Urgent and Emergency Care Recovery Plan

Lord Markham Excerpts

Thursday 2nd February 2023 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, as is usual for this kind of Statement, it is peppered with promises of more of everything. I hope the Minister will help us to dig into the numbers we have been given to see how much lies behind them. First, on the new hospital beds, this seems to come from a process of making winter surge beds permanent. For a real long-term increase in capacity, we need the promised 40 new hospitals. How many of these will be on stream by next winter?

The Statement also tells us that there will be 800 new ambulances, which I think most people would interpret as fully staffed, blue-light vehicles. Can the Minister offer a more detailed breakdown of the different types and capabilities of what is being offered here? The Statement itself said that, for example, 100 of these will be mental health emergency vehicles rather than classic blue-light ambulances.

Of course, staffing these beds and ambulances and the other measures in the Statement will depend on good workforce planning. Here, I echo the comments made by the noble Baroness, Lady Merron, and by these Benches over many months. The Statement tells us that the plan will come this year; can the Minister offer any more precision on when this year we might expect it?

The Statement also talks about data and transparency. We are told that integrated care boards will now have to focus much more on data about patient flow. Can the Minister commit to making more of those statistics public, as well as the ambulance wait time statistics?

Finally, the promised new care hubs can add value only if care services are actually there. This brings us back to workforce limitations. I end with three questions for the Minister: where is the staffing for the beds, where is the staffing for the ambulances, and where is the staffing for the care services?

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)]

First, I thank the noble Lords for their questions. To put the UEC recovery plan in the context of the three plans we will be announcing, there was last month’s elective recovery plan, which we spoke about, followed by this UEC recovery plan, and then, within the next month or so, we will also talk through the primary care recovery plan. That plan will seek to address exactly some of the points the noble Baroness, Lady Merron, rightly made about getting care in the right places, such as primary care.

I hope noble Lords agree that what we see today is a sensible and pragmatic plan. It has been welcomed by NHS Providers and described by the Royal College of Emergency Medicine as a

“significant step on the road to recovery”,

seeking to increase capacity in urgent and emergency care. The 5,000 beds that the noble Lord, Lord Allan, mentioned are a recognition that more capacity is needed in that space.

As has been mentioned many times, and as was raised by the noble Lords today, growing the workforce is crucial. This includes student places and getting to the bottom of whether there is a cap on those numbers, on which a written reply will be given soon. Again, the workforce plan is in draft and will be shown shortly—as I say, in weeks. I cannot give a date, but it will be soon. It is designed to tackle the whole question of how we are going to staff all of this and the points that have quite rightly been made. We need the staff: the nurses, the ambulance staff and all the others. There are 30,000 more nurses than three years ago, so we are on target to hit the 50,000 increase. There are 5,000 more doctors than a year ago, but that is not to say that we do not need more. That is what the workforce capacity plan should be all about.

This plan is looking to show those milestones and what we are trying to do to increase capacity, with the 5,000 new beds, growing the workforce, speeding up discharge, expanding and having better joined-up community services and making it easier to access the right care in the right places, such as primary care. I would say this, probably, because I am biased, but I feel that this is a useful and pragmatic plan because it is trying to build on the evidence of the things that we have seen work, which noble Lords have heard me talk about over the last few weeks. They include the Maidstone “mission control”, which really is making a difference there and we are now looking to roll out to all trusts and ICBs; the Watford virtual wards, which we are looking to roll out to 50,000 places; and, in all instances, using data-driven analysis to make sure we are making the right decisions.

The plan is backed up by funds and is part of a long-term plan. We are using the £1 billion of support for this year and the £500 million for social care capacity, but this is in the context of an increase of £14 billion over the next two years. It is part of a sizeable plan, but it is realistic action. I would love to be able to stand here today and give targets, but we are trying to be realistic about where we are coming from—for example, in setting the 30-minute category 2 ambulance wait time. Likewise, the target of 76% of patients being seen within four hours is not the limit of our ambition. That is the minimum, and from there we would look to increase it beyond that target. I would much rather come to your Lordships’ House with targets we think are realistic, with achievable plans behind them, as a statement of intent from which we can grow, rather than setting unrealistic expectations.

