Accident and Emergency Services

John Pugh Excerpts

Tuesday 14th September 2010 Westminster Hall

[Dr John Pugh (Southport) (LD)]

It is a pleasure to serve under your chairmanship, Ms Clark. I understand that this is your first time in the Chair, and you are to be congratulated. Obviously, years of fierce political independence have finally paid off.

The subject today is accident and emergency provision. We have to accept that most TV hospital dramas are set in casualty departments, in the same way that most soap action seems to take place in pubs. That is not simply because they are eventful places, but because they are actually very varied places. Traditionally, every hospital has a casualty—an A and E—and it traditionally confronts a whole range of varied cases, from major trauma to self-referred cases of all kinds. Some people are anxious and simply need assurance, and some are anxious and genuinely need treatment. A and E departments also deal with the self-inflicted consequences of over-indulgence in legal or illegal drugs. Alcohol is, of course, regrettably an enormous source of business to A and E departments. Too often, the people who come there repeatedly do not get precisely the kind of treatment that they require and need. A and E departments also deal with simple things such as sprains, breaks and simple mishaps. They deal with mental health cases of all kinds—cases showing a greater or lesser degree of urgency.

What all those cases have in common is the factor of urgency. A patient either needs treatment urgently or urgently feels—which is not quite the same thing—that they need treatment. In some cases, regrettably, people are simply too impatient to seek treatment that they could get in good time elsewhere.

I have made three visits to casualty departments over the past three or four years. All of them have been different in kind. In one case, I had pins and needles in my left arm, which my wife persuaded me was an incipient heart attack. I went to casualty, was given a good grilling, and was gently diagnosed as having pins and needles in my arm. As for the second time, for reasons we will not go into, I had hit myself on the head with an iron bar. Again, I was simply checked out for a large bump and a haematoma, which had no lasting consequences—or none as far as I can tell. More critically, having had an accident in a car on the M1—I was not driving—I accompanied my daughter to an A and E department in Northamptonshire. In none of those cases did I receive any treatment, but each case was, in a sense, different. Treatment in an A and E department can be very different. It can vary from massive defibrillation to a gentle word of advice; from simply a conversation to a major life-saving intervention.

The bottom line is that A and E departments are everybody’s community back-stop. It is their security; knowing that there is one in their town is crucial to a lot of citizens. As what is in an A and E department varies, they are very hard to assess by any normal yardstick or benchmark. They require a whole formidable range of skills. The skills to deal with someone who has had a cardiac arrest differ markedly from those that might be required if someone wanders in in a confused or deranged state. A and E departments have tried to deal with this informally and internally by, to some extent, organising their work streams in different ways. My local A and E department in Southport used to have a colour-coding system. One would be told what colour one was, and attached to that colour was an expected waiting time. One knew where one was, in priority terms. There was—and there still may be—the expectation, and maybe the hope, that the patients, the users of the service, would appreciate that kind of prioritisation and understand what it is about. After all, nobody wants to wait for a long time for something they themselves have defined as urgent care. Unhappily, in many hospitals some of the customers—if I can use that inappropriate term—do not always feel that they ought to wait as long as they should, even when there are higher priority cases being dealt with.

Recently—this is where the trouble starts—within the NHS there has been an attempt to disaggregate work streams. There are two reasons for that. One is that it is thought that A and E departments are dealing expensively and inappropriately with all sorts of cases that could be dealt with better in other settings; or that doctors are referring cases to A and E departments in circumstances where references should be made to other facilities or alternatively dealt with by the doctors themselves. Secondly, there is a raft of very good research that shows that in the case of the most severe traumas, the most critically injured and sickest patients are better dealt with at a major trauma centre that is kitted out and has all the facilities and expertise necessary to deal with the problem. We all have to recognise that there is quite a lot of empirical research about survival rates that points in that direction.

