Ukraine

Debate between Andrew Murrison and Philippa Whitford

Thursday 27th April 2023 Commons Chamber

[Mr Speaker]

I call the Scottish National party spokes- person.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

The current situation in Bakhmut is dire, with Russian forces pounding the town with rockets, mortars, attack drones and phosphorous incendiary bombs, which are banned under the Geneva convention. Russian forces have occupied the Zaporizhzhia nuclear power plant since last month, and they are now taking up positions on the roofs of reactor buildings. That raises the concern of damage in future fighting and the threat to the population should that occur. The Wagner mercenary group has admitted to killing hundreds of people who were sheltering in a basement, including 40 children.

What are the UK Government doing to get defensive weapons, in particular ammunition, to Bakhmut as soon as possible? Are the UK Government co-ordinating with producers and European allies with regard to the provision of iodine tablets and radiation treatment? Will the Government step up further the sanctions against the despicable Wagner mercenary group?

[Dr Murrison]

The hon. Lady is absolutely right, and I share her sentiments entirely. There is no excuse for nuclear blackmail at Zaporizhzhia or anywhere else. I am appalled by the war of attrition in Bakhmut. It is a most appalling slur on the continent that we call home, and it will be an enduring slur on Putin’s Russia. In terms of protection, I am pleased to say that the International Atomic Energy Agency is monitoring the situation in Ukraine, and the UK obviously stands ready to be of assistance in any way that it can be.

Health Inequalities

Debate between Andrew Murrison and Philippa Whitford

Wednesday 4th March 2020 Commons Chamber

[Dr Whitford]

I thank the hon. Member for that recognition. The Scottish Government are spending more than £100 million every year in mitigating some of these cuts—they pay the bedroom tax and they have set up the Scottish welfare crisis fund—but that is money that should be going into devolved areas, not patching up austerity decisions here; it is not the role of the Scottish Parliament just to mitigate.

Public health in England has been cut by £850 million—again, the greatest cuts to the poorest areas—and it is exactly the same with future planned cuts. This has led to cuts in smoking cessation projects. There is no point standing up and talking about the importance of stopping smoking—we all know that. People who have smoked for decades need help to stop and those services are critical. We have also seen cuts to drugs and alcohol projects and to sexual health projects, and all those have an impact on the poorest people.

The Minister, who is no longer in her place, might have listened to Dame Carol at the drugs summit in Glasgow but, sadly, the Minister for Crime and Policing, the hon. Member for North West Hampshire (Kit Malthouse), did not. He came to Glasgow, made his speech and then left before all the expert evidence was given. We also hear of a social care gap across England of over £6 billion. Again, that affects women if they have to give up work to look after elderly relatives or disabled children. This rolling back of the state has affected the social determinants and increased health inequalities. Child poverty has increased, as we have heard, with 4 million children affected, and 1,000 Sure Start centres have been closed. Education funding is down. There is a housing crisis and therefore a rise in homelessness. People with insufficient funds to afford a healthy life are depending on food banks, and deprived communities are simply losing hope.

Poverty is simply the biggest driver of ill health and has the biggest individual impact on life expectancy. The increase in life expectancy in England has stalled for the first time in 120 years—the first time since 1900. The gap between the most and least deprived has widened: the gap is now almost 10 years for women and the life expectancy of some women in areas of the north-east of England has dropped by almost a year.

[Dr Murrison]

I always listen with great respect to what the hon. Member has to say, but given that the SNP has its hands on many of the levers relating to the things she has discussed this afternoon, I am assuming from what she has said that Scotland is in the wonderful position of having narrowed health inequalities. Could she perhaps compare and contrast what has happened in Scotland with what has happened in the rest of the United Kingdom? I rather think that the two are very similar.

[Dr Whitford]

If the right hon. Gentleman waits to hear the rest of my speech, I will highlight some of the differences in child poverty.