Of course, I say all of this in the context of what the House knows is an unprecedented challenge. It is not just England facing these challenges; I have spoken to colleagues across Europe, the US and Canada, and within the UK, in Wales and Scotland. Every health system is facing these problems off the back of Covid, and there are also the demands coming from flu coinciding with that this winter in particular.

I believe that this is a realistic plan. It is centred on the workforce; I agree on that. Prevention is also a key element of this. The five-year life expectancy improvement target is still key. We are looking at what we realistically need to do to make a difference on that—so, what are the causes of death, and what are the things we need to tackle? Again, the House has heard me speak many times about Chris Whitty’s concern about cardiovascular disease, and that it could be the next cohort of potential excess deaths among 50 to 65 year-olds, because they missed out on their blood pressure monitoring over the last couple of years. We all agree that rectifying those sorts of prevention actions is key.

When this plan is seen in the context of the primary care plan, which will also come out shortly, I hope it is understood that this is about treating people in the right place, which is not A&E. We all know that far too many people go to A&E who do not need to be there, and that is because we need more primary care spaces. We are on target to achieve the 50 million more primary care spaces, but, again, we need to do more. We really need to look to expand capacity in pharmacies, as I have mentioned before. We need to look at what some of our colleagues in Scotland are doing and the ability of pharmacists, for instance, to prescribe a lot more. Longer term, the new hospitals are a key part of this. Just this morning, I was going through the plans and some very good virtual reality examples, which we are going to bring to Westminster Hall for one day in the next few weeks. I look forward to showing colleagues exactly what is happening and how that will be the future.

I hope that noble Lords will see this plan in the context in which it is meant. I will, as ever, write in detail on the points I have not managed to cover in this quick reply. I hope noble Lords will see this as a down payment for the future, within the context of the elective care recovery plan and the primary care plan that we will see later, building on solid things that we know work and making sure that we are expanding those rapidly, so that we have learned the lessons from this winter and have them in place in time for next winter.

[Baroness McIntosh of Pickering (Con)]

My Lords, my noble friend will be aware that this problem is not unique to this country. I am ashamed to say that Denmark, my mother’s original country, is building new hospitals all over the place but people cannot be treated because there are not enough doctors to treat them. Is my noble friend aware of the report from the Health and Social Care Committee in the other place, which noted that there are almost 500 fewer full-time equivalent GPs in a three-year period and that the committee realised that that accounts for the fact that there is an increased challenge in accessing GPs and also a lack of continuing healthcare? Will my noble friend take this opportunity to explain to the House what proposals the Government have to retain GPs so that recently qualified GPs are not working as locums in preference to being salaried or partners in a practice? I declare my interest as an adviser to the Dispensing Doctors’ Association.

[Lord Markham (Con)]

I thank my noble friend and agree that the GP service is the backbone. As per the earlier comments, a lot of the issues and challenges we have with A&E are because people are not getting their appointments in the GP space, and fundamental to that is having enough doctors. I did not quite recognise the figures. I am aware of an increase of over 2,000 GPs since 2019. That is not to say that that is enough, and so, again, the workforce plan will be key to making sure that we are building for that long-term future. However, we are also looking to retain them. We had a very good debate in the House about pensions and what we need to do in that space, and we will make sure that everything we do—including, I hope, the primary care plan—will show that primary care is key to the solution.

[Baroness Armstrong of Hill Top (Lab)]

My Lords, I am sure the Minister has taken note of the House of Lords Public Services Committee report on emergency access to healthcare, which came out two weeks ago. Many of its recommendations have been taken up by the Government. I thank the Minister in particular for the one on the 12-hour waiting list. We found out to our shock that that was not honest, as the witness said to us when they came to talk about it. I am pleased that the Government have done something about it. Our previous report was on workforce, and I urge him to read that too. Any report or plan is worth the paper it is written on only if it will and can be delivered. We were promised the outline of the workforce plan last September—we have had nothing yet.

Can the Minister help me on what I see as a major problem this week? As he has said today, a major part of the plan is increasing capacity. As others have said, you need the staff to do that. However, the Government, having said on Monday this week that increased capacity was really important as part of the emergency plan, wrote on Wednesday to Lincolnshire ICT to say, “You have a deficit. In order to deal with that deficit, you must cut beds”. What are people there to think when on one day the Government say, “We will sort emergency access by increasing capacity and beds” for one thing, and then two days later say, “Oh, you have a deficit—cut the beds”?

