NHS: Accident and Emergency Units

Lord Kennedy of Southwark Excerpts

Tuesday 26th November 2013 Lords Chamber

[Lord Kennedy of Southwark (Lab)]

My Lords, I am most grateful to my noble friend Lady McDonagh for securing this debate on the future of NHS accident and emergency units. At the start I declare an interest: I chair, on an entirely voluntary basis, a small committee at Lewisham hospital. It is impossible in just three minutes to get across the scale of the problems and the anxiety and concern of local communities about the A&E crisis that is unfolding before us as the winter sets in.

What did the Government do as soon as they came into office? They had a top-down reorganisation of the NHS, after pledging not to do that, which only made matters worse. What is clear is that this is the Government’s problem. It has happened on their watch, with poor implementation of their already flawed policies, and the cuts they have made to the NHS, to social services and other budgets. There has also been the running down of NHS Direct and the ramshackle way in which the NHS 111 service has been introduced.

I hope the Minister will be able to tell the House how the Department of Health and the NHS are going to respond to the challenges they face, and how they propose to do that with thousands and thousands fewer staff than we had only a few years ago. I fear that things could be even worse than last winter, and we will be back with rising numbers of patients waiting on trolleys at A&E.

We have already had an A&E summer crisis, with more than 1 million people waiting more than four hours to be seen, all on the Minister’s watch. The problem is all of this Government’s own making, and they are not going to get away with trying to wriggle out of it. The Minister and the rest of his team would have us believe that it is everyone else’s problem—it is the doctors’ fault, and the fault of the nurses, the GPs, the porters, the radiographers, the support staff, the patients, or even the weather. It is too cold, or it is too warm, or it is the wrong time of the year. But it is this Government’s problem; it is down to mismanagement by this Conservative and Lib Dem coalition.

If the Minister is going to tell us the problem is caused by too many people going to A&E when they should go somewhere else, can he tell the House why the Government cut Labour’s extended opening hours for doctors’ surgeries and why they are closing NHS walk-in centres up and down the country? Can he confirm how many walk-in centres have closed since the Government came into office? Why did they close NHS Direct, and why did they introduce NHS 111?

My noble friend Lady McDonagh has got it right. We have a dangerous mix of incompetence and ideology. They want to get rid of the NHS, but they realise how unpopular that would be, so instead they pare down to the bone, to the minimum that they can get away with.

--- Later in debate ---

[Earl Howe]

I shall say more on Lewisham in a moment. This is a time-limited debate, and I hope that I may be allowed to conclude my speech.

The principles that I have just enunciated are further enshrined in the four reconfiguration tests first set down to the NHS in 2010, which all local reconfiguration plans should demonstrate. These are support from GP commissioners, strengthened public and patient engagements, clarity on the clinical evidence base, and support for patient choice.

Our reforms allow strategic decisions to be taken at the appropriate level. We are enabling clinical commissioners to make the changes that will deliver real improvements in health outcomes. That is the purpose of reconfiguration. Furthermore, local commissioners proposing significant service change should engage with NHS England throughout the process to ensure that any changes are well managed strategically and, crucially, that they will meet the four tests that I have just referred to.

Given the scale of change across the health system, it is important that local NHS organisations are now supported when redesigning their health services. We are working with our national partners, NHS England, the Trust Development Authority and Monitor, on the continuing design of the interfaces, roles and responsibilities of organisations in the new system. For example, stroke care in London, which has been centralised into eight hyper-acute stroke units, now provides 24 hours a day, seven days a week acute stroke care to patients regardless of where they live. Stroke mortality is now 20% lower in London than in the rest of the UK, and survivors, with lower levels of long-term disability, are experiencing a better quality of life. That is why we must allow the local NHS to continually challenge the status quo and look for the best way of serving its patients.

I turn specifically to accident and emergency departments and points raised by a number of noble Lords. The NHS is seeing more than 1 million additional patients in A&E compared to three years ago and, despite this additional workload, it is generally coping well. I can say to the noble Lord, Lord Kennedy, that we are meeting our four-hour A&E standard and have done since the end of April. The latest figures show that around 96% of patients were admitted, transferred or discharged within four hours of arrival. There are now 500 more A&E doctors in the NHS than there were under the previous Government. Trusts expect to hire 4,000 more nurses, due to the Francis effect, as a result of the public inquiry that the party opposite decided not to pursue.

I have heard many noble Lords describe the current situation as a crisis. I do not share that perception. The NHS is performing well under pressure. Dealing with an extra 1 million patients in A&E does, however, mean that we must look at the underlying causes. Providing urgent and emergency care for people is not just about A&E. It is about how the NHS works as a whole and how it works with other areas such as social care, and how it faces up to the challenge of an ageing population of more people with long-term conditions. Therefore, the Government are taking action to respond to the immediate winter pressures and, looking longer term, we will tackle the unsustainable increasing demand on the system.

