Emergency Healthcare (Public Services Committee Report)

Lord Markham Excerpts

Thursday 20th July 2023 Grand Committee

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

First, I add my thanks to the noble Baroness, Lady Armstrong, and all the contributors to the report. It was a thoughtful and constructive report, just as today’s debate has been. I thank noble Lords for that.

Probably one of the benefits of debating the report now, a few months later, is that we have had an opportunity to learn some of the lessons from last winter. I will try to reflect those in my reply. We have also had the opportunity to take on board the evidence from the committee’s report and, as the noble Baroness, Lady Merron, mentioned, the NAO—and, I hope, to reflect quite a few examples of best practice, which I will try to take your Lordships through.

As has featured so much in this debate, I completely agree that this is all about flow. I will try to respond by talking through the flow, because we all agree that that is the vital component.

Of course, the first step of the journey in terms of the flow, as a few noble Lords have said, is demand. We know that as many as 50% of the people going into A&E do not need to be seen there. To me, the first step is how we manage demand and make sure that we treat people in the right place. Of course, that comes in two parts, the first of which is making sure we have sufficient primary care in place, because we know people that often turn up in A&E because they feel that they cannot get the necessary GP appointment. The emphasis we are putting on our primary care recovery plan is very much part of that, as is the direction of travel for the long-term workforce plan—investing much more in primary care and prevention, and having that emphasis versus treatment in hospitals, which is the wrong end of the telescope to be always looking through.

Also we want people to use 111. There will be a complete reset of 111, seeing it as a real navigation tool. Again, as noble Lords have heard me mention a number of times, when we relaunch the app in September, that will be a very important feature, so that people can use the 111 app to establish whether they really need to go to A&E, or whether there is a better place for them to be treated. The other side of this is to establish whether it is appropriate for someone to call 999 and whether they need to be conveyed to A&E. It is about having the right treatment in the right places, and it is all about the “falls” ambulance service, which it is now the responsibility of every ICB to supply. We know that sometimes, you can rectify the situation there and then, set someone right and make sure they are okay, and they do not need to be conveyed to hospital.

It is also about making sure that we have experienced mental health handlers in ambulance services and somebody in the control centre trained in mental health who can help. As for steps in the right direction, we are starting to see the numbers being conveyed go down, which is of course what we want. Whereas 58% of people were being conveyed to A&E a couple of years ago, the current figure is 52%. Clearly, there is more that can be done.

The point that the noble Baroness, Lady Morris, and the noble Lord, Lord Allan, made about the risk-averse nature was absolutely spot on. I shall not pretend that we have proper answers to that, but we need to have a grown-up conversation about it, because we all have very good examples to give. The hope is that the 111 navigation I referred to can help to address that issue, but the human attitude to risk is also a factor.

I turn now to the supply side, response and the ambulances themselves. We are putting more resources into 999, and we are investing in 800 new ambulances. A vital part of that is the discharge hubs for ambulances, so that they are not waiting in the car park with their patients and can instead get back out on the road as quickly as possible. As we know, that is all part of the UEC plan.

Crucial in all this and in managing flows—this links to the point made by the noble Lord, Lord Allan, about data and process improvement—are the flight control systems. As I think I have mentioned before, one of the first hospital visits I ever did was to Maidstone, where they had a fantastic flight control system, managing everything in real time. You knew whether the ambulance was there and whether a person was likely to need a bed; the system looked straightaway at finding that bed and managing the person through the system. What impressed me was that it addressed head-on the often risk-averse nature of clinicians. Amanda Pritchard herself explained the situation to me. She said, “If I were a doctor talking to you, Nick, I’d be saying, ‘I’m pretty happy with how you’re doing, but I’m just going to keep you in one more night to be sure.’” However, when that clinician is armed with real-time data and knows that ambulances are coming and there are people with much greater need of a bed than me, they can make the clinical decision that I am 99% probably going to be fine, and another patient needs that ambulance much more. That is an example of real-time data being used by clinicians, and we are rolling that out as we speak to make sure that it is in place for the winter in 16 trusts. I know that 16 is not 120, but it is a good first step towards that, and I hope we will see improvement.

