Accident and Emergency Services

Diana Johnson Excerpts

Tuesday 14th September 2010 Westminster Hall

[Diana R. Johnson (Kingston upon Hull North) (Lab)]

It is a delight to serve under your chairwomanship, Ms Clark. I congratulate the hon. Member for Southport (Dr Pugh) on securing this important debate. I know that he has particular interests in health concerns not only in his constituency but around the country. He set the scene very clearly at the outset and described why we need good A and E facilities in this country. However, I was concerned when he talked about hitting himself on the head with an iron bar. I hope that had nothing to do with his frustrations with some of the health policies of the coalition Government.

[The Minister of State, Department of Health (Mr Simon Burns)]

That happened when your party was in government.

[Diana R. Johnson]

Let me refer to the three points that were pertinent to this debate.

First, the hon. Member for Southport spoke about a patchwork system that reflected the haphazard way in which emergency services are provided. The White Paper “Equity and excellence: Liberating the NHS” says it plans to develop

“a coherent 24/7 urgent care service in every area of England that makes sense to patients when they have to make choices about their care.”

My hon. Friend the Member for Hartlepool (Mr Wright) raised the issue of local communities understanding where they can best access care. The hon. Member for Newton Abbot (Anne Marie Morris) mentioned the standardisation of services around the country. I will come back to that point later, because I have great concerns about the rest of the White Paper, which is much more about localism and ways to provide service. Such a thrust might be a problem for the particular aim that the White Paper sets out around emergency care.

Secondly, the hon. Member for Southport mentioned the need for baseline standards around waiting times, access and so on. I am again concerned with the thrust of the White Paper and that we may not have that baseline standard around the country. We have already seen the reduction in the waiting-time target in A and E from 98% to 95%, and I understand that it will be removed completely in the future.

Thirdly, the hon. Member for Southport raised the issue of democratic accountability. I have to say that I raised an eyebrow at that point because it was clear that the Liberal Democrat party had got one of its manifesto promises in the coalition agreement, which was to have directly elected members of the PCT, but just a few weeks later, the White Paper basically ripped up that section of the coalition agreement. As I understand it, democratic accountability is now to be through the scrutiny function of local authorities. Although I know that local authorities can carry out such scrutiny very well—we heard from my hon. Friend the Member for Hartlepool about the excellent scrutiny that has taken place in Hartlepool—I am concerned about how they will do it now that their budgets are being cut. To scrutinise health services will require further resources, not least because local authority members will need to be trained up. There is a difference between being able to scrutinise effectively the emptying of bins and so on and being able to scrutinise the very difficult, complicated and technical clinical health services.

[Mr Burns]

I am staggered by the shadow Minister. She is a very reasonable person and I understand that she has a job to do because she is now a shadow Minister in opposition. However, I was surprised that she did not mention, let alone give any credit to, the concept of the health and wellbeing committees, because they will play a crucial role. And there is another thing that surprises me. Presumably, she was perfectly happy when local authorities took on a greater role in public health, so why should they not do so under the proposals in the White Paper?

[Diana R. Johnson]

I am a great supporter of local government and served as a local authority councillor for eight years, so I understand clearly the important role that a local authority can play in a community. However, I am saying to the Minister that effective scrutiny and the effective ability to look at what is often quite complicated work would demand a rethink about the resources that we put into local government scrutiny. If we look back over the years during which there have been scrutiny panels in local government, we find that there is a concern about the capacity of local government to scrutinise services effectively that are outside their own remit.

[Mr Charles Walker in the Chair]

I want to move on, because I want to pay tribute to my hon. Friend the Member for Hartlepool, who, as ever, is a strong advocate for health services in his locality. Importantly, he also raised the issue of NHS Direct. Over the summer, there was a lot of confusion because of the unfortunate way that announcements were made about the future of NHS Direct. So it was important that that issue was raised in the debate, because I think there is genuine concern in the community about it.

The hon. Member for Newton Abbot raised the issues of minor injuries units and the need for appropriate networks of care. The hon. Member for Burnley (Gordon Birtwistle) gave a very full history of what had happened in his community. He discussed the problem of trying to define the difference between “urgent care” and “A and E services.” However, I noted that the Secretary of State for Health has made it clear that the naming of facilities is very much an issue for the locality in which a facility is situated, so the local area needs to determine what title best fits the services that a facility provides.

The hon. Member for Burnley also raised a number of points that I wish to discuss briefly regarding the confusion that exists at the moment about reconfiguration and the current Government’s position on that issue.

