Accident and Emergency Services: Merseyside and Cheshire

John Pugh Excerpts

Tuesday 22nd November 2016 Westminster Hall

[John Pugh (Southport) (LD)]

I beg to move,

That this House has considered accident and emergency services in Merseyside and Cheshire.

It is a pleasure to serve under your chairmanship, Sir Roger, and a pleasure to see the Minister in his place. We spent many a happy hour on the Public Accounts Committee in years gone by, and I have great respect for him. I am sure he will give due consideration to what I say.

The debate title is a slight misnomer, however, because it was intended to entice other colleagues from the Cheshire and Merseyside region. Sadly, they have not taken the bait, perhaps because of the limited time available, so I will talk largely and almost exclusively about my own patch.

Southport is a large seaside town on the Lancashire coast, with one of the most elderly populations in the UK. I have to point that out, because for some reason I am often confused with the Member for Stockport and I am referred to as such. Southport, however, is nothing like Stockport. Southport is a seaside town and has one district general hospital on a split site with Ormskirk. The accident and emergency provision, though, is split by age between the two sites, which is a bone of contention in Southport.

For the purpose of the sustainability and transformation review, Southport was grouped with other hospitals ringing Liverpool, including those in Aintree, St Helens, Whiston and Warrington. Southport has recently had a poor Care Quality Commission report on its A&E department and an equally poor review of its surgery. It has responded positively with further investment of £600,000 into the A&E department, so that now, according to the stats—I checked this with the chief executive only this week—it has one of the best-performing A&E departments in the north-west.

That might have been the end of the story, because the CQC report dates from some time back and because of the improvements, but for suppressed drafts of the Cheshire and Lancashire sustainability and transformation review that have been leaked. The leak showed a number of things, including a possible downgrading of Southport A&E and of other A&E departments in the area—the hon. Member for Macclesfield (David Rutley) is now in the Chamber, and his is one of the areas affected, as we have discussed—as part of a cost-saving exercise.

That is not the first time that the suggestion has been made apropos of Southport, but the Minister knows from his own experience in Ludlow how politically explosive such suggestions can be and have been. He will also appreciate that those suggestions are sometimes entirely simplistic and often linked to another further bright suggestion that people come up with, which is to close down wards. The consultants charged with balancing the books, and often deferred to by the national health service, might come up with the brilliant suggestion that the best thing to be done with a loss-making hospital is to get it to do less—to stop admitting people to A&E, and finding space for them in wards, and therefore to close down A&E and shut down a few wards.

The Cheshire and Merseyside sustainability and transformation plan proposals were reneged on somewhat in the final draft, so they fell short of actually advocating downgrades. However, that is not to say that that is not in mind as an ultimate objective.

[David Rutley (Macclesfield) (Con)]

I congratulate the hon. Gentleman on securing the debate. Like him, I am concerned about the proposals set out in the STP and, with regards to east Cheshire, the document actually sets out that options being considered include downgrading from an A&E to an urgent care centre in Macclesfield. There needs to be greater transparency about the options and a frank conversation with people. There is already a Macclesfield petition signed by 8,000 people opposing any downgrading of A&E services in our area.

[John Pugh]

There is also a petition in Southport, and I am sure there will be petitions wherever in the country this sort of thing happens. As the hon. Gentleman suggests, the ownership of the sustainability and transformation reviews is wholly unclear. No one quite knows who writes the plans, or how they are agreed, and few democratically elected bodies or people, or patients, have any kind of input. In fact, the Liverpool local authorities wrote in some indignation to the authors of the report to ask, “How can we be involved? It alleges in your report that we are involved, but we do not appear to be.” Furthermore, no one quite knows why the hospitals have been grouped as they are.

Southport hospital is in a particularly unfortunate position, because it has changed its chair recently and suspended its chief executive over a period of a year, so it is unclear to me how Southport and Ormskirk’s views could have been represented in any review. Roadshows were organised by the clinical commissioning groups to talk about the financial plight of the local NHS and things that need to be done, and I have attended some of them, but they spend all their time talking about things such as savings on prescriptions and none on the big league stuff that is agreed and discussed in NHS boardrooms. There is absolutely no transparency, and I am sure hon. Members share in my cynicism. We await the real cost-saving proposals—or, in some cases, the empire-building proposals that are often disguised by blather about clinical efficiency and safety, which come almost after the event.

