Accident and Emergency

Andy Burnham Excerpts

Wednesday 18th December 2013 Commons Chamber

[Andy Burnham (Leigh) (Lab)]

I beg to move,

That this House is concerned about recent Government statements on Accident and Emergency (A&E) and Government claims that it is not in crisis; notes that last week, 79 A&Es and the NHS overall missed the Government’s A&E target; further notes that attendances at hospital A&Es have increased three times faster since 2009-10 than in the period from 2004-05 to 2009-10, and that in the last 12 months more than one million people have waited more than four hours; believes there are a range of reasons for the current pressure on Accident and Emergency but that difficulty in accessing GP services is one of the primary causes; regrets the Government’s decision to cut funding for evening and weekend GP opening and scrap the guarantee of a GP appointment within 48 hours; and, to ease the pressure in Accident and Emergency, calls on the Government to reverse for winter 2013 its scrapping of the 48-hour appointment guarantee.

As we approach the end of 2013, it is becoming clear that this has been the worst year in accident and emergency for at least a decade. All year, the pressure has been relentless. It is not just a winter crisis, but a spring, summer and autumn crisis. Across the 12 months, more than 1 million people have waited more than four hours to be seen, which is a threefold increase since 2010. For the past 22 weeks, hospital accident and emergency departments have missed this Government’s target. Last week, the target was missed by the NHS as a whole, which is a warning sign that winter has now arrived and things are getting even worse.

Accident and emergency is the barometer of the whole health and care system. All year, that barometer has been warning us of severe storms ahead, and yet, three weeks ago, the Secretary of State stood at that Dispatch Box and claimed that this was

“a crisis that is not happening”.—[Official Report, 26 November 2013; Vol. 571, c. 155.]

He should try telling that to the families of people left waiting for hours on trolleys in corridors; to the people who have been ferried to hospital in police cars and taxis because ambulances are trapped in queues at accident and emergency; and to the A and E sister who attended our A and E summit here in Parliament last week and said:

“It feels like we’re fire fighting. It’s crisis management.”

[David Wright (Telford) (Lab)]

Is this problem not compounded by the fact that in many places such as Telford and Wrekin and the wider Shropshire area, the future of full A and E services at many hospitals is in doubt? That situation is bad for morale, and it compounds the other problems such as waiting times. People want some reassurance about the future of their A and E services.

[Andy Burnham]

That is a question for the Secretary of State. How can it make sense to close so many A and E departments in the middle of an A and E crisis? This year, the facts on the ground have changed. As I have said, it has been the worst year for a decade. Any proposal to change A and E in areas such as that of my hon. Friend needs to be considered in the light of that new evidence. We need to consider whether it is safe to proceed. As the A and E sister said, it is crisis management. That is the view from the real world. In here, it is a different story. It is, “Crisis, what crisis?”

My purpose in holding this debate is to cut through the spin. I want to bring into our debate today the voices of those A and E nurses, occupational therapists, paramedics, community nurses, and NHS 111 staff and mental health professionals who came to our summit. For instance, there is the paramedic who told us of his worries about ambulance response times getting longer because ambulances are trapped at A and E; and of the time when a patient who was held a long time at the door of a busy A and E suffered a heart attack and had to be rushed back to the ambulance. Another paramedic told us about being at the scene of a serious incident in a city centre. After calling for back-up, he was joined by a private ambulance which did not appear to have adequately trained staff to take patients to hospital. A community nurse spoke of her frustration at spending an hour and a half on the phone trying to get a GP appointment for a frail patient. An A and E-based occupational therapist said that she was now regularly diagnosing dementia for the first time in older patients who had ended up in A and E. Surely we can do better than that.

[Grahame M. Morris (Easington) (Lab)]

My right hon. Friend is giving an excellent argument as to why we are in this crisis. Is it not completely predictable given the response that we have just had on the local government grant settlement? Increased pressures on the system will be felt by old people and in deprived areas.

[Andy Burnham]

I agree. The Government have made grave mistakes. I warned them—they misquote me every week—that it would be irresponsible to give increases to the NHS, which is what they were promising, if they had to ransack local government, particularly social care budgets, to pay for them. That is a false economy. It means that older people have support withdrawn from the home, and they drift towards A and E in ever greater numbers. That is what is happening today on this Secretary of State’s watch.