I think there is genuine agreement that all changes in health services should be clinically driven and, of course, locally led. My right hon. Friend the Member for Leigh (Andy Burnham) made it clear when he was Secretary of State for Health that tough decisions would have to be made about moving services out of hospitals and into communities, where they would be closer to people’s homes, and about centralising specialist care where it made sense in terms of protecting patients’ safety. The hon. Member for Southport referred to the great deal of research on patient safety that is available and he and my hon. Friend the Member for Hartlepool said that more consideration needs to be given to the transport links that are so vital if communities are to be able to access health care facilities.

I do not wish to take very long to make my comments, because I want the Minister to respond to the particular constituency issues that have been raised today. I just want to raise more general issues regarding the concerns that exist about the Secretary of State’s announcements on reconfiguration.

Before the election, the Secretary of State made great play of touring the country and promising that A and E services would not be closed; he said that such closures would not happen under his watch. Two weeks after the election, he made an announcement at Chase Farm hospital that there would be a moratorium on service changes. The revision to the NHS operating framework 2010-11 was published on 21 June and it states:

“A moratorium is in place for future and ongoing reconfiguration proposals.”

However, several local areas have pressed ahead and made decisions to downgrade A and E services and other facilities, including the downgrading of a maternity unit in Kent, which local GPs are opposed to, and the downgrading of a maternity unit at Chase Farm hospital, where before the election the Secretary of State had said that the plans for the north central London review would be scrapped. Now it appears that those plans are being brought forward again.

Ministers in the coalition Government have made it clear that it is not their approach to intervene in health care services and reconfigurations. Curiously, however, despite the Government’s saying that strategic health authorities should not take decisions relating to service changes, on 29 July David Nicholson, the chief executive of the NHS, wrote to strategic health authorities, asking them to

“undertake an assessment of which proposals have successfully demonstrated the test and should proceed, which require further work and which, if any, should be halted. This initial assessment should have been completed by 31 October 2010.”

I just want to refer to the “test” mentioned in that letter. As I understand it from what the Secretary of State has said, it involves commissioners—the commissioners being GPs—having to reconsider whether or not they support the proposal that is being put forward. It also includes strengthening arrangements for public and patient engagement with local authorities; that is particularly referred to in the “test”. There must also be greater clarity in the clinical evidence for any reconfiguration and the need to develop and support patient choice must also be taken into account. As I understand it, that is the “test” that the coalition Government are putting forward, which has to be gone through, step by step, for any reconfiguration.

However, when we refer back to the statement on the moratorium, that is all rather confusing and contradictory.

[Mr Burns]

May I help the shadow Minister by reading to her what the Secretary of State announced in May would be the guiding principles for new and current reconfigurations? He said that

“reconfigurations must have the support of GP commissioners; demonstrate strong public and patient engagement; be based on sound clinical evidence, and consider patient choice.”

I hope that helps to clear up her confusion, although I expect it will not.

[Diana R. Johnson]

I am grateful to the Minister for going through that list of criteria again. However, I think that the hon. Member for Burnley will remain confused, because in his contribution to the debate he made it very clear that local GPs overwhelmingly opposed the proposal that was being put forward in Burnley but that the primary care trust was pushing ahead with the proposal. That does not quite fit with the “test” that the coalition Government have put forward.

[Gordon Birtwistle]

The actual movement of the A and E unit to Blackburn was carried out under the hon. Lady’s Government and the decision to move the children’s ward was made under her Government. I am hoping that the coalition Government will reverse the decisions that were taken under her Government to move the children’s ward, in order to fit in with what the Minister has just mentioned.

[Diana R. Johnson]

I do not wish to rewrite history.

[Gordon Birtwistle]

I do not wish this debate to be political—I just want my hospital back.

[Diana R. Johnson]

With the greatest of respect, I do wish to be political, although I do not want in any way to rewrite history. I understand very well the events that the hon. Gentleman has just set out, which happened under the last Labour Government. However, what concerns me now is that we have a coalition Government who have made contradictory statements about their plans for reconfiguration of services. The hon. Gentleman is faced with a particular issue in his constituency. At the moment, there seems to be confusion. Overwhelmingly, GPs in Burnley do not want the transfer of services to go ahead, but their feelings are being completely ignored by the PCT. I do not wish to intrude on private grief, because obviously this is a matter for the hon. Gentleman’s Government to deal with, but I just want to point out that that is an example of the contradiction that exists at the moment and the confusion that exists around the country.