[Lord Markham (Con)]

I thank the noble Baroness for her question and her recognition of the 12 hours. In all these spaces, data is always the way that you give a backdrop to better services, and 12 hours is part of that. As regards capacity, I totally agree that we need more of it. I was surprised by what she said—I will find out some more about it. However, the absolute direction is a recognition that, with Covid and flu, what might have been the right number of beds a couple of years ago is not today. That is why we are committed to the 5,000 extra beds and, just as importantly—potentially more so—the 50,000 in virtual wards, because that is using technology to look at how we can expand supply, and absolutely critical to that is having the workforce.

[Lord Forsyth of Drumlean (Con)]

My Lords, my noble friend quite rightly pointed out that there are more doctors than ever in the NHS, but many of them are in training. As my noble friend Lady McIntosh pointed out, we are losing very senior and experienced doctors because of the rules that apply on pensions. My noble friend said that this was being addressed. I remember raising this several years ago—it is a continuing problem. What is worse is that doctors leave the NHS because of the tax implications for their pensions and then come back and cost it even more money. My noble friend says that this is being addressed, but in the autumn I heard the Chancellor say that he was going to freeze the level of the maximum amount that counts towards the pension before you pay tax for the next three years—so how is that addressing the problem? Is it not an urgent problem? We may be putting more people into the service who are in training, but we are losing people out the bottom at a greater rate.

[Lord Markham (Con)]

I thank my noble friend. As I mentioned just now, retaining doctors is critical, and pensions are a key issue. We had an excellent debate on this a couple of weeks ago. Again, we are working on all of that with the Treasury. However, as I said then, the simplest thing is that, while I understand the Treasury’s concern about making special rules for special groups and the potential knock-on from that, we can very quickly make sure that, if people are hitting that pension ceiling, they can get the equivalent pay in their pay package very quickly. As a health department we have the ability to do that, to make sure that no one is financially losing out from that. If it does not make sense for them to get it through their pension, they can get it through their salary instead. I am not saying that that is perfect, and more work needs to be done across the Treasury, but we can do that quickly.

[Baroness Blower (Lab)]

My Lords, the Minister has attempted to give a full response on this. However, there is clearly an absolute urgency about the workforce plan, and noble Lords would have been very pleased to have heard something rather more specific about the date on which it would come before us. If it is in draft, perhaps he could go back and say, “Can we speed up the final drafting of it?” The Minister also used the word “realistic” on a couple of occasions. Can he say whether he understands that the workforce plan will not be realistic unless we can pay staff in an appropriate way to make sure that we can hold on to their services, without which any attempts to remedy the difficulties we are facing are, frankly, a forlorn hope? Finally, on virtual wards, can we make sure that there are not people in the digital divide having difficulty engaging with the virtual ward if they have broadband problems and other problems?

[Lord Markham (Con)]

I thank the noble Baroness. Taking those questions in reverse order, yes, it is understood that virtual wards do not work for everyone. At the same time, I am constantly surprised by the data: for instance, the average age of an NHS app user is in the mid-60s—so it is not a particularly young demographic who use this. Obviously, the examples I have seen, particularly on COPD at Watford, show that an older population is using that. However, we absolutely need to make sure that there is not a digital divide from that.

On the noble Baroness’s points on the workforce, she is quite right. We live in a competitive market, and one of the benefits of full employment is that, again, most people who want to work have a job, but one of the downsides is that there is competition for jobs. We have to face up to those realities and be realistic in terms of workforce, in that if you are going to attract and retain the good people, which you need to have as the bedrock of your services, you need to make sure you have an attractive and rewarding place to work. Clearly, that has to be a feature.

[Lord Bellingham (Con)]

My Lords, the Minister mentioned new hospitals. Is he aware that the biggest obstacle to major health improvements in west Norfolk is the chronic state of King’s Lynn’s Queen Elizabeth Hospital, which I gather is the most internally propped-up hospital in the UK? He will be aware of an all-party campaign to secure the building of a new hospital. Can he tell the House where are we with that process?