I speak with some cynicism, because I am a veteran of such carryings-on. I regret all the back-stage manoeuvres and, in particular, that no one has been around to champion my local hospital in the review. There is a good case for keeping our A&E—elderly people throughout the country are the major clients of A&E, for obvious reasons.

[Jim Shannon (Strangford) (DUP)]

The debate is clearly about Merseyside, but the issues for accident and emergency are the same everywhere in the United Kingdom, including in Northern Ireland. Does the hon. Gentleman share my concern about A&E being on the frontline of the NHS, so that is where the spend clearly needs to be? Does he also share my concern about Government policies to close some pharmacies, with their role, which will push many minor ailments to A&E, creating even more problems?

--- Later in debate ---

[John Pugh]

Precisely. I am going on to some brief analysis of the problems of A&E, but it is certainly the line in the sand that we must defend.

Elderly people are obviously the major clients for A&E, and Southport by any analysis has an enormous number—a very high percentage—of people who will require A&E. Moreover, as the ambulance service says, and as the hospital will confirm, when people arrive at A&E these days they are iller than ever before. The reason for that is that access to GPs and to social care is worsening—social care has suffered extensive cuts, and has done so in my area, and is struggling.

To make matters worse, one reason for A&E throughput being a little slow is that, more than ever, people going to A&E are not being turned around and sent home, but need to be admitted, so beds are needed for them, although previous reports recommended ward closures in Southport hospital. Furthermore, discharging people from existing wards is a slower process, because social services are, frankly, struggling. The system is getting logjammed, with ambulances at one end and people not being discharged at the other.

To add to the problem is a matter that the hon. Member for West Lancashire (Rosie Cooper) will wish to bring up: the CCGs have taken the community care contract off Southport hospital, where I thought it was well placed, and given it to two organisations new to the field. How that is supposed to help integration, I do not know.

[Rosie Cooper (West Lancashire) (Lab)]

There is a serious problem in West Lancashire and the Southport conurbation. The local population has been excluded from all these decision-making processes. There is a serious need for the NHS bosses to explain what they mean by “downgrading”, as their perception of A&E can vary quite significantly from my community’s understanding. Simply sharing information without any explanation leads to anxiety and serious distress about the future of health services. I come back to the point that the hon. Gentleman has just been making: in the face of the fact that it will destabilise the hospital, the CCG—that is the local GPs—has just awarded the contract for urgent and community services to Virgin Care, which has no real track record. We do not have a real assessment of what is going on, and my constituents are being put at risk.

[John Pugh]

I thank the hon. Lady for that clarification and amplification. There really is a problem with integration, and I do not know how that will be better solved by bringing more organisations—particularly untried organisations—into the fray.

We are all exasperated by watching people make a hash of things and create rather than solve problems. CCGs are neither accountable nor always reasonable, and frankly sometimes have their own agendas. They are often tough on hospitals but less so on GPs. They are of course GP-led organisations, which is a weakness in how they are structured. I have a letter from the biggest surgery in my patch complaining about abuse received by receptionists. Hon. Members will be able to guess what that abuse is about. It is not excusable, but the rationale for that abuse is that people are having real difficulty making appointments in a timely and effective way, and as a result they are going to A&E, sometimes in desperation. Surveys that I have done over time have shown GP access to be as much of an issue in my constituency as A&E waiting times. As the hon. Lady just said, NHS bosses collectively are either deliberately or accidentally causing the destabilisation and unbalancing of provision in the area, and no one can stop them.

[Margaret Greenwood (Wirral West) (Lab)]

I thank the hon. Gentleman for being so generous. Does he share my concern that the STP for Cheshire and Merseyside talks of

“leaving the work at STP to focus on creating a framework to support development of”

accountable care organisations? ACOs are generally associated with insurance-based systems such as those that exist in the US. Does he share my concern that that fragmentation is to do with breaking up the national health service?

[John Pugh]

I am not sure whether that is the deliberate intent, but that is certainly a possible result.

[Rosie Cooper]

CCGs are nominally accountable to the Secretary of State or NHS England. Will the Minister address who actually guarantees that CCGs will provide really good service? The incompetent CCG in Liverpool that presided over the unholy mess at Liverpool Community Health NHS Trust has been allowed to preside over future services and new contracts in Liverpool. It is the same incompetent organisation. How is that okay?