[Steve Rotheram (Liverpool, Walton) (Lab)]

Given that we have just heard that Liverpool will face 62% reductions in local government settlements, does my right hon. Friend agree that the obvious consequence will be to put additional pressures on A and E in Liverpool hospitals?

[Andy Burnham]

The Government are tearing up the social fabric of England’s most deprived city. This is a city in which people struggle to feed their kids and to make ends meet. Council services are utterly crucial in helping people to cope. The Government do not understand, or they do not care, and they just rip up the fabric of an entire city. It is disgraceful.

[Caroline Lucas (Brighton, Pavilion) (Green)]

Does the right hon. Gentleman share my concern about the impact of the fines that are being levied as a result of delays in ambulance handovers? Many hard-working staff at the Brighton hospital say they are incredibly demoralising because they punish A and E for a problem that is actually hospital-wide, and it is hospital-wide because of cuts to the national tariff and because of the top-down reorganisation that nobody wants and that is hugely costly.

[Andy Burnham]

As the hon. Lady says, ambulance services and A and E are often now not working well together. I mentioned the paramedic held at the door, and we are hearing of queues at A and E. What we cannot have are perverse incentives in the system. The Secretary of State needs to look at the issue that she raises.

[Several hon. Members]

rose—

[Andy Burnham]

I will make some progress because I am conscious that many Members want to speak in both debates.

The picture that emerged from our summit was of a health service on the edge, creaking at the seams, with corners being cut and A and E as the last resort for people failed by other services—people who, in an ideal world, ought not to have been there. We heard of people with severe mental health problems in A and E because of a lack of crisis beds, people with severe dental pain who could not afford treatment, disorientated older people with dementia and, perhaps saddest of all, palliative patients in A and E waiting areas.

It is clear that the cost of living crisis and this Government’s failure to support people through it might also be driving people to A and E. The House is soon to debate the scourge of food poverty that now blights our land. Food banks are growing at an exponential rate. Indeed, we now read that it is Government policy to ask councils to set up more, even though they have just cut the funding of the councils with the most food banks. It is unbelievable. It suggests to me that they expect food poverty to be with us for some time to come and have no real intention of tackling it. People will go on having to choose between eating properly and putting the heating on—[Interruption.] The Secretary of State chunters, but he has no idea what it is like to do that, has he?

People are making other impossible choices that might damage their health. I am told of the growing number of people now taking prescription medicines on an empty stomach because they cannot afford to eat properly. Dr Ellie Cannon, a GP who also writes for The Mail on Sunday, recently tweeted:

“I’m sad to say that at my NHS practice if we have a patient who has unexplained symptoms, we have started asking if they can afford to eat”.

How can that possibly be right in England in 2013? Has the Secretary of State considered reviewing the effect on people’s health of the growing problem of food poverty and has he discussed the effects of benefits policy on people’s health with the Secretary of State for Work and Pensions? If he has not, I suggest that he does so immediately.

[Barry Gardiner (Brent North) (Lab)]

As my right hon. Friend is talking about general practitioners, does he agree that the Government’s failure to honour the guarantee that we gave that people could see a GP within 48 hours means that more and more people are going directly to A and E?

--- Later in debate ---

[Andy Burnham]

That is the central point of my speech: the removal of the guarantee that patients could get an appointment within two working days. The Government removed it in June 2010 and, as a result, we all hear stories, do we not, of people saying that they are getting up and ringing the surgery at 8 or 9 o’clock in the morning and are being told that there is nothing available for days. That is a result of the Government’s decision to remove the two-day guarantee. That is why people are facing that frustration. I shall explain that in more detail—[Interruption.] Government Members say that the guarantee did not work, but in 2005 nine out of 10 people said that they could get an appointment within two days. Have those Members checked the figures recently? There is falling satisfaction with GP services and it is happening on their watch.

I asked the Secretary of State whether he had spoken to the Work and Pensions Secretary, and he needs to do so urgently. The truth is that pressure has been growing all year on A and E and he has been ignoring the warnings, sticking to his usual line of blaming everyone else. His original line was to blame the 2004 GP contract, but that was undermined by the Chair of the Select Committee on Health and the inconvenient fact that there was no winter crisis in 2005, 2006, 2007, 2008 or, indeed, 2009.