Carrying on in the flow journey and coming to the beds themselves, we are on target to have a real increase of 5,000 beds in place for the key winter period, as per the question from the noble Lord, Lord Allan. In addition, 10,000 virtual ward beds will be available, with the intention of treating about 50,000 patients per month. That will strengthen everything we are trying to do in terms of the back door, the flow and, as mentioned by many noble Lords, the social care element.

We have started to see the impact of all the things we are talking about. The investment that we are putting into social care is starting to have an impact. As for discharge, right now, we are seeing 2,300 fewer beds blocked, for want of a better word. There is still some way to go; as noble Lords will remember, the target is 13,000, but there has been progress towards that. Our action in terms of the extra money is about learning the lesson around getting the discharge fund out early, instead of suddenly getting to January and thinking, “Oh, we’ve got a problem”. A lot of the social care providers have talked about getting it out early so that they can then plan in advance. Those are all things that we are doing towards that aim. Of course, as many noble Lords have mentioned, underpinning all this is the long-term workforce plan, to make sure that we have cover in the appropriate areas.

Best practice more generally was mentioned in the report and by many noble Lords, and I agree that it is often an issue. We do not have a problem with pilots—I am sure that many noble Lords have heard the quip that the NHS has more pilots than British Airways—but the issue is adoption. I have mentioned a couple of examples of that. We now have tiering in place. The performance of hospitals in each area of UEC is looked at and specific plans are put in place with the leadership to address the tiering. There has been some good progress there, but I agree that, of all the things we need to do, that is definitely a work in progress. On that note, the noble Lord, Lord Allan, will be pleased to know that I am spending the summer visiting hospitals. After the last couple of weeks and those coming up, I will have notched up another 15 or 20 on my visit list. I am definitely trying to get out there.

I really appreciated the thoughtful contribution of the noble Baroness, Lady Bennett. She talked about the environmental impact, and I must admit that it made me think about it in a different way. The NHS recognises that it has a role to play in this. I want to give her a proper response because I was struck by what she said and appreciated her sharing that.

The noble Baroness, Lady Armstrong, mentioned the publication of figures on 12-hour waits. We have been publishing them since February 2023, but there is an understanding of the need for complete transparency in this, as mentioned by the noble Lord, Lord Allan. I know that this is something we are trying to achieve.

The right reverend Prelate the Bishop of St Albans mentioned the rural response. We are looking at each ICB to make sure that they are responding with plans that look after all the needs of their area and where they need more help. We know that it is often hard to recruit people to some of those areas, so there is the possibility of these special incentive payments in order to recruit people to them. As ever, if I run out of time and do not manage to answer everything, I will follow up with a detailed letter.

“Frequent flyers” have been mentioned a couple of times. I saw a very good example the other day of one of the best practices we want to roll out. Redhill is taking its top 1% of “frequent flyers” and getting upstream with them by proactively going out to visit, screen and check them. That has resulted in them needing 30% less treatment. What struck me, and as noble Lords have mentioned, is that one of the first experiences I had as NED in DLUHC’s forerunner was the troubled families programme, which I thought was an excellent example of trying to look holistically at the problem. I wonder—I am wondering out loud with your Lordships—whether we need to look at that more holistic approach for some of these cases; that is one of my takeaways.

As for the NAO report on the NHP, I am still very confident about the 40 new hospitals. The NAO report talked about the original list of 40 but ignored the fact that we have brought in the RAC hospitals. It says that of the original list of 40, we are committing to only 32 by 2030. That is absolutely correct, because we have brought in the RAC hospitals on top of that which were not previously on the list. It is 40—but it is not the same 40 hospitals. That is what the NHP was pointing out, but I think all of us here today would agree that the RAC hospitals were clearly the priority which should have been brought into the list.

The £150 million is new and is a separate part of the budget which I look after as part of the whole capital programme. It will be subject to bids from the hospitals, which need to make sure that they have the revenue to do it.

To conclude on the question on the assessment: yes, I do think there will be improvements next year. Is it going to be challenging? In all honesty, I think it will. I am not going to pretend that there will be one leap and we will be there, but we have a number of measures in place through which we will see step-by-step improvement next year, and, I hope, reflect a lot of the points made in today’s debate on the report.