[John Pugh]

The hon. Lady reinforces the point that I was going to make next. No one in the NHS locally is in a position to bang heads together and say, “Hang on, what do the public actually want or expect here?” The CCGs speak to NHS England and the Secretary of State. They are the decision makers. It seems to me that one of the coalition Government’s biggest mistakes was abolishing the regional strategic arms of the NHS—the bodies accountable for integrating and making things work together and making services across an area work effectively. Instead, we have groups of special interests—the big providers on one side and wholly unaccountable CCGs on the other—and, frankly, a recipe for chaos.

[Margaret Greenwood]

On accountability, does the hon. Gentleman share my concern—I would welcome a response from the Minister on this point—that the Health and Social Care Act 2012 took away the Secretary of State’s duty to provide and secure a national health service in England? That is one of that Act’s key flaws.

[John Pugh]

There was actually an attempt to make clear in that legislation where responsibility lay. I am very familiar with that debate and do not want to re-engage with it at the moment.

There is an absence of a genuine force for integration at a local level. We all know that there are institutions in any local environment that will be shored up at all costs, regardless of the clinical benefits to the population. Like the banks, a big private finance initiative such as the Royal Liverpool hospital will never be allowed to fail, because when PFIs fail, they revert to the Government’s books. Such services therefore tend to attract neighbouring services, whether or not it is a good idea for those neighbouring services to be attracted and regardless of the practicalities or the patients.

To come to some sort of conclusion, without a 24/7 A&E in Southport and all that follows from that—a great deal follows from that in terms of what other services may then go—people will suffer longer and more anxious journeys. I shudder to think what would happen if there were an incident at a big event in Southport, such as the flower show, the air show or the musical fireworks, and we did not have a 24/7 A&E. For better or worse, Southport is on the periphery of Merseyside and the hospital is also used by large parts of Lancashire. Southport straddles the boundary between Sefton and West Lancashire. The local hospital trust has to interact with two CCGs that face different ways. As it stands, the hospital is massively convenient for patients but inconvenient for those who like symmetry in the NHS. Precisely because of that, we are in constant danger of being overlooked and not championed, which is why Sefton Council recently passed a motion drawing attention to its concerns, particularly about the A&E.

Hon. Members will have gathered that I do not have entire confidence in the transformation process. None of us will say that we are not aware of the need to work more smartly and in a more integrated fashion to make the health pound work a lot harder, but the record will show that this is not the first time that I and the hon. Member for West Lancashire have brought the affairs of this hospital and this health service patch to the House’s attention. I fought off a previous attempt to get rid of our A&E when that was mooted by consultants on the usual ground that if the NHS ceases to do anything, it will cease to cost anything. The public have campaigned vigorously for an urgent care centre in Southport, and a succession of Ministers have been lobbied in this place about that plan, only for it to be scuppered by behind-the-scenes NHS politics. I have no reason to feel any confidence at all in this process—not when I see the hospital trust itself make a complete hash of whistleblowing charges against senior management and protract the process through its own simple incompetence.

[Rosie Cooper]

rose—

[John Pugh]

The hon. Member for West Lancashire is positively bursting to get in.

[Rosie Cooper]

Does the hon. Gentleman agree that STPs are in danger of becoming a managerial exercise in contingency and risk planning, where the NHS speaks to itself? Several years ago, in the Health Committee, I put to Bruce Keogh the charge that where we were going, there would be 30-plus trauma centres in this country and every A&E would be downgraded. With STPs, the NHS is talking to itself, not the communities it serves, and it will come up with that very same plan. I can see that happening in front of me right now.

--- Later in debate ---

[John Pugh]

Thank you, Sir Roger. We are on the home straight now. The trust that we are talking about has been under the management of a series of interims over the past year. That has not helped its affairs. Why should the people of Southport suffer? We have been poorly served—not by the doctors, the nurses and the hard-working staff, but by the NHS high command. People are angry. If they are to be repaid for their anger by having further services taken off them, that anger will simply come the Government’s way, to the Secretary of State who will make any final decisions.

I want to make a plea. Let us not have another NHS stitch-up on any patch, where MPs, councils, local people, patients and all the access issues provoked by these arrangements normally are ignored. Let us not have a fait accompli that suits special interests that is covered over at the last minute with a veneer of clinical justification. Let us have local decision making that is not a sham or a pretence, but is genuine local decision making. Lord Lansley had a frequent saying in many a debate on health—I am not a great fan of his, but the saying bears repetition—which was, “Nothing about me, without me.” We have had lots done to us with the health service on our patch, but it has always been without any genuine involvement of the population or their representatives. I make a plea to the Minister that he tries to correct that or to reassure me that this time it ain’t gonna happen.