Having seen his original spin dismissed, the Secretary of State changed tack. In a message to NHS staff on 6 December he said:

“Our ageing society has meant 1.2 million more people in A&E every year compared to 3 years ago”.

Finally we have an admission that the pressure has built on his watch, but as ever, it is nothing to do with the Government. It is nothing to do with the break-up of NHS Direct and its replacement with the disastrous NHS 111, nothing to do with the closure of a quarter of NHS walk-in centres, nothing to do with the severe cuts to social care and the removal of home care from vulnerable people, nothing to do with the loss of 6,000 nursing jobs and nothing to do with the reorganisation that no one wanted and no one voted for that threw the entire NHS into chaos just when it needed stability and that has led to precious NHS money being spent on redundancy payments only for those people to be re-employed by new NHS bodies. No, it is now all the fault of the ageing society. You could not make it up, Madam Deputy Speaker.

[Ms Margaret Ritchie (South Down) (SDLP)]

My right hon. Friend is making a compelling case about the problems in accident and emergency. Is he aware that they extend to Northern Ireland? Although devolved arrangements are responsible, we are told that the problems are down to the shortage of doctors, which emanates from Whitehall and the Department of Health. It is no longer a compulsory part of GP training for doctors to do a component in A and E and that is causing a problem.

[Andy Burnham]

I mentioned the reorganisation, through which we saw the complete disruption of training arrangements in the NHS. The Government’s eye was taken completely off the ball of the growing problem of recruitment, not just of GPs but of A and E doctors. That is a real problem around the country. We now have fewer GPs per 1,000 of population than we had a few years ago, so my hon. Friend is absolutely right to raise that issue.

The new spin is that the Secretary of State admits that A and E has got worse on the Government’s watch, but it is not his fault and it is not a crisis. That is the public line, at least. In private, it is a different story. This is the Secretary of State who has taken up ringing hospital chief executives who are not meeting their A and E targets. I have heard from two senior sources that the Secretary of State has discussed within government whether Cobra should be convened to discuss the A and E crisis. Can he confirm or deny whether that is the case? I have no way of knowing, but he needs to give a straight answer.

The longer we see the Secretary of State in this job, the more familiar we become with his style: spin before substance. That is the real danger when someone holds a job as important as his. If they use spin to distract people from the real causes of the problems, they end up neglecting those problems and precious time is lost.

[Dr Thérèse Coffey (Suffolk Coastal) (Con)]

I know that the right hon. Gentleman is passionate about the NHS, but he seems to ignore the history. In the last year of the Labour Government, the average wait in A and E was 77 minutes. It is now 33. The Labour-run Welsh NHS has missed every target since 2009. Frankly, I am proud that our Government are putting the patient at the heart of the NHS by tackling the issues in hospitals and in our ambulance services.

[Andy Burnham]

Last week, the NHS missed its A and E target—the hon. Lady’s A and E target—which is a lowered target. If she is going to maintain that complacency through the winter, I suggest that it might well backfire on her.

[Mr Gareth Thomas (Harrow West) (Lab/Co-op)]

My right hon. Friend’s description of rising waiting times in A and E and ambulances queuing outside A and E will be recognisable to my constituents who use Northwick Park hospital. What is his view of the Government’s proposed new funding formula, which, I hear, might mean that £20 million will be cut from Harrow’s NHS budget?

[Andy Burnham]

Since the change of Government, the previous Secretary of State and this one have talked about a formula based predominantly on need, not deprivation. The worrying thing about that is that it means that we have a formula based on the use of NHS services as opposed to the need to improve health. NHS England has been debating that issue this week and I hope that it has taken heed of what has been said in this House, because to do this to the NHS alongside the local government cuts mentioned by my hon. Friend the Member for Liverpool, Walton (Steve Rotheram) will be catastrophic for the communities in this country with the greatest need.

[Mr David Lammy (Tottenham) (Lab)]

Does my right hon. Friend recognise the perversity of our having a debate about airport expansion, with the London population rising to 10 million, while at the same time closing A and Es in west London, experiencing problems at St Helier in south London, closing Chase Farm and making changes in the east? Does that make sense with a rising population? Will it not lead to chaos?

--- Later in debate ---

[Andy Burnham]

The Secretary of State really needs to answer for the cuts to London’s A and E departments, particularly at a time of unprecedented pressure, and for the desire to bring forward closures supported by a financial case, rather than a clinical one, as in Lewisham.

