Upper Gastrointestinal Haemorrhage

Andrew Murrison Excerpts

Monday 11th April 2016 Commons Chamber

[Dr Andrew Murrison (South West Wiltshire) (Con)]

I am sure we are all very relieved to be having the Adjournment debate at this hour, rather than at two o’clock in the morning, as was previously rumoured.

I must first declare my interest as a doctor. I am grateful for the opportunity to bring forward this extremely important debate—it is certainly important for our constituents—about the management of acute upper gastrointestinal bleeding. I am grateful to the British Society of Gastroenterology, and particularly to its president, Dr Ian Forgacs, for helping me with research in preparing for the debate. The BSG has done a great deal of work over many years to highlight this issue.

Between 50,000 and 70,000 people every year are admitted with acute upper gastrointestinal bleeding, and 10% will, sadly, die. That presents a significant challenge to our national health service.

For the avoidance of doubt, let me say that upper gastrointestinal bleeding is what was so vividly portrayed by Hugh Bonneville, as Lord Grantham, in Julian Fellowes’s “Downton Abbey”. As the New York Post said, the Downton ulcer his lordship had been moaning about for weeks finally erupted all over the dinner table and all over Lady Cora. That is at the extreme end of the spectrum, but when it happens it needs to be dealt with very quickly and proficiently.

I want to start with a little bit of good news. Lord Grantham was lucky to survive in the 1920s, but mortality from upper gastrointestinal bleeding has been falling in the UK, with modest improvements in recent years as new treatments and innovative therapies have emerged, despite an ageing demographic. That is a tribute to our NHS and to some great pioneering work in therapeutics and interventions, much of which has been trialled and researched in the UK.

[Jim Shannon (Strangford) (DUP)]

I thank the hon. Gentleman for giving way; I asked him beforehand for permission to intervene. Northern Ireland has seen some improvements by allowing relatively experimental procedures, provided they are regulated, such as nitrogen treatment systems, to name just one. Does the hon. Gentleman agree that all trusts across the UK need to share such information on any and all new developments, to advance treatments nationwide so that we all gain across the whole of the United Kingdom of Great Britain and Northern Ireland?

[Dr Murrison]

I am grateful to the hon. Gentleman, who takes an interest in these matters. He is right to say that we need to do more networking, to ensure that good practice is understood and inculcated. I will deal with some of that in my remarks.

Two major studies—one by NHS England and the British Society of Gastroenterology in 2013, and the other by the National Confidential Enquiry into Patient Outcome and Death in 2015—highlighted significant shortcomings in provision, confirming earlier studies.

The foreword to the NCEPOD report is starkly entitled “A Bleeding Shame”. NCEPOD found that the clinical care of 45% of acute GI bleed patients was sub-optimal, with a similar number receiving care judged to be good overall. Alarmingly, a quarter of all hospitals treating upper gastrointestinal bleeding were found not to be accredited by the joint advisory group set up 20 years ago to set standards for endoscopy. More hospitals told NCEPOD that they could deliver open surgery of the sort Lord Grantham had in the 1920s than interventional radiology for this particular range of conditions.

Some would say that that is down to inadequate resources. That is the mantra we often hear, particularly from the Labour party, but the situation is far more complicated than that. Alarmingly, NCEPOD reported that organisational issues led to less than satisfactory care in 18% of cases. “Organisational issues” is a polite way of saying poor management, such as failure to organise rotas—the “Bleeding Rota”, as NCEPOD graphically puts it—and I will come back shortly to how that can be addressed with minimal resource implications.

I support the concept of the seven-day NHS, or at least my interpretation of what a seven-day NHS actually means. The management of this range of conditions provides an excellent case study of why seven-day working is important and why Ministers are right to pursue it.

Overall, the evidence does not support the proposition that relatively poor weekend healthcare outcomes for conditions across the board are attributable to a lack of seven-day working. As Professor Matt Sutton’s work, reported by the Office of Health Economics last year, has shown, the quality-adjusted life-year evidence just does not support the cost of translating midweek working to the weekend. Data on increased mortality for those admitted at the weekends are alone insufficient to justify organisational change. The much cited Freemantle paper on weekend deaths does not say that excess weekend deaths are avoidable. Unfortunately, it has been quoted incorrectly by some who have confused association and causation.