The net effect of both those thrusts is that across the country there has been a downgrading of many A and E departments at many district general hospitals. Given that they are the community back-stop for many people, there is significant alarm attached to that. One notes, in Health questions and so on, that that is a common refrain. The situation is aggravated in many cases by the fact that the NHS, by and large, disowns any interest in transport arrangement. Having reconfigured services, it does not think too hard or too long about how people will get to those services. Superimposed on that is a degree of political manipulation of the proposed changes, because they are politically very sensitive. We have had an independent MP elected to this place purely on the back of the reconfiguration of such services.

In many cases, there is an attempt to think the matter through, and to soften the change and manage whatever changes are deemed necessary by means of the introduction of community facilities—walk-in centres, minor injuries centres and urgent care centres. That is a fine expression: urgent care centres. I think people respond positively to that. How and whether those changes happen in individual places seems to be a matter of chance, or certainly not a matter of clear planning. Across the country, we get a haphazard, patchwork system of urgent referral, if I can call it that. That is localism, if we can call it that. The Government have a responsibility here to set a standard. The public may accept that major trauma services sometimes require, even in these days of telemedicine, to be concentrated to be most effective. What they will not accept, and should not, is a longer journey for basic urgent care. That, sadly, can be what they get.

I want to emphasise that point by giving an extreme example in my constituency. In my town, as a result of a report that divided the spoils between two sites in a single hospital trust, children’s A and E facilities were taken 9 or 10 miles down the road to a smaller country town, Ormskirk. Adult A and E remained in the town and is still there. We have an odd configuration, with adult A and E and children’s A and E in two different places. The net effect of taking children’s A and E out of a town as large, and with as many children, as Southport was one of mass outrage. There were major demonstrations, huge petitions that were handed in at Downing street, and the kind of documents that eventually wash up on a Minister’s desk. People recognised that a genuine problem had been precipitated by ill-advised reconfiguration. Successive primary care trusts acknowledged the problem and endeavoured to deal with it. Southport and Formby PCT, when it still existed, endeavoured for some time to progress what it called a health village, which would have had a minor injuries unit. The PCT got £500,000 for it and was going to proceed with it, but, unfortunately, it was abolished, and the hopes of the people of Southport were, pro tem, crushed.

The new, successor PCT discovered exactly the same thing as the previous PCT—that there was a huge, yawning gap in service provision, which nobody could quite explain rationally and which needed to be addressed in some way. The new PCT made progress towards establishing a minor injuries, or walk-in, centre in Southport. The PCT involved stakeholders, as the previous PCT had done, as well as parents and various groups and political representatives in the town. We should bear it in mind that that was done to address only some of the issues precipitated by the reconfiguration.

It was absolutely unthinkable to people that a large seaside town would have to tell children who had had any kind of accident, such as falling over on the rugby field, hurting themselves in the street or whatever, to leave town in a taxi or in their mother’s car, supposing that she had one. People thought that that was wholly irrational, given the talk these days of bringing services closer to the community.

For two years, we spoke to the PCT. For two years, we had meetings. For two years, we planned the new centre. Then, a few weeks ago—to some extent, this is what precipitated my calling the debate—we suddenly found that the PCT had commissioned a report saying that the centre could not go ahead. It argued that the viability of the out-of-town, Ormskirk-based paediatric A and E required there not to be a walk-in centre in Southport. It argued that the costs were prohibitive and that what is done in many other places—such as Solihull, where two hospitals have exactly the same arrangement as Southport, but deal with the matter very differently and more sensitively—cannot be done in Southport.

As is often the case when someone needs a report to make their case, the PCT amassed a set of statistics, which have been questioned. It spoke to witnesses, all of whom were hand-picked to take a relatively adverse tone and not to be enthusiastic about the project. It presented shaky arguments, and as is often the case on such issues, it confused financial viability, which is a completely distinct, although important issue, with clinical safety, which is a different and separate issue. It did not bother to consult the local council’s overview and scrutiny committee. It spoke to GPs, but it did not consult the GP body. The result is that the public are absolutely baffled as to why we cannot have a sensitive and sensible set of clinical networks for children, based partly in Southport.

