Accident and Emergency Services: Merseyside and Cheshire

Debate between John Pugh and Rosie Cooper

Tuesday 22nd November 2016 Westminster Hall

[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.

[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.

[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.

Diabetes

Debate between John Pugh and Rosie Cooper

Wednesday 9th January 2013 Westminster Hall

[Rosie Cooper (West Lancashire) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Crausby, for this debate.

I congratulate the hon. Member for Torbay (Mr Sanders) on securing the debate on such an important issue, which affects a growing proportion of our population. Indeed, having listened to the contributions that have already been made, it is very clear that there are many facets of diabetes that could be covered during this debate, but I think that we will all probably concentrate on amputation. I will spend a few minutes focusing on the importance of podiatry services, which can reduce preventable amputations for those with diabetes.

Currently, 4% of the population live with diabetes, and a fifth of those people will develop a foot ulcer at some point. At any one time, there are 61,000 diabetics in England who have foot ulcers. A foot ulcer may not sound like a very serious condition, but for a diabetic the consequences of foot ulcers can be severe, and even fatal if the appropriate treatment is not given. Statistics for England alone show that, of those diabetics with foot ulcers, 6,000 people—that is 10% of the total number—had leg, toe or foot amputations in 2009-10. Based on current trends, that figure is projected to rise to 7,000 people by 2014-15. An amputation is devastating. If any individual loses a limb, it will have a far-reaching impact on their life. For many diabetics, an amputation can increase the likelihood of premature death.

Let me put those figures for diabetes in context. The five-year survival rate for those with breast cancer is just over 80%, but for those with a diabetic foot ulcer the five-year survival rate falls to just under 60%. For those people who have a lower limb amputation, their survival rate worsens after five years. The consequences are even more horrific when we consider that 80% of those amputations are preventable. In 2012, that is simply incredible. We are not doing everything we can to rectify that and to ensure that people have the information and services that will help them protect their limbs.

It is scandalous that with our 21st-century health care we are allowing people to go through the completely unnecessary, torturous and miserable experience of amputation. Prevention is supposed to be the watchword of the modern national health service; through prevention, people can enjoy a better quality of life and the NHS can save itself millions.

It is therefore hard to understand why better prevention is not deployed with diabetes and amputations. Why is more effective use of podiatry services not a priority for the health service? At a time when the number of diabetics is growing, and with it the costs of treatment, podiatry could be a means of improving a diabetic’s quality of life and saving the NHS money. Amputations cost the NHS considerable sums, which are estimated to be in the region of £600 million to £700 million each year.

Results from pilot projects can demonstrate the positive impact of investing in good podiatry services. A multidisciplinary foot care team for in-patients with diabetes in Southampton led to a reduction in the length of in-patient stays from 50 days to 18 days. Not only were patient outcomes improved but annual savings to the NHS of £900,000 were generated from an investment of £180,000. That savings ratio of £5 saved for every £1 invested was bettered in another example. In James Cook hospital in Middlesbrough, a multidisciplinary foot care team generated annual savings of some £250,000 at a cost of £30,000, which is a ratio of £8 saved for every £1 invested. Those figures show how it would be not only the Government and the NHS that reaped great rewards from a small investment, but diabetics and those who need podiatry care. Based on the pilot evidence, logic would suggest that even in these straitened times we should be investing in podiatry services, because that could save even more money and improve health.

There is evidence, however, that the opposite is happening and that services are not improving. The danger of the new arrangements is that important issues fall between the cracks, are left to local decision making and do not get the prioritisation they deserve. More than half of hospitals do not have a multidisciplinary foot care team. In fact, 31% of hospitals do not even have an in-patient podiatry service, according to data from the national diabetes in-patient audit in 2011. That reflects a worsening service, because in 2010 only 27% of sites had no provision. The amount of provision has dropped, and nearly a third of hospitals no longer have that service.

There is also evidence that there is a problem with GPs having no incentive to refer their patients on to a foot protection team for education or follow-up. Why is that? Why is this woeful situation tolerated? If more referrals were made, we would see a beneficial reduction in ulcer and amputation rates.

[John Pugh]

Will the hon. Lady explain why a GP would need an incentive to do what is clinically desirable in the first place?

[Rosie Cooper]

I absolutely share that concern, which is why I cannot understand the current view that doctors do only what they get paid for and if there is no money attached to something, it may not be the first thing they do. As I pointed out in Westminster Hall yesterday, when we had a debate on the Liverpool care pathway, financial rewards to clinicians should not be the driver of what happens or the pathways that are followed. That is good clinical practice. Surely to goodness, if a referral to podiatry is required, that is what should happen. It could also be said that if the services are not there or are being reduced, the GP has less incentive to refer, knowing that it will take so long to get an appointment.

The College of Podiatry is

“fearful that public expenditure constraints mean that rather than being prioritised through the QIPP”—

quality, innovation, productivity and prevention—

“agenda, current podiatric services are at best, being frozen and in some cases being reduced, with patient services including the diabetic foot service deteriorating as a consequence”.