[Lord Markham (Con)]

I am very familiar with the problems with the so-called RACC—reinforced, autoclaved aerated concrete—hospitals. King’s Lynn is one of those, and there are a handful of others. There is a recognition that everything we do in the new hospital programme has to ensure that those hospitals are rebuilt in time, because they have a useful life that is fast reaching its end. Our priority number one is making sure that they are replaced.

[Baroness Masham of Ilton (CB)]

My Lords, what are the government plans for long-term rehabilitation? We need more physiotherapists and occupational therapists. There is an idea of getting people out of hospital quickly, but some of them need confidence and ongoing care.

[Lord Markham (Con)]

That is absolutely right. The figure that struck me on one of my many hospital visits was that apparently people lose 10% of their muscle mass each week they are in hospital, making it harder for them to look after themselves. The noble Baroness, Lady Merron, mentioned that we need to make sure the resources and investment are in the right places. All too often, hospitals become the place of last resort, when we all know that it is much better to put resources into the primary care at the front end or the social care and domestic help for physios who can visit homes at the back end. Central to the plans of my colleague, Minister Whately, is recognition that we will solve this in the long term, as all noble Lords want, only if we invest those resources in the right places.

[Lord Brooke of Alverthorpe (Lab)]

My Lords, I welcome the plan and hope that the Government can keep to the targets they have set. I had experience of being in a major London hospital recently, spending five hours in A&E. It was the first time I had been in A&E for a long time. I was surprised at the number of young people there. When eventually I was seen by a nurse, I asked why so many young people were there. She said, “We’re surprised; there was a good football match on tonight, and we thought there wouldn’t be so many”.

It is odd when people are in A&E. Should they be with a GP? We wait with interest to see the report on GPs. I suspect that we have far more people now getting involved in health, for a whole variety of reasons, than need be in the system. This takes us back to prevention. I still do not believe we are addressing prevention as we should—trying to reduce the number of people in ill health. The programmes we have on obesity and in a whole range of areas where we are trying to get people to change their lifestyle are not having any impact. Until we seriously address those and put money and personnel into them to get ourselves reasonably healthy by comparison with the rest of Europe, we will just see the health service getting into even more difficulty, no matter who is in power.

I am sorry for going on at length. I hope the Minister will say something about a proper plan on prevention.

[Lord Markham (Con)]

I agree with the noble Lord. We have a manifesto pledge about five years of healthier living. I am keen to do exactly that, to say, “Okay, let’s unpack this—how can we make that realistic?”. We have all talked about being realistic. What are the causes of death or ill health that we need to get on top of? I mentioned cardiovascular disease earlier. We need to quickly address that because there is a cohort of people of my age who have missed out. Obesity is a clear thing. It is not just the treatments but everything we talk about in terms of supermarkets. I know that there is some discussion in the House on whether we have gone far enough on some of those things, but the action we have taken is hitting the big numbers. It is hitting about 95% of the planned reduction in calorific intake; we are seeing that have an impact already. There is also anti-smoking; I am keen to make that into a coherent plan. We all know that we can spend more and more money on hospitals and the health service, but we will have healthier lifestyles only if we can get up stream on the problem and talk about protection.

[Lord Porter of Spalding (Con)]

My Lords, I declare my interest as a non-executive director of a care company and lead Peer for the Local Government Association.

It is great that politicians are trying to sort out problems with the health service, because those problems have largely been created by politicians—national politicians from both sides of the other Chamber. Clearly, the last Labour Government’s disastrous changes to GP contracts exacerbated the situation we are living in now. The even worse contracts for construction companies to build new hospitals at exorbitant prices were bizarre and are currently impacting the health service.

The coalition Government and this Government are responsible for the chronic underfunding of social care services. We have all contributed to people not being able to see the right GP or whatever at the start of the process, and we are now contributing to people not being able to get out of hospital.

That is not really what I wanted to say, even though I have just said it. I live in Lincolnshire. If a member of staff somewhere in the Lincolnshire health network has suggested, contrary to the Government’s position of increasing hospital beds, that they have to reduce their hospital beds, one way they could save some money is by deleting the post of the person who suggested that. That is probably a good place to start, because a lot of people want to use acute services but cannot because some of the budget is being diverted away to people dressed like me rather than to somebody dressed in those suits they wear in hospitals.