[Mr Burns]

The shadow Minister does not want to “intrude on private grief” and I appreciate that. I want to help her to stop digging. If she waits until I make my response to the debate and address the point made by the hon. Member for Burnley, my response might help to clarify her mind.

[Diana R. Johnson]

As always, I am very interested to hear what the Minister has to say. However, there are three specific points that I would like him to address. First, is there currently a moratorium on reconfiguration proposals, and if there is, why are local areas able to take decisions to downgrade A and E Departments?

[Mr Burns]

Do you want me to answer that?

[Diana R. Johnson]

I am very happy to let the Minister respond in full in a few moments. I am reaching the end of my comments.

Secondly, does the assessment of proposals that SHAs have been asked to carry out apply to existing schemes? Thirdly, if it is not for Ministers to intervene in service changes, why did they promise to halt closures of A and E departments and maternity departments before the general election?

I also want to say, Mr Walker, that I am delighted to serve under your chairmanship today. I am not sure if this is your first opportunity to be in the Chair in a Westminster Hall debate, but it is certainly a pleasure to see you in the Chair today.

[The Minister of State, Department of Health (Mr Simon Burns)]

What an unexpected pleasure it is to serve under your chairmanship, Mr Walker. It is a first for me, and I hope that there will be many such occasions in future. I congratulate the hon. Member for Southport (Dr Pugh) on securing this important debate. I will start by dealing with some general aspects, and will then discuss some of the specific issues raised by hon. Members and the Minister.

[Diana R. Johnson]

The shadow Minister.

[Mr Burns]

Sorry, the shadow Minister. I was trying to make the hon. Lady relive old glory days.

[Mr Burns]

Obviously they were not happy for the country, or the hon. Lady would not be a shadow Minister now. But there we are; that is life. I pay tribute to the many members of NHS staff in the constituency of the hon. Member for Southport for all the hard work that they do to provide dedicated, committed health care to his constituents and those of other hon. Members in the neighbourhood who are served by the facilities there.

This Government were elected on a platform of reform of the national health service. Our White Paper, to which the shadow Minister alluded, sets out our plans. More than any other Government in the history of the NHS, we will devolve real power to patients, GP commissioners and all clinicians working on the front line. As the NHS becomes increasingly locally led, it will become locally accountable to local authorities and health watch groups. As the White Paper unfolds and reforms are implemented, subject to current consultations, I hope that that commitment will give some reassurance to all those hon. Members who mentioned democratic accountability. Local authorities and health and well-being committees will have a significant role, in terms of democratic accountability, in a way that primary care trusts and strategic health authorities did not.

[Diana R. Johnson]

I would be interested to know what the Government’s rationale was for removing the section in the coalition agreement that said that PCT boards would be elected. Why was that in the coalition agreement if it was to be ripped up five weeks later, and if the White Paper was to get rid of PCT boards?

[Mr Burns]

As the hon. Lady will be aware, this is a coalition Government. That means merging the best practice that each party to the coalition has to offer. That is why we have adopted from the Liberal Democrat manifesto the policy of abolishing SHAs. When we unveiled our proposed reforms, which concentrate commissioning with GP commissioners and GP consortiums, because GPs are at the forefront and are closest to patients, it became clear that if we were to have proper democratic accountability with local authority involvement, the role of PCTs would be diminished to the point where it would have been a waste of resources to keep them, as their functions would be performed by other groups, such as GP consortiums and local authorities. It is a question of merging best practice to get the best solutions and provide the best health care for all our constituents.

--- Later in debate ---

[Mr Burns]

I am grateful for that intervention. The hon. Gentleman makes a valid point.

As we do away with politically motivated, top-down-process targets, we will focus all the NHS’s resources on what doctors and patients most want: improving health outcomes. Accident and emergency and urgent care services will be reshaped to reflect those changes in the coming years. I will outline some of our plans.

For many years, accident and emergency services have been operating under the rigid law of the four-hour wait target. How long someone waits in A and E before receiving treatment is important, of course. Not only does it affect the patient’s overall experience of care, but timely treatment generally means better and more effective treatment. However, the problem with the four-hour wait target, an incredibly blunt instrument by itself, was that it became the be-all and end-all of performance management. Such a narrow focus led to the distortion of clinical priorities. I am sure that we are all familiar with tales of hospitals admitting patients unnecessarily, solely in order to meet the target. There have even been persistent allegations that some hospitals have failed to record figures properly, undermining confidence in the whole system. I am sure that hon. Members will agree that that will not do.