[The Minister of State, Department of Health (Mr Philip Dunne)]

It is a great pleasure, as always, to serve under your chairmanship, Sir Roger. I congratulate the hon. Member for Southport (John Pugh) on securing the debate. He referenced the fact that we served together on the Public Accounts Committee many years ago in the early days of my parliamentary career, and I have therefore long understood his forensic approach to matters affecting his constituency. He has shown that again today with his characterisation of the health needs of Southport. It is good to see a number of neighbouring MPs joining this short debate. They share a common interest in guaranteeing high-quality health services for their local residents. We in the Department of Health obviously share that interest.

I have listened carefully to the concerns the hon. Gentleman has expressed about A&E services in particular in the local area. He and other Members have touched on wider health issues, and I will try to address some of those in the few moments I have today. I am particularly aware of the concerns he concluded with about the potential of the sustainability and transformation plan proposals for the area, which include urgent care among many other things. I will touch on that in my remarks.

We all recognise the increasing pressures in the NHS, particularly as we move into winter. I am sure all Members would acknowledge the hard work and dedication of those providing high-quality services across the NHS, including in Southport, which the hon. Gentleman referred to. The NHS cannot stand still, however, and services need to change to continue to meet patient need and patient expectation. Nationally, there were some 1.95 million attendances at A&E departments in September, compared with around 1.86 million in September 2015—an increase of 4.9% in only 12 months. Some 1.77 million patients were admitted, transferred or discharged within four hours, compared with 1.73 million a year ago—an increase of 1.85%. I give the House those statistics to point out that the NHS is seeing and treating more people within its targets than ever before. In Merseyside and Cheshire, that means that more than 2,400 more patients were transferred, admitted or discharged within four hours of arrival this September as compared with last September.

Turning specifically to the Southport and Ormskirk Hospital NHS Trust, there are clearly performance matters that need to be addressed. Although its A&E performance does not meet the national 95% target, at 91.5% it is above the national average of 90.6%. As the hon. Gentleman said, its current A&E performance is relatively better than that elsewhere. However, the CQC report that he touched on, which was published last week, rated the A&E department as “inadequate” for safety and “requires improvement” for all other fields apart from caring. Although that may be based on work done some months ago, I am sure he would agree that it is unacceptable. The trust needs to improve its performance for the people of Southport.

[John Pugh]

The Minister is making an important point. The argument about the CQC inspections is to some extent related to what the CQC inspects. If it is inspecting an A&E department—I hope I made this clear in my speech—the CQC often has to bear in mind the fact that it is not an isolated unit. A&E works in conjunction with adult social care, the ambulance service and so on. Getting snapshots of a poorly performing department without taking into account the background and the other arrangements in and around A&E can give a false picture of where the problem lies.

[Mr Dunne]

I am not going to get into a prolonged debate about the CQC report, but it rates the entire trust as “requires improvement”. We have confidence in the overall reporting, and looking at A&E in that context reflects an accurate impression of the current status of the trust. For example, three of the trust’s seven A&E consultant posts are filled by locums or agency staff. That mix of staffing is not sustainable for any A&E department. I am aware that the trust and its commissioners are looking to address that.

Several hon. Members referred in interventions on the hon. Member for Southport to the NHS sustainability and transformation plans. I emphasise to the House that STPs are collaborative plans designed to help local organisations deliver on the “Five Year Forward View”. They are formed by CCGs, providers and local authorities working together in an area to develop a plan. Some have also involved other stakeholders who will be affected by changes in their area and can contribute to improvements. The true test will be whether a revised healthcare system really improves matters for patients.

We are still at an early stage in the process. The local NHS describes the plan for Cheshire and Merseyside as a plan for a plan at this stage. I will not therefore pass judgement today on the STP process or the content of the Cheshire and Merseyside STP. I am not in a position to do so. I do not know the local position as well as the local clinicians who have drawn up the plan; no one in Westminster or Whitehall does. Local clinicians must ensure that they involve the public and patients—and Members, as the hon. Gentleman called for in his closing remarks—and explain what they think is best for each local area. I reject the charge that the plan will not involve the local communities; it absolutely needs to involve local communities to be taken forward. It is a central tenet of the approval of the plans that there is public engagement.