We have seen life expectancy for those women falling, but when we look at healthy life expectancy, the gaps are even bigger. Time spent in poor health is increasing, and that of course puts pressure on the NHS and care services. We in this Chamber are always discussing the pressure that the NHS is under. Emergency admissions in areas with low life expectancy are double the numbers in wealthier areas. Women in deprived areas will now spend two decades or more of their life in poor health. Improving the healthy life expectancy by at least five years was actually a policy in the industrial strategy, so that people could be active and engaged in the economy, but what we have seen is an adverse effect both on health and health equality.

We know that someone’s health for most of their life is determined in the early years, even starting when their mother is pregnant. Child poverty is central to this and it is rising. It is defined as children in households with less than 60% of median income. England had child poverty down to 27%, but it is now 31%. Scotland had it down to 21%, and it is now 24%. That is because welfare changes are taking place right across the UK. Poverty is decided in this Chamber; it is not decided anywhere else, and the Scottish Parliament, as we have heard, spends a lot of energy on trying to mitigate it.

As we know, housing costs are a major contributor because of the shortage of housing. This is a rising issue among the poorest: 38% of the poorest will spend 30% or more of their income on rent or housing. That figure was 28% 10 years ago. The Scottish Government have built 87,000 affordable houses, and that is part of why our child poverty level is lower. It is the housing impact. In the 2015 general election, the Conservatives promised 200,000 starter homes. They built precisely zero.

Some 4 million children are growing up in poverty, and that will affect their whole lives. Whenever the issue is raised at the Dispatch Box, we are told that unemployment is down and that people must work their way out of poverty. We are told that that is how we change things, yet two thirds of those children already have a working parent. The problem is that all of this drives ill health.

Universal Health Coverage

Debate between Andrew Murrison and Philippa Whitford

Wednesday 10th July 2019 Westminster Hall

[Dr Murrison]

I was about to say that I am really comfortable to do so, because the decisions he made, and those he is associated with vicariously, are good ones. I am happy to have inherited his portfolio, but he is a difficult act to follow, that is for sure.

My right hon. Friend identified all the issues in his contribution, as I would expect him to do. He started by highlighting universal health coverage and its contribution to SDG 3, but he also made the point that universal health coverage touches on the other SDGs as well. In advance of the high-level meeting on 23 September, he was right to ask about the aims and ambitions the UK Government have for that meeting. They are encapsulated in getting more money—obviously—and getting better quality and integrated healthcare. That is something many of the contributions have touched on one way or another. I have been struck by the level of support for an holistic approach to delivering universal healthcare.

We have talked about immunisation and about the mistake we would be making if we simply imagined that going around the world offering people vaccinations and inoculations would be “job done”. It really would not be. Those interventions would be treated with a great deal of suspicion by communities, as they are at the moment, if that were all we were offering. It has to be much more than that; it truly has to be integrated. I look forward to making this point loud and clear in September in New York.

On a broader theme, as I have gone around the world, I have been struck by the roll-out of healthcare systems. Very often, there is a temptation for politicians to roll out shiny things that they can demonstrate to their constituents. That generally means hospitals, and hospitals are great things, but they may not be the right thing in low and middle-income countries.

[Dr Whitford]

In the four health systems across the UK, we are trying to address our obsession with hospitals and tertiary centres, realising we have not got enough resources in primary care, and certainly not in prevention. We need to share that knowledge with developing countries.

[Dr Murrison]

I agree with the hon. Lady. In the context of low and middle-income countries, my focus would be on primary healthcare and public healthcare, by which I understand something slightly different from public healthcare in the context introduced by the hon. Member for Birmingham, Edgbaston (Preet Kaur Gill), who speaks for the Opposition, and I will come to that in a minute. The focus needs to be on prevention and on things that deal with the problems that the poor are exposed to, first and foremost. The difficulty with shiny stuff—electorally obliging though that might be—is that it risks exacerbating health inequality; shiny things tend to be in urban centres and accessed more easily by the better-off, rather than the poor, and particularly the rural poor. We need to be very careful about that.