Sir Bruce Keogh is right to say, however, that general hospitals are under-resourced at weekends, and the Academy of Medical Royal Colleges is right to point out that junior doctors are, to a certain extent, “winging it” out of hours, because consultants do not tend to be around to the same extent and many support functions are not, either. I remember it very well indeed. Sir Bruce was also right, in his 2013 review of 14 trusts with persistently high mortality rates, to commission Professors Nick Black and Ara Darzi to try to bottom out the relationship between excess mortality rates and avoidable deaths. Sadly, the report published last year did not seem to take us much further forward, other than to call into question the basis of the selection of trusts for the original Keogh review.

In my view, there is a firm argument for a seven-day-a-week NHS, but we need a common understanding of what that actually means beyond the soundbite. Upper GI bleeding is a good case in point, which the Government could perfectly reasonably use to support their proposals for seven-day working without resorting to selective quoting from, for example, the Freemantle paper. Most people are really not bothered about the inability to get an outpatient appointment in dermatology on a Saturday afternoon. That is a luxury bordering on an indulgence. However, if their Downton ulcer erupted on a Friday night, they would not really want to wait until a chaotic Monday morning list before getting endoscoped. They would need to be scoped on a routinely scheduled endoscopy list the following day, and they should not be subjected to delay in investigative and interventional radiology if that is necessary to manage their case optimally.

As far back as 2004, a large study by Sanders published in the European Journal of Gastroenterology and Hepatology showed that dedicated GI bleed units are associated with reduced mortality. NCEPOD asserts that patients with upper gastrointestinal bleeding should only be admitted to units with on-site endoscopy, on-site or networked interventional radiography, on-site surgery and on-site critical care. It promotes the model of comprehensive, dedicated GI bleed units in hospitals on acute medical take. We are far from achieving that.

That highlights some broader issues around right-sizing the NHS estate for optimal acute and critical care outcomes, which is a subject that I have raised before. Because critical care requires multi-specialties, because of the need for increased sub-specialisation and all that implies for populating staff rosters, and because of the better outcomes in large specialist units, not to mention the cost pressures, optimal management of this range of conditions underscores neatly the need for the model hospital concept outlined in February by Lord Carter of Coles. Why are we not moving faster towards having secondary and tertiary care in regional and sub-regional centres, where critical mass, and therefore quality of outcome, can be more readily assured?

I am proud to support a Government who are spending more on the NHS than ever before—spending, let it be remembered, that was opposed by the Labour party at the general election. However, outcomes in the UK routinely compare unfavourably with those in similar countries, with which we can reasonably be compared. I have no specific comparative data for acute upper GI bleeding, but I have no reason to suppose that they run counter to that general trend. The unavoidable truth is that our neighbours spend significantly more on healthcare than we do. The right hon. Member for North Norfolk (Norman Lamb) and I, with colleagues across the House, have called for a commission to achieve consensus on long-term funding. That is despite Simon Stevens’s five-year forward view, which does not come close to addressing what is needed to make progress, given the assumptions on which it is based, which we know we cannot rely on.

It is not just about money, however. The impression given by the studies that I have relied on is that the management of acute upper GI bleeding is a hit-and-miss affair. The BSG blames a

“lack of engagement from senior managers”

for that patchiness. That ties in with the remarks made last week by Dame Julie Moore, who said that there was a “culture of indecision” in the NHS, and that there was “gross incompetence” and a “failure of leadership”. That is pretty hard hitting from a very senior NHS manager, and I wonder how individuals can justify salaries well in excess of the Prime Minister’s if they are failing to get a grip on the sort of shortfalls described as “A Bleeding Shame” by NCEPOD. Dame Julie is right to ask why incredibly expensive senior NHS managers who are managing failure on this scale are still in post.

Last year’s NCEPOD report on acute upper GI bleeding is a wake-up call. Its first and prime recommendation —that patients with any acute GI bleed should be admitted only to hospitals with 24/7 access to on-site endoscopy, on-site or formally networked interventional radiology, on-site GI bleed surgery and on-site critical care—must be implemented without further delay. The answer is dedicated GI bleeding units that are seven-day NHS-compliant, and, with very few exceptions, no unit that cannot match the BSG’s guidelines should take patients with acute upper GI bleeding.

I look forward to hearing how the Minister will make this so. I invite him to return to the House after 12 months, if I am fortunate enough to secure another Adjournment debate of this sort, to tell us how the position has improved.