From next April, we will introduce a range of more meaningful performance indicators balancing timeliness of treatment with other measures of quality, including clinical outcomes and patient experience. I trust that the shadow Minister will reflect on that. She is looking a little puzzled, because that is at variance with the shock-horror statement about targets and A and E that she made in her contribution.

[Diana R. Johnson]

Just so that we are all clear, is the Minister saying that there will still be a waiting time target for patients in A and E?

[Mr Burns]

No, that is not what I said. I am sure that you were listening carefully, Mr Walker, but for the benefit of the shadow Minister, I will repeat what I said, so that there can be no misunderstanding whatever. From next April, we will introduce a range of more meaningful performance indicators balancing timeliness of treatment with other measures of quality, including clinical outcomes and patient experience. Those performance indicators are currently being drawn up by the profession and will enable doctors and nurses on the ground to deploy their greatest asset: their own professional judgment. Based on clinical advice, the Secretary of State has already reduced the threshold for meeting the four-hour target from 98% to 95%, as the shadow Minister said. The move has been widely welcomed within the medical profession.

The shadow Minister will understand that the issue is about locally led, clinically led services. The same goes for the configuration of those services. It is vital that the NHS continues to modernise and improve for patients’ benefit, but it is also vital that when that means reconfiguring local services, reconfiguration is based on sound clinical evidence, has the support of GPs, clinicians and the local community and considers patient choice. The days are over when a select group of people could meet behind closed doors to decide the future of local health services. In future, change will be led from the ground up, not from the top down.

Where local NHS organisations have already started to consider changing services, we have asked them to go back and ensure that the proposals meet the new criteria and, if they do not, to take steps to ensure that they do so before they proceed. We have asked commissioners to complete any such reviews by 31 October. However, we do not intend to ask the NHS to reopen previously concluded processes or to halt work that has passed the point of no return—that is, projects where contracts have been signed or building work has started.

The hon. Member for Southport discussed the lack of clear definitions for various services. When somebody walks through the doors of an A and E department, a walk-in centre or an emergency care centre, what exactly should they expect? What ailments or injuries are most appropriate for each setting? It is not only an issue of general confusion; it is also a matter of safety. If someone presents at a place describing itself as an accident and emergency department, but it does not have the same facilities as most A and Es, that patient could face delay and unnecessary risk.

As part of the quality, innovation, productivity and prevention programme, work on standardising urgent and emergency care is under way. Its aim is to clarify what services can be expected in various facilities. By using criteria based on clinical evidence, it should be possible to standardise those terms across the country. That is currently being done in three pilot areas: east Lancashire, Manchester and Salisbury. The conclusions should be published by the end of the year, alongside the operating framework. However, it will not state which types of service should be provided in particular areas. That decision will be made locally.

The hon. Member for Southport specifically raised the issue of children’s services in his constituency. I understand that services were reconfigured across Southport and Ormskirk hospitals in 2005. As a result of that reorganisation, emergency surgeries, including adult accident and emergency, were centralised in Southport. All children’s services, including A and E, were concentrated in Ormskirk, as the hon. Gentleman said.

I know that the hon. Gentleman has been vigorously campaigning for the development of a children’s walk-in centre for Southport for some time. Sefton primary care trust commissioned two national experts in paediatric emergency medicine to conduct an independent clinical review of that proposal. On 8 September this year, I understand that the hon. Gentleman met Mike Farrar, the chief executive of the North West strategic health authority, to raise some serious issues about the content of the report that he was shown in advance—issues such as his belief that the report mixes up issues of clinical safety with those of affordability.

The SHA has suggested that the PCT receive that report as a preliminary report, and that further work should be conducted to address the hon. Gentleman’s concerns. The final report should be completed by December. I understand that my right hon. Friend the Secretary of State fully endorsed such an approach when he met the hon. Gentleman yesterday. Although that will add a further three months to an already drawn-out process, I hope that it will provide a far stronger platform for moving forward. Such an approach will also underline the Government’s determination that decisions about local services should be taken locally and include the views of GPs and the wider community.

On the question of children’s A and E services, one important aspect of high-quality care is ensuring that a particular institution receives a sufficient volume of cases to be safe. Patients are best seen by professionals who have access to the right equipment and support services, the right specialist skills and frequent opportunities to exercise those skills. Mercifully, serious illnesses and injuries are relatively rare but, when they occur, it may be better for a patient to travel slightly further to a specialist centre where the appropriate skills are concentrated. That is why regional trauma and stroke centres have been set up and are proving such a success. Similarly, children are best seen by specialist paediatricians in a child-friendly environment. Of course, that is and remains a matter for local decision making, based on local demand for urgent care for children.