We need to introduce the notion that countries themselves must grow their healthcare systems, and a number of contributions touched on that. That means addressing unpleasant things such as taxation. In addressing universal health coverage, we need to ensure that we encourage Governments to establish proper mechanisms for raising taxation, so that countries can ultimately stand on their own feet. I am pleased that the UK has introduced some trailblazers in that respect—the four in Africa are Rwanda, Ethiopia, Ghana and Uganda, and the other is Pakistan—where we will be assisting Governments to build structures that will make their healthcare systems sustainable in the longer term.

A number of contributions touched on polio. I know that will be the subject of my grilling later by the hon. Member for Liverpool, West Derby (Stephen Twigg)—I will say lots of nice things about him in anticipation that he will give me an easy ride this afternoon. I am sorry that he is standing down; it will be a great loss to the House, and I urge him to think again. Polio is on the cusp of being defeated. There were 33 cases last years, from only three countries—only two countries, really. We must make sure the boot remains on the carotid, because there is a real risk that, if we are tempted to divert funds from this, we will be back to square one. That would be a tragedy because of the lives that would be lost, and because, at some point, we would have to pick up the pieces. It makes no sense, in raw economic terms, to relieve the pressure on that particular nasty at this point. I hope we will make sure in September that the pressure stays on that particular one of the “Captains of the Men of Death”.

I appreciated the comments made by right hon. and hon. Members about nutrition; they were absolutely right. The hon. Member for Central Ayrshire (Dr Whitford) rightly said in an intervention that there is no point vaccinating people if they are undernourished. It is nonsense epidemiologically and in public health terms to do so, and we must adopt an integrated, holistic approach to universal health coverage. If we can get that across to people in New York in September, we will have done the world a great service.

I am proud to be a member of a Government who are fully committed to not just the Global Fund but other funds that require replenishment. Our leadership has been salutary over many years—not just under the present Government, although I am pleased about the commitment they have made to the Global Fund—and I am confident, whoever wins in two weeks’ time, to answer the point made by the hon. Member for Dundee West (Chris Law), that that process will continue.

Health, Social Care and Security

Debate between Andrew Murrison and Philippa Whitford

Wednesday 28th June 2017 Commons Chamber

[Dr Whitford]

I am not saying that the local authority was scrimping and saving because it did not have money; it was because it was not spending the money. It used cheap panels and it did not put in sprinklers. Some 600-plus buildings across London and England are covered in panels that clearly contain flammable materials. We hear from Camden that fire doors were missing, despite millions of pounds having been spent. As Ben Okri says in his poem, there has been a focus on surface and appearance rather than on the substance of such buildings and the protection of people who live in them.

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

I always listen to the hon. Lady with care and respect, but I appeal to her to look at the evidence base before making the remarks that she has. Words are important. We have established an inquiry that will establish the facts and make recommendations. Until then, with the greatest respect, I think that her remarks are premature.

[Dr Whitford]

The hon. Gentleman may feel that my remarks are premature with regard to Grenfell, but they are not when it comes to Lakanal, Irvine or other terrible fires that were clearly shown to relate to cladding and where sprinklers could have made a difference.

We have been repeatedly warned over the past 18 years and we have not taken action. The people in Grenfell died not only because of fire regulations, but because of inequality. They lived in the richest borough in the richest city, yet they were among the most poor and vulnerable. That tower stands like a black monolith shadowing the whole city and this place. The people in it were not well served.

We see people dying in Grenfell, suddenly—the drama and the horror. Yet people die of inequality, poverty and deprivation all the time. There is a 20-year gap in longevity between the richest and poorest, both in life expectancy and healthy life expectancy. Some 1,400 children under 15 die every year as a direct result of poverty—that is like the roof of a secondary school collapsing on them every year. If that happened, surely we would take action.

NHS and Social Care Funding

Debate between Andrew Murrison and Philippa Whitford

Wednesday 11th January 2017 Commons Chamber

[Dr Whitford]

Money is not the only problem. I accept that part of it is about how things are done. The Secretary of State talks about variations and many hospitals performing well, but, as I said, only one trust is meeting the target and only nine are at over 90%, so it is not that the majority are doing well and a few are failing.

