I rang the emergency service at 5.30 pm on Wednesday afternoon and at 4.30 am on Thursday morning the ambulance arrived—so she had been disabled on the floor for 11 hours at that stage. I said to the ambulance people that I thought it was appropriate that I follow them to the hospital, but they said, “I wouldn’t do that if I were you. It’s an hour’s journey to the hospital and there’ll be a waiting time of two hours before she’s admitted because we’ve just come from a queue there”. So that took it up to 14 hours.

I have to say that the good cheer and good manners of the people on the 999 line when I was calling them every two hours was exemplary, as were the good humour and good treatment that my mother subsequently received at the hospital, but I had difficulty answering her rather acerbic comment at 3 am that she wondered why she had fought so vigorously in the last war if she was going to be left lying on the floor for that length of time before being taken to hospital. I myself really felt the comment about the darkest moment of the night coming before the dawn, being completely helpless and not knowing what to do with someone in considerable pain, with no one able to tell me whether or not to administer painkilling pills and whether or not to give her something to eat or drink. It made me realise how helpless other people feel in similar circumstances.

So I ask the Minister to do whatever he possibly can all the way down the chain to make sure that this sort of situation does not occur to too many people. We have had noble Lords in this debate talk about the length of hours that people are now waiting to be admitted to hospital, but it is perfectly clear, on the strength of my mother’s experience, that in many cases those hours are extended. It really is a third-world situation in which we find ourselves, so anything that the Minister can do to help with that, I, she and the public in general would be extremely grateful for.

[Lord Kamall (Con)]

I start by thanking my noble friend for sharing that very personal experience with us. One of the reasons why my right honourable friend the former Secretary of State wanted to issue this Statement was that when he came in he saw that they were sadly far too many such stories—my noble friend will not be the only one with such a story; undoubtedly, there will be other noble Lords with similar stories—and it was important for him to say, “Look, this has gone on long enough. Let’s get all the people together in the room”. That is why he made this a priority. He wanted to put the numbers on the wall but was told he should not do so for various reasons—but at the same time he wanted to make sure that he spoke to the leadership of trusts as well as NHS England to make sure that they were really focused on this.

Some of the measures announced in the Statement will take time to filter through while others, hopefully, will be immediate, such as the St John Ambulance. All I can say is that I will continue to push and, if I stay in post, I will encourage my right honourable friend the current Secretary of State to continue the work that their predecessor put in place to really make sure that we get a grasp of this issue and try to pull as many levers as we can to tackle it.

[Lord Scriven (LD)]

My Lords, I declare my interest as a non-executive director of Chesterfield Royal Hospital NHS Foundation Trust and as a vice-president of the Local Government Association.

It is not hubris when I say that the Minister needs to understand that this is a crisis and the health service is at the point of breaking, when you see what is happening to patients and to staff trying to deal with the total number of procedures and patients coming into the health service. An absolutely breathtaking statistic from analysis shows that in July only 40% of patients who were ready for discharge were discharged on the day that they were medically fit. That meant that 60% of beds were blocked in England by people who could not get social care or go home.

It is anticipated that at a bare minimum £7 billion per year is required to deal with the social care issue. The Government have a vision but no road map, no timetable, no milestones and no measures of success for social care. What is happening with social care? It is one of the key issues that are leading to ambulances being held at A&E and potential deaths before people can get into hospital for the medical care that they need.

[Lord Kamall (Con)]

I assure the noble Lord that we are aware of the situation; it is one of the reasons why this Statement was made in the first place. We know there are problems with delayed hospital discharges. That is why we have the national hospital discharge task force, which has been set the 100-day discharge challenge, focused on improving the processes but also on digging deep—not just the Secretary of State issuing an edict from afar and saying “Get on with it” but following up with NHS leadership to make sure that we are looking at this issue.

We are selecting these national discharge frontrunners from among ICSs and places to look at new ideas but also to see what has worked in a particular place. A number of noble Lords often give me an example of a hospital that they believe is doing very well. When we take it back to the NHS and say, “Can we replicate this elsewhere?”, they talk about the specific circumstances of that local area and the way that system is set up and why it could work. The ICBs and the integrated care partnerships have committees to look at this, and they know it has to be done as quickly as possible. So first there is the 100-day challenge between DHSC, the NHS and the local government discharge task force.