It is not just the public, but schools that are baffled. What do they do in the middle of the day if a child falls over in the school yard and someone has to take them not to a local facility, but to a facility outside town? In the past day, I have had constructive and helpful discussions with the Secretary of State for Health, and my views, far from being outrageous, strange and madly populist, are actually quite sane and rational, and it is legitimate that the PCT should take them into account.

The PCT’s report set out to answer a fundamental question, although, significantly, it failed to answer it: if a mum or grandmum finds that a child whom they are caring for on that day has fallen over and hurt themselves, and they think that an urgent attempt should be made to get the medical advice that is probably required, why the heck should they have to think through getting an expensive taxi, finding a neighbour to ask for a lift or doing something else that most people in less deprived areas do not have to do? I use the word “deprived” quite deliberately because although Southport might not be defined as generally deprived, we are deprived of a resource that is widely available elsewhere.

I hesitate to argue with clinicians, and I do not know a great deal about clinical matters, but I do know something about logic, and I am fairly confident about what I know. I am confronted here with the perverse argument that if we are to have a state-of-the-art clinical facility outside town—it is suggested that it must be there because it needs to be a specialised, full paediatric facility—that can dedicate itself to playing an important role in dealing with certain things, we cannot have run-of-the-mill care in another place to deal with the ordinary hazards of childhood life. We are told that if services are to be centralised in Ormskirk, it is necessary to have no services anywhere else. That does not follow at all, because it contradicts one of the basic premises of moving A and E services in the first place—that they should not be bogged down by, or confused with, minor injuries services and that they should be fielded closer to home.

It has been suggested that if what I am saying is the case, people should have nothing in Southport and should simply go to their local GP, but that presupposes some important things. It presupposes that every GP offers the kind of service that I have outlined, which is not the case. It also presupposes that everybody has a GP. People might or might not know this, but Southport is a seaside town, and a number of children arrive every week and every weekend simply to enjoy themselves. They do not have a GP in town. If they hurt themselves on the beach, they do not expect to be told, “I’m sorry, there’s nothing in this town for you. You have to go somewhere else.” That is an absolutely absurd scenario. Southport should provide assurance, triage and a diagnostic base for the worried mum, grandma or teacher who does not necessarily need a blue-light service, but who, in most other parts of the country, would be the sort of person to turn up in A and E.

The people of Southport are no longer uninformed about the issue; they have an intelligent grasp of what is required, but they have difficulty getting their point across to the NHS quango that disposes of the resources and commissions the facilities. The general direction in the country should not be that clinical networks are designed on the assumption that children, patients and parents will travel indefinitely—at any time, to any place—but that clinicians should not.

I do not need it spelled out to me that there are constraints on finance in this age of austerity; finance is always an issue. Equally, it is perfectly valid, particularly in paediatrics, to say that there are chronic staff shortages in various parts of the country. The lady who did the report that was so useful and helpful to my local PCT told me that the situation is so critical in paediatrics that any new facility is almost a threat to any existing facility. However, that presupposes that the provision and availability of staff, as well as demands for them, are the same right across the country. I would take some convincing that we cannot staff a modest facility in Southport and that we must sacrifice any basic care just to keep a unit down the road going.

There is a genuine need for local commissioners to think further about this issue, and, encouraged by my discussions with the Secretary of State yesterday, I am convinced that they will. I am convinced that some of the points that I have tried to get across today have got across—albeit the hard way—to local commissioners. There are, however, two important general issues, on which other Members might wish to comment, that arise from that case and from others with which I am familiar.

First, there is the general issue of standards. Where, amid all the reconfiguration that is going on across the country—we think that we understand some of the rationale behind it—is the baseline standard for urgent care that we can expect and accept in the UK? Clearly, it will vary between urban and rural populations, and with the age of populations; demographic factors will kick in. We set standards for waiting, and most of us believe that such a standard should be set, although as hon. Members will appreciate, there have been all sorts of problems with the gaming that sometimes results from that, and with the difficulties generated. We should also set a standard for access; I am afraid that we are forgetting that in all the reconfigurations across the country that have been carried out on the basis of clinical advice. Someone cannot wait for a service that is simply not there. That is one issue raised by the Southport situation, and others.