The ability to look at how we deliver the NHS is crucial, but change costs money. We must therefore invest in our alternatives so that our community services and primary care services can step up and step down to take the pressure off. One of the concerns about the STPs is that because people do not have enough money, a lot of them start by thinking that they will shut an A&E, shut a couple of wards, or shut community beds—even though those are what we need more of—to fund change in primary and social care. Then the system will fall over. We need to have double running and develop our alternatives and then we will gradually be able to send the patients there.

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

I always enjoy listening to the hon. Lady’s well-informed remarks. I agree that most people do not want to go to A&E if they can avoid it. Does she agree that part of the problem is that when people phone general practices, they tend not to be offered an appointment that they regard as being within a reasonable timeframe, or they cannot get to see the doctor with whom they are closely associated, which particularly applies to people with chronic and long-term conditions? As today’s National Audit Office report makes clear, we need to address that as a matter of urgency. Paradoxically, seven-day-a-week general practice may militate against being able to provide people with such continuity of care during core hours.

[Dr Whitford]

Many doctors in general practice would accept the argument for having access to a GP on Saturday morning, particularly for people who are otherwise at work. However, someone who cannot see their favourite doctor is very unlikely to go to A&E and wait eight hours to see a doctor they have never seen before in their life. This is not about that; this is about the fact that people feel they cannot find an alternative. If it takes three or four weeks to get any appointment with their GP and they do not yet have a community pharmacy offering such a service, they will eventually end up at A&E. It is therefore the service of last resort for people who go there and just stay there. We have to develop alternatives first, but as the hon. Gentleman says, no one in their right mind would choose to go and wait four hours in A&E if they could be seen in half an hour in a community pharmacy.

[Dr Murrison]

The hon. Lady is being very generous in giving way. I have to disagree with her, because winter pressures and the pressures we are seeing at the moment tend to involve not people with short-term, self-limiting conditions, but the chronically sick. Those people in particular, and with good reason, want to have a relationship with a particular practitioner who understands their needs and their family context. That is surely the essence of general practice.

[Dr Whitford]

I totally agree, but in fact the chance that their doctor will be on duty would actually be lower on a Saturday morning or a Sunday afternoon. One of the things we have done in Scotland with SPARRA—Scottish patients at risk of readmission and admission—data is to identify that 40% of admissions involve 5% of the patients. Those patients are all automatically flagged and will get a double appointment no matter what they ring up about, because it will not just be a case of a chest infection or a urine infection, but of having to look at all their other comorbidities.

That is the challenge we face; it is not a catastrophe of people living longer. All of us in the House with a medical background will remember that that was definitely the point of why we went into medicine, and it is the point of the NHS. However, we are not ageing very well. From about 40 or 50 onwards, people start to accumulate conditions that they may not have survived in the past, so that by the time they are 70 they have four or five comorbidities that make it a challenge to treat even something quite simple. My colleagues and friends who are still working on the frontline say that it is a question not just of numbers, but of complexity. Someone may come in with what sounds like an easy issue, but given their diabetes, renal failure and previous heart attack, it is in fact a complex issue.

That is part of the problem we face, and we need to look forward to prepare for it. We need to think about designing STPs around older people, not around young people who can come in and have an operation as a day case and then go away, because that is not what we are facing. Older people need longer in hospital, even medically, before they reach the point of being able to go home. It takes them a couple of days longer to be strong enough to do so. They probably live alone and do not have family near them, so they will need a degree of convalescent support and they may need social care. That is really where the nub of the problem lies. Social care funding has gone down, and therefore more people are stuck in hospital or more people end up in hospital who did not actually need to be there in the first place.

NHS Sustainability and Transformation Plans

Debate between Andrew Murrison and Philippa Whitford

Wednesday 14th September 2016 Commons Chamber

[Dr Whitford]

As I said, the proposals leave only £300 million. We cannot transform a system on the scale that is being considered with £300 million.