Adult care capacity is a problem that has been brewing for a long time. One of the things that we have been trying to do with social care, particularly through the integration White Paper but also with the Health and Care Bill, is finally to put it on an equal footing with health so that it is no longer the poor Cinderella service, and indeed to professionalise it. One of the reasons why we have the voluntary register is to make sure that we understand what is out there, who is out there, who is working and what qualifications they have so that we can build a proper career structure for people in social care to make sure that it is an attractive vocation for life and not just something that they do rather than working in Asda or elsewhere, and also that they have parity with the health service.

We are also looking in the medium to long term at some of the discharge frontrunners and at streamlining the intermediate care service, which could reduce delays by about 2,500 by winter 2023-24. Some of this stuff is to tackle the crisis now but some of it is long term to make sure that if we resolve it and get the numbers down we still do not forget about it, and that we build resilience into the system.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, I phoned 999 two weeks ago after my wife had a nasty fall at home. The good news for the Minister is that the ambulance and paramedics turned up within half an hour, they were extraordinarily good and she was admitted to a major hospital—it was St George’s Hospital; I may as well name it. Unfortunately, it was just before the bank holiday. She had problems with her spine and she waited five days in a brace before they could do an MRI because, apart from the most acute emergencies, MRI scanning had closed down. In 2014, the Government were attacked for failing to provide proper services over bank holidays. They said they would look at it and change it, but here we are eight years later, and it is no different. Had it been done quickly, she could have been out, the bed would have been freed and the waiting list would have been shortened. I actually offered to pay for an MRI to be done if they would do it quickly to relieve her of the pain and torture she was going through, but they said, “Sorry, we can’t do that.” This is the problem we have with the NHS.

The real elephant in the room is that much, much more money has to go in. Those who can pay more must pay more and be willing to pay more. That will shorten the lists and produce more money to make conditions for staff even better so that they work in a different way. It would reduce the lists for everybody, but we are not radical enough and not prepared to do it. With the change that has taken place, nothing fundamental is going to happen in the next two years and this problem is, regrettably, going to continue. My question is: can the Minister please do something to make sure we use the equipment available to the maximum, which is not happening at present?

[Lord Kamall (Con)]

I thank the noble Lord for sharing that personal story—the good and bad side of it. I was on a visit to a hospital a few months ago where they showed us a nice, new scanner, which they were very proud of. The question was: how much is that used? Does it sit empty at weekends? With more networks and being more connected, we can find out where there is capacity in the system. If there is equipment, why are there not staff available? It could be for staff absence reasons. If it is not there, where can people go? With more community diagnostic centres, you will find lots more diagnosis facilities and scanners, so if the acute place does not have it, there should be availability in the community.

On the wider question about being “radical”, the noble Lord will know that, while we may have candid conversations as friends from different parties, sadly, health is too tempting to use as a political football. There are some issues that people feel very strongly about. Some of the points about charging that the noble Lord mentioned would be seen as too radical by some, or as undermining the very ethos of the NHS. I think we have to be prepared to be radical and think the unthinkable, but, sadly, this is the formal, political debate that we have got, and we have to work within the remit of that debate. Why should it be, for example, that millionaires could not pay a little bit more to help—not through taxation, but maybe direct?

Some local trusts have tackled this issue. For example, my local trust has set up a private arm, but the money paid for private diagnosis or surgery is reinvested into the hospital to help NHS patients. I know that more than one trust has done that. That might be an interesting way of raising more money and making sure that people value the service and care they get.

On the specific issues, one of the reasons we are having this discussion is because the former Secretary of State was looking at all the issues that need to be tackled now, both in the short term and the long term.

[Baroness Bennett of Manor Castle (GP)]

My Lords, the noble Baroness, Lady Brinton, referred to overseas recruitment of doctors and nurses. The Statement refers to the “international recruitment task force” for social care. I am not sure if the Minister is aware of the report prepared by the Rights Lab at the University of Nottingham, The Vulnerability of Paid Migrant Live-in Care Workers in London to Modern Slavery. If not, I ask him to assure me that the department will be looking at this. The report highlights real issues about the treatment of migrant care workers, particularly in live-in situations. It is a cross-departmental issue, looking also at immigration issues like being tied to one employer where migration status is a real problem. It also looks at the need for a registration system for recruitment agencies. Can the Minister assure me that the department will look at that?

[Lord Kamall (Con)]

I thank the noble Baroness for the question. I am not aware of that report. If the noble Baroness would be happy to send a copy to my parliamentary email, I will happily forward it to officials in my department and see if we can get an answer to that.

House adjourned at 8.03 pm.