I want to set the record straight about the 2004 contract and dismiss the myths that have been put about. The fact is that it gave the public much quicker and more convenient access to GPs and relieved the pressure on A and E. Let me explain the changes it made. First, it created the ability to add an incentive to allow patients to book an appointment several days ahead. Members might recall Tony Blair being challenged on that very point during a live TV debate before the 2005 general election. As a result, he brought forward a new measure to give people that ability to plan ahead. Secondly, it created incentives for GPs to offer evening and weekend opening. Thirdly, it allowed the previous Government to offer people a new guarantee of a GP appointment within two working days. And it worked. In 1997 only half of patients could get an appointment within 48 hours, but by 2005 nine out of 10 patients could do so. As a result, A and E was performing much better than it had been in 1997.

What has happened since? This Government have scrapped all those measures to improve patient access and convenience. They removed the right set out in the NHS constitution to an appointment within two days, stating that it was no longer a priority. It might not be a priority for them, but let me tell them that it remains a high priority for my constituents and those of my hon. Friends. This is the simple truth that they do not like to admit: it has got harder to get a GP appointment under this Prime Minister and this Government. People who call their surgery early in the morning only to be told that nothing is available now know why.

There are now 854 fewer GP practices in England offering evening and weekend openings than there were in July 2009. The Patients Association has found that six out of 10 people said they could not see a GP for at least two days and four out of 10 said they could not book an appointment for at least two days in advance. All that is leading to some people turning straight to A and E and others getting sicker while they wait and then arriving in A and E as a more serious case.

The Government have tried to blame GPs for the problem, but that is unfair, because this Government have cut the funding for general practice, cut the funding for delivering better patient access and convenience and, I have already said, cut the number of GPs per thousand of the population. The analysis could not be clearer. The question is where do we go from here.

The House has got used to the Secretary of State’s stock speech, which takes no responsibility for what is happening now in the NHS and seeks to blame the previous Government for everything that is going wrong. Well I have news for him: that will not work today. A and E is getting worse on his watch. He has presided over the worst year in A and E for a decade. People need an honest assessment of the situation, and of the urgency and the NHS’s ability to cope this winter. Does he accept that there is a crisis in A and E? He has gone quiet, but we will hear from him in a moment. Or does he still maintain that it is not happening? We need to know.

With January just around the corner, people want practical answers to straight questions and some proposals to make things better. First, will he consider making urgent changes to NHS 111 and putting nurses and clinicians back on the other end of the phone line? Evidence from across the NHS tells us that the cut-price model of call handlers with computer algorithms simply does not work. Too often the computer says, “Call an ambulance or go to A and E.” The sensible change back to an NHS Direct-style system was recommended by Sir Bruce Keogh in his report and should be made right now ahead of the winter.

Secondly—this is the centrepiece of what I want to say today—given the evidence to show that the 48-hour guarantee worked to divert people from A and E, there is a clear case for reintroducing it this winter. It is true that GPs might not be so keen on it, but it was valued by patients, and that is the most important thing. The Secretary of State needs to listen to what people are saying about their difficulties in getting an appointment in office hours, not in out-of-office hours. He must do something to address that. Will he divert some of the funding that he has made available to meet A and E pressures to that purpose, or indeed will he reclaim some of the funding he has handed back to the Treasury? It is so important that people can get appointments when they need them.

Those are two practical suggestions that I hope the Government will consider and accept. If the Secretary of State will not accept them, he needs to put forward other suggestions of his own to help people get access to good advice via a GP or over the phone and to avoid A and E this winter. If he refuses to do that, is he really saying that everything possible has been done to ensure that things do not get worse in the months ahead?

In conclusion, the NHS today stands on the brink of its most dangerous winter in years. It is a serious situation and people are looking for straight answers from the Secretary of State. It has got harder to get a GP appointment on his watch and people want to know what he is going to do about it. A and E is getting worse and worse on his watch and people want to know how he plans to turn things around and ensure that all A and E departments and ambulance services can get safely through the winter. He now needs to put away his stock speech, cut the spin and get a grip, and fast.

--- Later in debate ---

[Mr Hunt]

I am going to make some progress.