As I said, the guidance talks about prevention. We need to be tackling health inequalities. We need to be focusing on health and wellbeing—and by that I do mean physical and mental wellbeing. We need to be strengthening public health—something else that has been cut. We need to be looking at the quality of health and care, and that means right across into social care. We must fund social care, because it can make a difference to things like delayed discharges. We are not even three years into the integration in Scotland—we are only two and a half years into it—but delayed discharges have dropped 9%. Yet, the last time the Secretary of State was in the Health Committee, they had gone up 32% in NHS England. So literally just moving things around and allowing one part of the system to fail will mean that the entire system fails.

[Dr Murrison]

I always listen with great care to what the hon. Lady has to say, and I agree with a great deal of it. Does she agree that part of the problem in England in relation to delayed discharges has been that we have seen a retrenchment of community hospitals and their beds, which have provided step-up, step-down care—intermediate care beds. Unfortunately, they are no longer available, which means inevitably that hospital discharges are delayed, with all the distress that causes.

[Dr Whitford]

I totally agree with the hon. Gentleman. I think it is about care in the home for those who are able to have that and convalescence for those who require it; that, basically, is the step up, step down. In my health board in Ayrshire and Arran, we have rebuilt the three cottage hospitals. They are now modern, state-of-the-art, small units. That means that our population has less far to travel and that older people will not, in the end, need to come to hospital. Now, we are still in that transition; those units are not doing everything they have the potential for—indeed, we are a rural population. However, certainly in Scotland, there is much more recognition that we need intermediate care between people being at home and being looked after by their GP, and people ending up in a very expensive acute unit. It is not just about finance; any Member who has been in hospital knows they do not want to be there, and nor do our elderly population. These levels of care are therefore crucial, and it is important that that grows out of the STPs. I see that as a crucial opportunity for the NHS, which cannot be missed.

NHS Spending

Debate between Andrew Murrison and Philippa Whitford

Wednesday 6th July 2016 Commons Chamber

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

God, the pressure.

We recognise that this figure of £350 million a week chimed with people in the country, because people are concerned about the funding of the NHS. The Secretary of State for Health talks about an extra £8 billion going forward, plus the additional £2 billion that was added to that, which was for bailing out massive debts. However, that is a change of description. Normally, funding is described as being for the Department of Health, but that is just NHS England. Public Health England and Health Education England were facing cuts of £3.5 billion. Therefore, the extra money going forward is only £4.5 billion. We have heard Members talk about their local trusts being in deficit. This is now so widespread, it cannot be blamed on management.

Despite the fact that the NHS somehow always managed to come out just in the black up to April 2013 and has been careering into the red ever since, the Secretary of State never seems to accept that this is to do with the Health and Social Care Act 2012 changes and the huge administration costs of outsourcing and fragmentation. The Secretary of State lays the blame for all this with agency staff.

Given the debate that we have just had on EU nationals working in this country, particularly in our public services, I have to say that we could be facing an absolute meltdown. We have 50,000 nurses and doctors from the EU in the NHS, and almost 80,000 careworkers. The Minister for Immigration hinted that those who have been here for over five years can stay, but that their benefits and rights may not be quite the same. So my husband, who is from Germany, can stay, but is his pension going to disappear? He has worked here for 30 years, but what protections will he no longer have? What about the people who have been here for less than five years—the high-flying researchers, academics or medics —who could go somewhere else? Do the Government really think that these people are just going to sit at home with their families until the last possible minute? No, we are going to lose them, and agency costs for nurses and doctors will go through the roof. For social careworkers, it will not matter: they do not earn over £35,000, so they are unlikely to get to stay, and we are unlikely to be able to replace to them.

As well as the fact that the £8 billion we always hear about is not actually £8 billion, we know that local government has faced huge cuts and, as was referred to earlier, that social care is where the real problem lies. The NHS money is just going to haemorrhage out the back door.

The £350 million a week figure that was painted on that bus was a disgrace. The shadow Health Secretary, the hon. Member for Hackney North and Stoke Newington (Ms Abbott), talked about it being an Eton game, but I think that it was an Eton mess. People were just playing with the facts. The rebate was not included. Public service payments, such as the common agricultural policy and regional funds, were not included. However, as the Secretary of State says, when we get down to the £110 million or so a week, that does not include all the other benefits that support the NHS and our economy. How much will it cost us to take part in Horizon 2020? How much does Switzerland have to pay to be part of this?