I shall turn briefly to the points raised by the hon. Member for Hartlepool (Mr Wright), who mentioned a number of issues concerning the provision of health care in the Hartlepool area. As he rightly said, we have had a number of debates on health care, and I am starting to feel extremely familiar with his constituency’s issues, although sadly I have not yet visited it. First, on the issue of NHS 111—which was, of course, inevitably picked up by the hon. Member for Kingston upon Hull North (Diana R. Johnson)—as I am sure the hon. Member for Hartlepool knows, NHS 111 is being piloted in four areas this year. We will evaluate the experiences and knowledge we gain from those pilots and roll out nationally the 111 number to replace the NHS Direct number. He will appreciate that a 111 number is more easily identifiable in everyone’s mind than the far longer 0845 number that NHS Direct uses. We will wait and see what happens on that matter.

The situation that the hon. Member for Kingston upon Hull North outlined was not quite accurate. There has been no confusion. Ironically, what my right hon. Friend the Secretary of State is doing in piloting a 111 number is simply reflecting and implementing a manifesto commitment made by the hon. Lady’s party at the last election. There are times when political parties share views and think that an idea should be experimented with. I am running out of time for my speech, but I reassure her that there is no confusion.

The hon. Member for Hartlepool also mentioned the issue of A and E and ambulance services. As he will be aware, ambulance calls are put into the category of A, B or C. Any cover from Hartlepool would be imaged under that system, and who should use what type of ambulance or transport would depend on the category that their condition, illness or injury falls into. At this stage, I believe—I shall choose my words fairly carefully, so that the hon. Gentleman does not immediately intervene and contradict me—that the A and E at Hartlepool has not yet closed. If he will allow me, I shall look into the matter a little further, because I would like to know for my own education and knowledge exactly what is going on there. If he thinks it would be helpful, I will write to him after I have looked into the matter. I hasten to add that I do so simply for my own education and knowledge, because decisions must be taken locally.

My hon. Friend the Member for Newton Abbot (Anne Marie Morris) raised some extremely important issues, not least those relating to mental health. She also mentioned a crucial matter that not only causes problems in the health sector, but gives rise to antisocial behaviour and law and order considerations: that of alcohol and alcohol-related admissions to A and E or minor injury units. I reassure her that considerable work on that is being done across Government, including in the Department of Health, because we are as concerned as she is to come up with solutions to alleviate and reduce that pressing problem, which affects all our towns and villages, particularly on a Friday and Saturday night. On the question that my hon. Friend raised about opening hours and the availability of some minor injury units at Newton Abbott, Teignmouth and Dawlish, I will make sure that her comments are drawn to the attention of the South West SHA, so that it is aware of her concerns.

The hon. Member for Burnley (Gordon Birtwistle) was courteous enough to give me advance warning of the issues that were of particular concern to him. I understand and appreciate the points he raised. I know that he has written to me and if a response has not yet been received, one will shortly be sent to him from the Under-Secretary of State for Health, my hon. Friend the Member for Guildford (Anne Milton). I must emphasise that it is not for me to reconsider the application of the new criteria with regard to the proposed reconfigurations in the hon. Gentleman’s area. That is for local people to consider. It is for GPs, the public, local authorities and local PCTs to reassess what they consider to be a viable and successful future for the services provided in Burnley and Blackburn.

The Department of Health has asked the local NHS to look at how ongoing schemes meet the new criteria, as laid down by my right hon. Friend the Secretary of State, including meeting patients’ needs. NHS North West has advised us that that work will be concluded in October 2010, and that it will be able to advise on the process and the progress of that review then.

As the hon. Member for Burnley outlined, he has done considerable work. I encourage him to share his and his constituents’ concerns again and again with NHS North West or the PCT, as is appropriate. He needs to ensure that the strong body of public feeling and opinion within his community and constituency is brought home to the relevant authorities that are considering the matter and recommending decisions on what should happen, so that they can fulfil the criteria that my right hon. Friend the Secretary of State has set out.

In conclusion, this has been an extremely helpful and useful debate. A number of very important issues have been raised by hon. Members across the divide, and by the shadow Minister, the hon. Member for Kingston upon Hull North. I know that there are a number of things that she will never accept, not least in the vision unveiled in the White Paper. However, as with all other areas of health care, on A and E—urgent care—I reassure her that the overriding principle of this coalition Government is to judge patients’ quality of care by raised outcomes, rather than through process targets. That will ensure that we can give the finest health care to all our patients.