I want to talk about what is happening in England, because the right hon. Gentleman wanted to know the truth. These are the statistics he did not want to tell the House about the comparison with his time in power, which he said was so good: 1.2 million more people are going through A and E every year, and more than 2,000 are being seen within four hours every single day, compared with when he was Health Secretary. The average wait to be seen is now 33 minutes compared with 77 minutes when he was Health Secretary—that is 44 more minutes longer, on average, to be seen under Labour than under this Government. For treatment, the average wait is now 75 minutes compared with 102 minutes when he was in office.

[Andy Burnham]

Will the Secretary of State give a straight answer to this simple question: is there or is there not a crisis in A and E?

[Mr Hunt]

I refer the right hon. Gentleman to the people who know about this at the College of Emergency Medicine, which says today on its website:

“There is now cause for optimism that the crisis is behind us.”

He should listen to that before whipping up fears of a crisis that the College of Emergency Medicine says is not happening.

--- Later in debate ---

[Paul Burstow]

My hon. Friend is absolutely right. One of the good things that came out of the work by Keith Willett and Sir Bruce Keogh is the more coherent, communicable and understandable way in which emergency care can and should be organised. Indeed, in some cases there are also staffing pressures. Those are not helped by some of the unintended consequences of changing medical careers, as that has had an impact on the supply of medical doctors.

Labour’s answer seems to be that we should go back to the good old days—whatever they were—of a 48-hour target, but that target was flawed. When it was removed by the Government, the British Medical Association welcomed the change, which it said would give GPs greater flexibility to organise their appointments. Today we have heard—quite rightly—from the chair of the BMA, Dr Maureen Baker, who said the proposal was ill thought out and a knee-jerk response to long-term problems, and that it would make a bad situation worse.

[Andy Burnham]

Do not the views of patients matter most? The right hon. Gentleman is quoting the professionals, but perhaps it is sometimes inconvenient for them to have to do things. Surely the point is that people are ringing surgeries and cannot get appointments. If he does not like the 48-hour target, surely he and the coalition Government should put forward their alternative so that people can get to see their doctor.

[Paul Burstow]

With all due respect to the shadow Secretary of State, when presenting arguments in support of his motion he set out a range of professional expertise and opinions for why there should be a 48-hour target. It is therefore not unreasonable for me to quote other professional opinion on why that would not be good for patients. I will come to some of the alternatives that I think are relevant to addressing the A and E problem, because I do not think that simply addressing it through a 48-hour target makes any sense at all.

The changes the Government are making to the GP contract will help—not least having a named person co-ordinating care for the over-75s. I hope the welcome focus on frailty and multi-morbidity will be extended to more people on the basis of their need, not simply their age. Figures show that the average number of diagnosed conditions for patients admitted from A and E has increased over the past five years. In other words, the medical needs of people attending A and E are getting more complex, and that impacts on the amount of time people spend in A and E departments. Therefore, the answer is not one simple solution but must be a combination of actions. Much of that needs to be centred in primary and social care, as well as mental health services. In primary care we must recognise that it is not just about GP services and that we need best practice around the country, for example in engaging pharmacies as first care centres or getting them to play a key role in managing long-term conditions—a big driver of pressure on A and E departments, particularly in winter.

We need concrete action to drive the integration of health and social care—that may be mentioned in the motion, but the Government are delivering it, not least with the £3.8 billion first steps for a better care fund, which is bringing health and social care together in a practical and unprecedented way that has not been achieved before. That must be welcomed as a first step which I hope will grow as more resources are pooled across the system. It is essential to delivering the integrated, co-ordinated care that people want.

Mental health was neglected by Labour, under which there were no access standards or targets for people suffering a mental health crisis. In fact, under Labour two thirds of people suffering from a mental health crisis waited for more than four hours to be seen. I applaud what the Minister is doing to improve that situation significantly by setting standards for the first time to drive improvement in that area.

I conclude with a quote from Dr Clifford Mann, president of the College of Emergency Medicine:

“While this winter will be tough for the NHS and A and E departments in particular—”

I think we should acknowledge that—

“I believe there is now cause for optimism and that the crisis is behind us.”

Yes, there have been problems, but the Government have been addressing them in a comprehensive way. That is why this debate is mis-timed, wrong, and does our constituents no good whatsoever. It does not identify the real problem, although this Government are getting on with sorting the issue out.