The second issue, which is also absolutely pivotal, is democratic accountability. What levers does a community, which ultimately pays for the local NHS in one form or another, have when its requests and demands persistently, and in some cases unreasonably, go unheeded? I am not calling for some type of naked populism; I can understand the concern of anyone in the NHS. We all tend to do things on the basis of what the crowd may or may not call for in all circumstances, but the NHS trusts are often confronted with a tension between how they want to deliver a service and how the population wants to receive it. That is certainly the case with paediatrics in the Southport and Formby area.

The Minister might advise me to the contrary, but I do not think that that tension will necessarily go away if GPs hold the purse strings; it may just appear in another form. All clinicians, I think, have a predilection, for a combination of personal, genuinely clinical and philanthropic reasons, for delivering any care in an optimal clinical environment, and we cannot afford that everywhere. To some extent, that will always conflict with access issues. I sometimes think that doctors’ heaven would be a massive all-capacity ward in the middle of Birmingham, with expressways joining the city to all parts of the UK in under 20 minutes. That is the implicit model behind some of the thinking that I have heard. In the real world, however, we cannot get that, but there is another way of doing things: having well-understood clinical networks with appropriate protocols. Designed in the right way, such networks can be just as safe. In their absence, we will get continual tension between communities and the local NHS on such issues.

I genuinely think that there is a democratic deficit of sorts here. If I may hark back to the subject without it being too tedious for hon. Members, who may have lost interest in the topic—I hope that they have not—a genuine tension can be almost felt in my constituency. Over the past few years, what we have had is not no expenditure but too-large Darzi clinics, which we struggle to fill; people wonder how they came about. Equally, there is something that we dearly want, and the PCT has twice let us down over it. One can stop any individual in the street in my town and hear their anger about the facilities that they would like. They are not asking for utopia; they are just asking for obvious deficiencies—in children’s services, in this case—to be corrected. I simply ask: why does this have to go on?

--- Later in debate ---

[Anne Marie Morris (Newton Abbot) (Con)]

This has been an interesting debate and I commend hon. Members on their contributions. It is clear that accident and emergency is close to all our hearts. I am particularly blessed with two very good district general hospitals—one is at Torbay and the other is the Royal Devon and Exeter hospital. I am extremely fortunate. However, there are three minor injury units in the smaller towns of Newton Abbot, Teignmouth and Dawlish. The challenge for me is in many ways an echo of the points raised by my hon. Friend the Member for Southport (Dr Pugh). Clearly, the issue is access. I am concerned to ensure that we use the minor injury units to their fullest extent. For my constituents the journey to Torbay or the Royal Devon and Exeter is quite a long one. My concerns, on which I hope the Minister will look favourably, are that we should think about making better use of the minor injury units. If we do so, we shall help the overall NHS budget very much.

I do not know how many people realise that the number of people who attend A and E is growing faster and faster. In just the past three months of this financial year, 5.49 million people have been seen at A and E. Mathematically, extending that over the year gives a figure of 22 million people visiting A and E throughout the country. That breaks last year’s record of 20.5 million. Such a figure would mean 40% of the population visiting A and E at least once, assuming that each individual who visited was responsible for only one attendance. That is a huge figure. The challenge for the Government and the country, given the current economic climate, is how we afford that. One of the issues is the number of people who inappropriately attend A and E—not through any fault of their own.

Just going through the door at an average hospital costs the NHS £100. By comparison, the average cost to go through the doors of a minor injury unit is £50. Those figures are averages, but the cost differential is significant.

[Dr Pugh]

The hon. Lady has mentioned the statistics and the increased number of inappropriate self-referrals. She is probably also aware, because she is extraordinarily well informed on the issue, that GPs are referring more people than hitherto to A and E. Therefore primary care—the GP setting—is not the answer. The answer is probably the minor injuries unit.