This is going to cost a lot of money. The Secretary of State said that it would take a 0.06% fall in GDP to negate the £100 million, but economists estimate that the fall will be between 1% and 3%. We do not want that to happen, but all the experts agreed that that was the likely outcome.

Like most people in Scotland, I absolutely believed in the remain campaign, but to me there was a poverty to the debate. Why are we having these two debates today instead of before 23 June? We had very little open discussion of the issues in this place. One of the problems is that we have never talked about anything good that we have got from the EU in the past 40 years. Of course, I have been lucky—I got my other half from the EU—but, to be honest, most of us have had many gains. We have cleaner air and cleaner water, and we have tackled acid rain. We have cleaner beaches. We have a single European medicines agency, so new drugs get to patients quicker. That agency is located here in London, but it is unlikely to remain here.

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

I always listen very carefully to what the hon. Lady says, but is she not being a little unfair on the United Kingdom? I seem to remember that the Clean Air Act 1956 set the bar for the European Union in the regulation of one of the areas that she has identified—namely, the cleanliness of the air that we breathe.

[Dr Whitford]

I was not on the planet in 1956, so I do not quite remember. We know from the recent cheating that there is a lot more work to be done on the control of car emissions, which cause a lot of ill health, but some of the progress in that area has come from EU regulation. Problems such as poor air quality and climate change cannot be dealt with by one country alone; we need to work together. In a health sense, we have had massive gains in the past 40 years, but politicians have never talked about that.

The EU has been a great whipping boy. All that the public have heard about the EU in the last 40 years is, “It wasnae my fault; the EU made me do it,” or stories about straight bananas. That is the responsibility of everyone who has had access to a microphone or spoken in this place about the EU. We should not be surprised that when people had the £350 million figure drummed into them by it being on that bus and on the news every night, they would fall for it. The mainstream media have a lot to answer for in not challenging these figures and not asking, “Exactly what is your plan? Exactly where is that money going to come from?” We should not blame people who want extra money for the NHS for wishfully accepting those claims, even when the cracks appeared around the edges.

Part of the problem has been the quality of the debate. Several of my colleagues warned people who believed in remain not just to go for a “Project Fear” type campaign, and I think that running such a campaign was a mistake. People think that “Project Fear” worked in Scotland, but in actual fact Better Together support started, as a percentage, in the mid-60s and fell to 55%. We started at 27%, and we ended up at 45%. “Project Armageddon” clawed back a little bit in the last two weeks, when we were told that the supermarkets would go and the banks would go, and that we would have no money and no food to buy, but a negative campaign of saying that the sky will fall does not lead to success.

A&E Services

Debate between Andrew Murrison and Philippa Whitford

Wednesday 24th June 2015 Commons Chamber

[Dr Whitford]

Absolutely, we have seen the performance drop across the UK. The Minister quoted a report showing that England was performing better than Scotland. I would be interested in seeing that one—where it is comparing like for like with core A&E services—because those are not the figures I have seen. However, we all face the same challenge. We are dealing with older patients, who are more complex. The figures from Scotland last winter showed that we did not have a huge increase in numbers, but far more of those patients had to be admitted. Nothing else could be done, and we will face that situation more and more in future. The problem is that we are losing the staff to deal with that, and we are talking about A&E, but in the vast majority of cases, they key issue does not lie with A&E. There are two simple things: the number of patients coming in, which relates to out-of-hours GP access, and patients getting back out, which is described by the Royal College of Emergency Medicine as exit block.