That has massive implications for the NHS budget and for the patients themselves. During a debate in the other place on 29 November 2012, the Under-Secretary of State, Earl Howe, accepted that

“rapid access to multidisciplinary foot care teams can lead to faster healing, fewer amputations and improved survival. Savings to the NHS can substantially exceed the cost of the team.”—[Official Report, House of Lords, 29 November 2012; Vol. 741, c. 336.]

My question for the Minister is whether the NHS, which is in the throes of a reorganisation and being more localised through clinical commissioning groups, as well as being put under increasing financial pressure, will move towards or away from having more multi- disciplinary foot care teams, given that fewer than half of hospitals currently have such a team. Investment in more podiatry services would result in improved foot screening, appropriate follow-up services, enhanced care when required, better outcomes—including fewer amputations—reduced length of stay in hospitals, increased quality adjusted life years and reduced morbidity. We would all win; we would have a healthier nation and significant financial savings.

Northern Rail Hub

Debate between John Pugh and Rosie Cooper

Wednesday 18th January 2012 Westminster Hall

[Rosie Cooper (West Lancashire) (Lab)]

It is a pleasure, Mr Hood, to have the opportunity to serve under your chairmanship today. I congratulate the hon. Member for Colne Valley (Jason McCartney) on securing this important debate. It is even more important following the recent announcement to give the go-ahead to High Speed 2. That announcement is a signal of just how important investment in high-speed, efficient rail services is for the future growth of our national and regional economies. I absolutely support the northern hub as an important strategic investment and opportunity.

In that context, I want to be slightly more parochial and to plead that places and communities such as West Lancashire should not be forgotten when planning and investing in our railways. The danger for West Lancashire is that we lose out because of the dominance of the city regions and core cities that act almost as capitals. The effectiveness of such schemes lies in connectivity and the quality of the entire rail network. West Lancashire is virtually at the crossroads of the north-west. If big circles are drawn around Preston, Liverpool and Manchester, West Lancashire is the bit in the middle. My plea in this debate and the wider debate on transport infrastructure investment is not to forget West Lancashire.

Since being elected in 2005, I have campaigned constantly for improved rail infrastructure across all areas of my constituency. My great concern is that places such as West Lancashire are in real danger of falling behind with rail infrastructure. I shall give a couple of brief examples. Skelmersdale is the most populated town in my constituency, but it has no rail service at all. A major redevelopment of the town centre is about to start and is the biggest investment since it was established 50 years ago. We have a brand new state-of-the-art college, and the town has an exciting new future with many opportunities, if people can get there.

The really good news for the north-west is the Lancashire triangle rail electrification, which will be transformational for the north-west. West Lancashire has three lines serving the area, and I ask the Minister to remember that our biggest town, Skelmersdale, has no rail service at all. Delivery of the Lancashire triangle rail electrification will leave West Lancashire in a strange position, because diesel trains will still run in a small area unless more investment is put into the electrification.

If nothing is done, there will be implications on rail development in West Lancashire. For example, the Manchester line carries an increasing number of passengers, with alternate trains going to Victoria and Manchester airport. Transport for Greater Manchester appears to be suggesting that the airport service may be sacrificed in favour of running trains from West Yorkshire and east Manchester to the airport. The Kirkby to Wigan line passes through Up Holland, which would form the basis of a rail station at Skelmersdale. That line was proposed for electrification in the early 1980s, and there is clearly a need to extend the existing Merseyrail service from Liverpool to Kirkby to serve Skelmersdale. That would provide an opportunity to consider a service between Skelmersdale, Wigan and Manchester, and that should be done because it is likely that many of the employment opportunities for those who live in West Lancashire will be found in Liverpool and Manchester.

My third example is the route between Liverpool, Ormskirk and Preston. Ormskirk has a superb service to Liverpool; the line from Ormskirk to Preston has recently received an improved timetable, and Network Rail is examining the business case for an hourly service. There is, however, strong demand to extend the existing Merseyrail service beyond Ormskirk to Burscough and the famous Burscough curves. That would enable an hourly service to Preston to be delivered at low cost.

[John Pugh]

Does the hon. Lady recognise that the Government are taking a huge step in restoring the Todmorden curve? It shows that they are ready to look at such projects and provides some hope that the Burscough curves will receive serious consideration.

[Rosie Cooper]

I did not quite hear all of that, but I am hopeful that a service on the Burscough curves will eventually be established. My point is that all three routes that I have mentioned will be operating in an area that is dominated by electric services. Electric trains run only where the line is electrified, so unless the trains have an additional power source that will enable them to continue for some distance, West Lancashire runs the risk of becoming isolated.

As well as the new electric trains on the newly electrified Lancashire triangle—well, not new exactly, but second-hand from the London area—the superb Merseyrail electric network also uses third-rail electrification. If lines in my area are not electrified and with the investment to improve the national and regional rail network infrastructure, my fear is that places such as West Lancashire will be left behind, which we cannot afford for a plethora of social and economic reasons. Such a move would begin to create greater disconnection and disintegration of the rail network. The challenge for me, West Lancashire and, I hope, the Minister is to ensure that West Lancashire does not become ever more isolated as a small island of diesel trains that are not included in the great opportunities and investment that is taking place.