[Anne Marie Morris]

I thank the hon. Gentleman for that valuable contribution; I agree with the earlier comments that the answer is probably an appropriate network of different provision. However, we need that to be clearly signposted. That is the way forward.

The challenge for the Government and the Minister is to quantify the percentage of people who present at A and E who would be better dealt with in, for example, an MIU. People have tried to quantify that, but the figures vary wildly, from 60% to a more modest 10% to 30%, which is the latest finding of the Primary Care Foundation. Further work on that would be very worth while. However, the Minister could sensibly consider several steps now, even before that investigative work, to examine how we can manage A and E attendance more effectively. The figures show that 20% of presentations at A and E are alcohol-related. We all know that is a huge burden on the NHS and the country as a whole, because of crime and other issues. Minimum alcohol pricing and improving education in schools might make a significant difference to the Minister’s problem.

Secondly, I suggest that the Minister and his colleagues consider the availability of other services, such as dental care, in communities. Often, it is because there is not adequate NHS dental care that patients present themselves at A and E units. A and E services are cheap, they are there, and they are now. If we could fix that situation it would make a big difference. Such problems cannot be the right reason to attend A and E. Although the PCTs have tried to assist the public’s understanding of where to go for which service, it is abundantly clear that they have failed. People know about 999 and A and E, and that is where they go. We need to find a much more effective way of educating them. I commend the Minister on the commencement of the 111 service, which is excellent, if we can educate people to use it appropriately.

The Minister might also like to take into account how we give prominence to and promote MIU services. However, to do it effectively we need to ensure that across the country everyone knows what the service is and that it is consistent—for example, that opening hours are consistent. In my constituency, it depends on which MIU someone attends; if they turn up at Dawlish after 6 o’clock, the door will be closed, but that would not be the case if they turned up at Newton Abbot. It is equally bizarre that for someone who needs an X-ray, the X-ray unit is not coterminous with the MIU opening hours. Those are exactly the sort of things that put people off going to an MIU. In that regard, some steps forward would be extremely helpful.

If I may, I shall take the opportunity to refer to a couple of helpful things that my local health community is doing in my constituency. First, in Torbay hospital, local GPs attend A and E at the point of entry, so, rather than going through standard A and E routes, some patients see GPs, which reduces costs. The second good initiative in my constituency comes from our mental health practitioners recognising that, often, a stay in hospital is extended because someone has the symptoms of depression. Devon Partnership NHS Trust, which is responsible for mental health care in my constituency, has placed mental health care practitioners in hospitals to assess individuals, and, as a result, is beginning to reduce the time that individuals stay.

I am grateful to hon. Members for their contributions and to the Minister for his attention. I commend to him the idea of looking further at consistency in MIUs, how to reduce alcohol-related admissions, using mental health care practitioners to reduce the length of stay in A and E, and making other services, such as dentistry, available, as they should be, to avoid people unnecessarily going to A and E.

[Dr Pugh]

On alcohol-related admissions, which the hon. Lady mentioned twice, one problem that besets many A and Es is repeat customers—chronic alcoholics who appear again and again. Clearly, alcohol pricing would make little difference to them, so a linkage between A and E and other services in the community is normally required in those contexts. In many parts of the country, that linkage simply does not exist, which creates repeat custom for A and E.

[Anne Marie Morris]

I have finished my speech.

--- Later in debate ---

[Gordon Birtwistle (Burnley) (LD)]

Thank you, Ms Clark. This is my first time in this Chamber, and I hope I succeed as well as you will no doubt succeed in the Chair. I congratulate my hon. Friend the Member for Southport (Dr Pugh) on securing the debate.