It is important to remember that the four hours does not involve someone sitting on a chair, waiting for four hours. People are often given that impression—that they turn up in A&E and sit there, and no one will touch them for four hours. However, they will be triaged, see a clinician, have a history taken and have investigations. They may well get sewn up or be given something, and they will go home. Those patients are moving through. Our problem is the patients who have to come in, and it results in a whole cascade of issues, such as people stuck on trolleys getting the start of a bedsore, or families made miserable, or staff very depressed at trying to look after people in a corridor. It also results in people ending up boarded to any ward—any port in a storm—so that people are not in the correct ward and not getting the correct treatment from the correct team. We know that that, bizarrely, results in longer patient stays, which exacerbates the problem.

What we need to do—as we have done in Scotland, where we set up the unscheduled care action plan—is to work with all stakeholders. That involves looking at how patients flow through. It is not about people being obsessed with measuring the target and counting it, but about people opening the gates in front of the patient. The data on how long patients wait should be automatically available to staff from their system; it should not require an extra body to generate that data.

If we have the data weekly, which means we are getting them timeously, we can see one week from the other and ought to be able to see the patterns. The problem with monthly data for something that is identified as a currently acute issue is that, by the time they are collated, verified and out, staff may not remember quite what made that a bad week, whereas with weekly data, they can see whether they are getting a response to their actions.

I support keeping weekly measurements, but I do not support them being used as a tool—and certainly not for beating one another across the Benches here. I can tell hon. Members that staff in the NHS feel that they are beaten over the head with these targets, so it is not about having a target, but about how it is used. In the paper released by the Royal College of Emergency Medicine here yesterday, one of its myths was that the four-hour target is a distraction. It pointed out that it allowed a focus.

To try and tackle the problem in Scotland, we have ensured that the majority of our A&Es have a co-located out-of-hours service. I mentioned before that achieving 8 till 8 in every GP practice is so far in the future that it cannot be reckoned on as a solution to this problem. We are unable to fill the GP vacancies we have now. Telling them that they will be working from 8 till 8 on Saturday and Sunday is not overwhelmingly attractive.

The pilots that have been done have started to report in the last fortnight, and they have reported a very poor uptake. When people want to deal with an out-of-hours problem, they come to A&E. Rather than trying to change the whole population, we could have a system in which people are easily diverted once they get there: “If you have this, please step next door to our primary care service.” We need to look at those solutions, and some are working quite well.

The other issue is health and social care. To get patients out at the end of their journey, they need to be able to get into care. We need to remember that, although extra money may be given to health and social care through the health side, if we are cutting local authority budgets at the same time, we end up cutting the legs from under the NHS.

[Dr Murrison]

The hon. Lady is making thoughtful comments and I am following them carefully. I agree with her that co-location can work in some places, but clearly it is not going to work everywhere. Does she not agree that most people who attend accident and emergency departments are neither accidents nor emergencies, and they would be much better cared for by general practitioners? To do that, however, GPs need to be trained for that case mix and incentivised for it, and most importantly, the public needs to be trained, too, about accessing the proper professional.

[Dr Whitford]

Before the movement of out-of-hours GP services under the banner of NHS 24, most local areas had a doctors-on-call service. In my county, we had Ayrshire doctors on call, which was provided by local doctors at rooms in the A&E departments in our two hospitals. Patients quickly learned where they could go to be seen quickly. We also had a car service that allowed us to make home visits. That functioned very well until NHS 24 came and pulled it away.

We have to get back to local GPs working like that as part of a co-operative in a focal position. Each practice cannot generate enough GPs or work to have someone sitting there all day Saturday and all day Sunday. When the Secretary of State talks about 8 till 8, it is not clear whether he means that that will happen in each individual practice or on a regional basis. Most of the pilots that have started to publish their experiences have quickly made it into a doctors-on-call service. There is more common sense behind that approach and it is more sustainable.

We have to look at the flow within hospitals. We should not have trackers running around bean counting when patients had what done, but people going in front of patients, opening the gates, looking at bed management and ensuring that patients are in the right place.

All these matters cascade back on to staff. We are struggling to maintain and recruit staff. There was only a 50% take-up of trainees for accident and emergency, and we are haemorrhaging senior people, which exacerbates the problem. We need the co-location of GPs and we need to look at the exit block, not only out of A&E and into the hospital, but out of the hospital.