Upper Gastrointestinal Haemorrhage

Ben Gummer Excerpts

Monday 11th April 2016 Commons Chamber

[The Parliamentary Under-Secretary of State for Health (Ben Gummer)]

I thank my hon. Friend the Member for South West Wiltshire (Dr Murrison) for his wide-ranging introduction to this important matter, and for his ability to make this difficult medical subject relevant using the important context of “Downton Abbey”. Lord Grantham’s ulcer is, indeed, a filmic representation of a dangerous clinical event that can happen to people. Mercifully, its incidence in this country is relatively low when compared with that of our European partners and colleagues, although the mortality rates associated with GI bleeding are higher than we would wish. The data are not as robust as I would like them to be, and comparisons can therefore not be nice ones, but none the less mortality rates are not as low as they should be when compared with European comparators.

My hon. Friend points out a number of reasons why that should not be the case. He speaks wisely about the need for on-site site endoscopy, on-site radiology, on-site surgery and on-site critical care, all of which were recommended by the NCEPOD report. That tallies closely with the most recent National Institute for Health and Care Excellence guidelines. The guidelines specify that endoscopy should be offered to unstable patients with severe acute upper gastrointestinal bleeding immediately after resuscitation and offered within 24 hours of admission to all other patients with upper GI bleeding.

Reports from NHS Improving Quality and the National Confidential Enquiry into Patient Outcome and Death, to which my hon. Friend referred, go further and state that that will require the appropriate structures to be in place at all hours of the day and on all days of the week. As he reflected, that tallies well with the aims of the Government in producing a seven-day NHS, although I will, if I may, take issue with certain aspects of his comments in a few moments.

The audit of endoscopy services for acute upper gastrointestinal bleeding in 2007 found that only half of all acute trusts in England were compliant with NICE guidelines in this area. The most recent survey has shown some improvement. In 2013, 62% of services are able to provide a formal 24/7 rota for endoscopy specialists, and 56% of services can offer acute admissions for endoscopy within 24 hours of admission. While this is an improvement, there is clearly a long way to go if only 62% and 56% of services respectively provide the kind of provision we expect. Our aim, therefore, is to ensure that every patient has 24/7 access to safe, high-quality GI endoscopy services with facilities to perform an interventional procedure linked to other essential interventions, such as interventional radiology and surgery. High-quality care will not only reduce mortality and complications but increase early discharge, through the use of formal risk assessment scores, and reduce lengths of stays.

It is therefore important that those services are available to those patients at all hours of the day, and on all days of the week. That is why we have made clear our commitment that, by the end of this Parliament, patients with urgent and emergency hospital care needs will have access to the same level of consultant review, diagnostic tests and treatment seven days a week; patients with upper GI bleeds will be one of many cohorts of patients to benefit from that.

At this point I should be very clear in my response to my hon. Friend. He restated the position, often quoted by Opposition Members, that somehow there is a lack of definition about our intentions for 24/7 services. I say to him gently that we have been very clear indeed about how we believe the seven-day NHS will be delivered. In secondary and tertiary care, it will be based entirely on the needs of urgent and emergency care pathways. Those pathways have been outlined in 10 clinical standards brought together by the Academy of Royal Medical Colleges, under the chairmanship of Sir Bruce Keogh. Those 10 clinical standards have informed the policy we have developed on urgent emergency care, which will be announced and rolled out in the weeks and months to come.

We could not have been more clear, both in this place—I believe we have been clear to my hon. Friend—and to the public at large, that our intentions for a seven-day NHS are rooted in the provision of a consistent urgent and emergency care pathway for patients. We have never intended to mandate from the centre non-acute dermatological services, as he suggested, or any other service like that.

Clearly, to support good 24/7 services in hospitals we have to be able to provide exceptional diagnostic services. Whatever the lacunae in the current evidence base around particular specialties in the NHS—we are never going to have a full picture in the way we might wish—we can draw general conclusions. One, which my hon. Friend rightly drew, is that the quality of diagnostics needs to be consistent, people need to have access to those diagnostic services on a regular, rigorous, robust and consistent basis, and those services need to be available on a Saturday night much as they would be on a Monday morning. That is why the Government’s intentions on 24/7 services involve consistent diagnostic services, as we have made clear since the beginning of the policy.