In Burnley, we have been fighting for over three years to resolve a major problem with our A and E. I shall give a brief history of the area, which is Pennine Lancashire and includes Burnley, Pendle and Rossendale. Not many years ago, we had five hospitals. That was reduced to one, which was a very successful, well-loved and well- thought-of hospital—Burnley general. Over the past three years, it has been decimated, and the A and E has disappeared. The hospital covers an area—Burnley, Pendle and Rossendale—with a population of more than 250,000, and the A and E services have been moved to the Royal Blackburn hospital, which is brand new, built in Blackburn, and, I believe, built for the area that Blackburn covers. It is attempting in some way, shape or form to cope with the extra influx of people travelling over from Burnley.

Our A and E was changed to an urgent care centre. What an “urgent care centre” is, nobody seems to know. I certainly do not know, and when people ask me what “urgent care” means, I say, “Well, if you need it urgently and you need some care, that’s where you must turn up.” They say, “Well, what’s the difference between that and an A and E?” That debate is still going on in Burnley, and it is a question that I have asked the chief executive of the trust to answer, without much success.

This started three years ago with the “Meeting Patients’ Needs” study by Sir George Alberti, who decided that the 250,000 people in Pennine Lancashire did not need an A and E and it could be transferred comfortably to Blackburn. The vast majority of the 250,000 do not feel that they have had their needs met in one way, shape or form or even at all. Royal Blackburn hospital is constantly overwhelmed and permanently on red alert. On one occasion, it had to close the A and E due to being swamped with what I would class as patients or, as my hon. Friend the Member for Southport said, customers—

[Dr Pugh]

A horrible word.

[Gordon Birtwistle]

Indeed. People turning up at A and E were being either stored in ambulances or transferred to Lancaster, and, in one case, a gentleman came to me who had been transferred to Bury. On arrival in Bury, in his carpet slippers and cardigan, after taking his wife initially to the A and E unit in Burnley, he was told that she was being kept overnight and he could go home. When he questioned where he was, they said, “You’re in Bury.” He said, “I only went to Burnley, how the hell have I finished up in Bury? How do I get home? I’ve got my carpet slippers on, I’m in my cardigan and I’m 76 years old.” He was pointed to a taxi, which took him home at great expense. That is an example of what is happening with an A and E unit that was built some 35 miles away from the outskirts of Pendle and some 15 miles away from Burnley—the area that it is supposed to support. How on earth can it cope with the extra work? It cannot. If it could, it would not be on red alert permanently.

The misunderstanding over what A and E and urgent care are is a big concern, and I understand that the Government are looking into renaming urgent care in future, which may make it easier for people to understand. I accept that we do not need to go to a major A and E unit for a cut finger, a stitch or something like that, but major traumas happen. In fact, a major trauma happened in Burnley when an old lady parking her car in a car park that was less than 100 yards from the entrance to the hospital got her foot jammed in the car pedals and crashed into another car. Burnley hospital refused to treat her. The hospital entrance was less than 100 yards away; they brought out a blanket and covered her up, and sent 15 miles for an ambulance to take her to the A and E in Blackburn. That old lady said to me, “I wasn’t badly injured. All right, I was shook up, I’d got my foot jammed in the pedals and I’d banged my head. I’m sure a hospital this size—a hospital I’ve been proud of all my life in Burnley—could have treated me for something like that.” But, they sent an ambulance 15 miles to pick her up, took her to Blackburn to give her a check over and sent her home under her own steam. In this day and age, 2010, when not many years ago men were walking around on the moon, that is outrageous. It is totally unacceptable. Either the urgent care unit should advise people what it does at the hospital and if it is prepared to do it, or the whole A and E facility should be transferred back to Burnley.

Following on from that point, I have stood behind a campaign table outside Marks and Spencer every Saturday morning for more than 107 weeks. A petition of 25,000 names has called for our A and E unit to be brought back. We have the support of almost all our GPs, the people of Burnley and the borough council. When Sir George Alberti conducted a study, he was supposed to consult all the relevant people in the area. He consulted the borough council, and I sat in on the meeting as leader of that council. However, there was no consultation; we were presented with a fait accompli. It was almost as if he was saying, “We are moving the A and E to Blackburn and that is that.” When we asked him why, he said that in his view people in Burnley would be better served in Blackburn. I have to say that the hospital in Blackburn is fantastic. It is brand sparkling new, except for the A and E unit, which is an oversized portakabin that is stuck outside and not yet incorporated into the hospital. Therefore, the people of Burnley, Pendle and Rossendale have an appalling service. My hon. Friend the Member for Pendle (Andrew Stephenson) is also supporting our campaign to get the unit back to Burnley.