NHS England, Monitor and the Trust Development Authority, working with ADASS, have been working together on the A&E improvement and winter planning since May. Staff across the service have worked extremely hard to prepare this year and are committed to making sure that their plans are robust and that patients will receive the services they should expect and deserve. This process was started earlier and is more comprehensive than in previous years. We are determined to do everything we can for the NHS to continue providing high-quality care to patients throughout the winter, which is why we are backing the system with additional funds in the short term to help local areas prepare for and manage additional pressure during the winter.

We have allocated £250 million of funding to NHS England to help cope with winter pressures, with another £250 million for 2014-15. There will also be an extra £150 million from within the NHS England existing budget this year to ensure that everywhere receives a fair share of the funding.

It is, however, clear that the current situation is unsustainable in the long term. That is why we asked Sir Bruce Keogh to lead a review of urgent and emergency care with the first phase published on 13 November, which was also roundly welcomed by the system, including, as noble Lords will be aware, by the NHS Confederation and the Royal College of Surgeons. There will be a further update in spring 2014.

The review is aimed at delivering system-wide change, not just in A&E but across all health and care services in England by concentrating specialist expertise where appropriate to ensure that patients with the most serious illnesses and injuries get the best possible care and ensuring that other services, such as primary and community care, are more responsive and delivered locally. This will mean that people will understand how to access the most appropriate treatment in the right place as close to home as possible.

The noble Baroness, Lady McDonagh, the noble Lord, Lord Patel, and others referred to NHS 111. The introduction of the NHS 111 service is part of the wider revisions to the urgent care system to deliver a 24/7 urgent care service that ensures people receive the best care from the best person in the right place at the right time. This is not only government policy; it was a policy fully signed up to by the previous Government and initiated by them. Although NHS 111 has had a difficult start, we have backed the service with a £15 million fund to support it over the winter. NHS 111 now deals with more than half a million calls a month, and 97% of them are answered in under a minute. The first phase of the urgent and emergency care review sets out a significant expansion and enhancement of the NHS 111 service so that patients know to use the 111 number first time, every time, for the right advice or treatment.

NHS Direct, which was referred to by the noble Baroness, Lady McDonagh, and the noble Lord, Lord Patel, will continue to provide 111 services to patients until alternative arrangements can be made by commissioners. The transfer of NHS Direct’s 111 services is progressing well.

Together with NHS England, we are putting together a strategy focusing on the people who are the heaviest users of the NHS, vulnerable older people and those with multiple long-term conditions. Here I am addressing particularly the points raised by the noble Lords, Lord Patel and Lord Kakkar, and my noble friend Lord Selsdon. The vulnerable older people’s plan will focus on improving out-of-hospital care services centred on the role of general practice in leading proactive, person-centred care within a broader team and is due to be published later this year. A key element of the plan is the provision of joined-up care for vulnerable older people, spanning GPs, social services, and A&E departments themselves, which is overseen by an accountable GP. The aim of proactive care management is to help keep people healthy and independent longer.

A number of noble Lords referred to the workforce challenge. Health Education England is working with stakeholders on a number of innovations to help alleviate the workforce problems in emergency medicine. Through the Emergency Medicine Workforce Implementation Group, Health Education England will work to develop alternative training routes for emergency medicine and a range of mid-level non-doctor clinician posts. They will work with NHS England on potential workforce and training requirements.

I would like to address the point made by the noble Lord, Lord Kennedy, about Lewisham. Lewisham’s A&E is not closing. The TSA proposals were a response, as he is well aware, to a very difficult, long-standing challenge facing south London. The new Lewisham and Greenwich NHS Trust must now work with its commissioners and community to deliver a clinically and financially sustainable future. As regards north- west London, which the noble Lord, Lord Dubs, referred to, the Secretary of State has endorsed the recommendations of the Independent Review Panel, and it is now for CCGs in north-west London, working with NHS England, to take this forward. The decisions here were supported by all the commissioners in the area and all the medical directors in the trusts and all but one of the relevant local authorities.

My noble friend Lady Manzoor spoke about public awareness and engagement. I agreed with a lot of what she said. Through our reforms we have strengthened local partnership arrangements through health and well-being boards. These will provide a forum where commissioners of services, local authorities and providers can discuss the future shape of health services. As I have said, local cases for clinical change should be driven from a local level. We know that these reconfigurations work best when a partnership approach underlies them.

The NHS is one of the greatest institutions in the world. Ensuring that it is sustainable and that it serves the best interests of patients sometimes means taking tough decisions, including on the provision of urgent and emergency care. However—and this is the thought which I leave with your Lordships—those decisions are made only when the local NHS, working with local people and local authorities, is convinced that what it proposes is absolutely in the best interests of its patients.

[Lord Kennedy of Southwark]

My Lords, before the Minister sits down—

[The Countess of Mar (CB)]

Order! It is a time-limited debate.