I am quite simple and do not understand why I saw a picture on the news the other day of 40 ambulances queueing up outside a hospital with 80 members of staff and only 40 patients inside the ambulances. Why can we not put up a big inflatable building of some description, offload the 40 people from the ambulances with 40 of the staff, and let the other 40 staff drive 20 ambulances back out again? Nobody seems to be controlling the resources that are being used, even though we all admit that they are scarce.

[Lord Markham (Con)]

I will take it in reverse order. We do have the ability to stand up that capacity quickly so that the ambulances can discharge. I have already ordered a number of those, and some are ready to go, to provide exactly that capacity. Others are coming on stream in the coming weeks, so we are rapidly responding to the exact point that my noble friend raises.

Just as important—I am glad to have the opportunity to talk a bit more about this—is that a lot of the time ambulances do not need to bring the person to A&E. The mental health ambulances we are introducing, or the falls service ambulances that every ICB now has to introduce and have running every day, are critical. They can go there, right the person who has fallen and set them back up again. That needs only one person, not a big ambulance. That sort of care in the community—solving those problems and the right access—is critical in this situation.

On Lincolnshire, I will find out. The key thing here is making sure that we are expanding capacity in terms of beds.

[Lord Hogan-Howe (CB)]

My Lords, I sat with the noble Baroness, Lady Armstrong, on the Public Services Committee for that report. Two things were left with me; they follow up on the point from the noble Lord, Lord Porter, about ambulances attending the scene. We heard numerous cases, the worst I heard being that of a 95 year-old man who lay on the floor for 24 hours with a broken collarbone and hip. His family put a tent around him and no one in the health service—I do not mean just the ambulance service—went to help.

I just cannot understand that. There are over a million people in the health service; the Minister just mentioned that he is trying to get action around this, but why did the bosses not get out and drive an ambulance? Why did a GP not attend? Why did someone in society not think that that guy should not be lying there for 24 hours on the floor with a tent around?

Those examples really shame us. I do not say “the Government” or anybody else; they shame us. A piece of evidence which stuck with me was that one of the paramedics pointed out that one of the good things that has changed in strategy to improve outcomes for patients is that they spend longer on the scene, so they improve the initial treatment and improve the outcome. Of course, I asked what the overall impact of that was; he reckoned that they were able to attend about half the incidents that they did before, so were halving the effectiveness of the number of ambulances that we have. It does not look like the number of ambulances and staff will shift as a result of that change, or that there will be a different model of delivery—perhaps that one person might go or whatever. But those good outcomes for the heart-attack patient, perhaps, were not replicated for everybody: if they never got the ambulance, that did not help them. It just struck me that the change of delivery had not changed as much as the change of the model—spending longer at the scene—had improved the outcomes where ambulances attended.

[Lord Markham (Con)]

Yes, what the noble Lord talks about is critical. To my mind, this is where the data—I know data and analysis sound dry—is needed to arm the local decision-makers. This is the whole idea behind the ICSs: that they can invest in the right services in the right places. We have often got too much into thinking that the one-size-fits-all model of the ambulance with the two paramedics is the solution, whereas we know that the full service can do things far more effectively and keep the person in the home. To my mind, that is the whole sense of direction of the ICBs, which need to understand and own their areas. I saw a fantastic example in Spain: Ribera Salud, with which many people here are familiar, I think. It ran the local hospitals and local primary care. There was investment in primary care, and A&E entrances plummeted. That is what I want ICBs to look at, and what I want the workforce plan to do: to make sure that we give the right care in the right places, and have flexible delivery of different types of ambulances and types of staff, who will go and problem-solve. Sometimes that is problem-solving as per the example that we gave, but mainly it is trying to give the local ICBs the analytical tools, powers—for want of a better word—and resources, so that they can properly shape things. Some of them will do very well, and others will probably take longer. But that is the critical thing about letting people run their own areas: making sure that they adopt best practice, but that they have flexibility in that approach so that they can solve the problems on the doorstep.