I am delighted to say that Burnley has a brand spanking new £30 million extension to the maternity unit, which has a birthing suite and all the related facilities, and we welcome it with open arms. Adjacent to that is a children’s ward, but that is now being closed down and moved to Blackburn, so we have all the facilities in Burnley for newborn babies but none for children. A child is classed as such from three months upwards, so if they are unwell when they are born they will only be treated in Burnley for three months. Thereafter, the parents will have to trail them to Blackburn, which is 15 miles away, and many of them, as the hon. Member for Hartlepool (Mr Wright) says, do not have cars. What happens to a young mother who has two children? Her husband or partner may be working or she may be on her own. How does she manage to take one of her children to Blackburn when she does not have transport? The hospital says that there is a minibus that runs from one hospital to the other. It is a joke.

[Dr Pugh]

My hon. Friend is clearly aware of the irrationality of the problem. However, he might not know that in Southport and Ormskirk, the paediatric department and the children’s A and E was moved to Ormskirk because that was where the maternity suite was based and it was felt that it was essential for the paediatric and maternity suites to go together. That is completely the opposite argument, and we are only about 40 miles away from one over in Lancashire.

[Gordon Birtwistle]

My hon. Friend makes a good point. The children’s ward is moved from one town to another because that is where the maternity suite is based. In Burnley, the children’s ward is being moved to make way for a maternity suite. It is hard to make any sort of sense of how all this is configured, who has dreamed it up and what they are going to do about it. To say the least, I am confused, and I have been involved in such matters for a long time. How on earth are the people of Burnley, Pendle and Rossendale supposed to know what is going on?

The movement of the children’s ward might not be totally linked to the A and E unit, but, none the less, it is being done against the wishes of the people and the new guidelines that have been laid down by the Secretary of State. The Secretary of State makes it quite clear that the borough council, the GPs and the people of the town have to agree to such a move. Of the 66 GPs whom I wrote to, more than three quarters have replied. One is totally in favour of the proposal, but that is because he sits on the health board, three are neutral about it and the rest are vehemently against moving not only the A and E unit but the children’s ward as well. The borough council has moved a motion opposing the proposal and the people of Burnley have signed many petitions against it.

We in Burnley demand that the children’s ward not be moved. I urge the Secretary of State to put a stop to such a proposal. Having said that, the trust is totally oblivious to such objections. I have challenged the trust to stop the move, and it is almost as if it says, “We are moving it and we don’t care what anybody says.” The trust seems to think that it is more powerful than anyone, and it takes no interest in what the people, the patients and the politicians say.

The situation is a mess. I am sure that Burnley, Pendle and Rossendale are not on their own. We have already heard that Hartlepool and Southport have the same problem. I am sure that it is the same all over the country. Torbay obviously has one hospital too many. The hon. Member for Newton Abbot (Anne Marie Morris) should keep her eye on it because it may well be closed. It is critical that we solve this problem because millions of people depend on their A and E unit and children’s ward. They need the confidence to turn up to such facilities if something happens. Deciding what urgent care does is important, but we should also be more linked to the idea of smaller, proper A and E units if we do not want full-blown A and E units across the country.

--- Later in debate ---

[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.

[Dr Pugh]

Will the Minister give way?

[Mr Burns]

I will, but I am relatively short of time if I am to deal with all hon. Members’ questions.

[Dr Pugh]

It should be said that the previous Government shied away from every chance to give a decisive voice on the construction of health services to anybody who held elected office. I promoted a private Member’s Bill that endeavoured to introduce a different form of democratic accountability, but the test of the White Paper will be whether people with a democratic mandate have a voice in deciding health services.

[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.