It is important to explain how those services will become priorities for trusts. In the roll-out of a consistent 24/7 service in diagnostics, we want to be clear to trusts about exactly what is expected of them. Patients admitted as an emergency should be seen as soon as possible by a consultant for review, but at least within 14 hours of arrival at hospital. In-patients must have scheduled seven-day access to the full range of diagnostic services, including endoscopy, with reporting of results within one hour for critical patients and 12 hours for urgent patients. In-patients must also have timely 24-hour in-patient access to consultant-directed interventions such as critical care, interventional radiology, interventional endoscopy and emergency general surgery, either on-site or through formally agreed network arrangements. Finally, all acutely ill patients in high dependency hospital areas, such as the acute medical unit and the intensive care unit, must be seen and reviewed by a consultant twice daily.

I hope my hon. Friend will see that we are already encapsulating his principal demands about upper gastrointestinal bleeding in the general outline of the clinical standards that we plan to roll out to ensure consistent quality of care for urgent and emergency care pathways.

We will monitor the implementation of those clinical standards through transparent metrics, and I hope that in a year, if my hon. Friend is successful in securing a further Adjournment debate—I would happy to brief him privately on this issue both then and in the interim—he will see that through the transparent metrics that we will publish on mortality, length of stay, emergency readmissions and whole series of other measures, there will be trust compliance across clinical standards.

[Jim Shannon]

I understand that mortality rates for hospitalised conditions can be as much as 35%. That worries me, and I am not sure whether the Minister has addressed that issue. He referred to 10% mortality, but some hospitalised conditions have a 35% mortality rate. We must address that.

[Ben Gummer]

There is variation in mortality, and I hope we will make progress in that area over the next period. We must understand comparisons of mortality across the country, and as the hon. Gentleman knows, the Secretary of State is interested in discovering and understanding that issue. We must also understand variations across the European Union, and in the United Kingdom where there are apparent variations between practice in England and that in Scotland, Wales and Northern Ireland. Some of that comes down to data collection, but we must understand where it comes down to practice and consider how we can improve in accordance with our most neighbourly health systems.

[Dr Tania Mathias (Twickenham) (Con)]

I appreciate the Government’s intention, but I do not know whether my local hospital is accredited. I am highly concerned about the current postcode lottery. What is the Minister’s plan right now, tonight, for people who are going to a hospital that does not have an adequate rota system and is not accredited?

[Ben Gummer]

The principles that inform the policy of creating a sustainable seven-day NHS are being announced in stages. The clinical standards to which I referred have been explained in this place and outside several times, and I expect that in the next few weeks and months, further details will be given on the pace at which units around the country will comply. My hon. Friend will know that in the autumn the Prime Minister made it clear that 25% of the population will be covered by 24/7 urgent emergency care services by March 2017, 50% by March 2018, and the entire service by 2020. Precisely how that happens will be made clear in short order, and I hope that my hon. Friend will be satisfied that her hospital will form part of the programme to provide the coverage she expects.

The fact that we are having this discussion is testament to the fact that we are willing to be open about variation and failure, and to do something about it. I thank my hon. Friend the Member for South West Wiltshire for bringing this issue before the House because, just as Lord Grantham popularised it for the nation at large, my hon. Friend has explained in a particular clinical area how the introduction of robust, sustainable 24/7 services will provide the improvements in clinical care that the Government seek. That is why the challenges and difficulties that face us in introducing 24/7 services require attention across the board—not just in hospital estates, but in the configuration of services, the way that services are commissioned and procured, and the contracts that ensure that rotas can be properly manned across the service. We must attack this problem on all fronts and ensure that we provide consistency of care to our constituents. They do not choose when they fall ill, but they should expect the same quality of care whether they go to one unit or another, or on a day not of their choosing.

Question put and agreed to.