A and E Waiting Times

Martin Horwood Excerpts

Tuesday 23rd April 2013 Westminster Hall

[Martin Horwood (Cheltenham) (LD)]

I pay tribute to the right hon. Member for Cynon Valley (Ann Clwyd) for securing this debate on such a topical matter. I had not intended to speak, but since the opportunity has arisen I would like to make some points, because the matter is very relevant to my constituency.

Cheltenham is in an unusual situation. We have two district general hospitals within eight miles of each other, one in each of the almost twin cities of Gloucester and Cheltenham. Some years ago, the hospitals came under the management of a single NHS foundation trust, and there is an almost inescapable business rationale for the trust management always to try to centralise services in one hospital or the other. Some services, including oncology and cardiology, have been centralised in Cheltenham, but with emergency services there has been a slight drift towards Gloucester, starting with neonatal intensive care and then trauma. That might make business sense to the trust, but it poses a problem because they are services that people clearly want to get to in a hurry. They are a bit like maternity services, in that people value having them within their town and do not want to have to try to find them in a hurry in an unfamiliar setting.

The current situation in Cheltenham reflects exactly the national picture that the right hon. Lady described, and we have heard from the King’s Fund that in the final three months of 2012, 232,000 people nationwide waited more than four hours in A and E, a 38% increase on the previous quarter. Some of that is clearly a seasonal increase, reflecting winter issues, but it has certainly been the case in Gloucestershire, where the situation has been rather unequal, with waiting times significantly and regularly higher in Gloucester than in Cheltenham. People are, therefore, concerned about the further centralisation of services in Gloucester, because they fear that the capacity of the emergency department there to cope with the increase will be even worse.

The situation has been explained in a number of ways. There can be a seasonal explanation—there is always a winter upturn, and we have had a series of bugs and infections, including the winter vomiting virus. Those are known factors, which vary from year to year. There is, however, a new factor in the mix, which is the 111 out-of-hours service. I have anecdotal evidence from local GPs that far more referrals into hospitals and A and E departments are occurring as a result of the introduction of the 111 service. The GPs think that they ran a rather good out-of-hours service before, under a different NHS trust, and the new service is clearly causing problems if their accounts are to be believed.

We must gather reliable data, but the evidence that I have from doctors is that they are getting fewer requests to call patients back, through the 111 service, and that a number of individuals have been referred unnecessarily to A and E, partly because the initial triage is done by people who are not really medically qualified. They have a stock set of questions and the approach is not very sensitive, so it seems that the safest thing for the operators to say is, “The best thing is to go to A and E.” If that is responsible for part of the upsurge in cases, it is adding to our existing problems.

The other problem in Cheltenham and Gloucester is the shortage of, and the difficulty of recruiting, emergency consultants and registrars. The guidelines are that there are supposed to be 10 doctors in each emergency department, which would mean 20 for Cheltenham and Gloucester. Gloucestershire Hospitals NHS Foundation Trust has told me that it has managed to fill only 11 of those posts. That is true: I have had independent corroboration from people working in the human resources department of the hospital, who have occasionally advertised for emergency posts and had no applicants. There is clearly a significant problem that they say is part of the national picture of a shortage of trained emergency doctors available to be recruited to emergency departments, which is adding to management pressures and the difficulty of managing the flow of patients into A and E departments.

That raises some other questions. Gloucestershire Hospitals NHS Foundation Trust is, as the name suggests, a foundation trust. It has the freedom to advertise higher salaries, to apply a “hard to recruit” bonus and to try harder to attract more consultants and registrars to its emergency department. As far as I can see, it does not appear to be doing so at the moment. It may be that that does not make such good sense in business terms. Emergency is a relatively expensive function for a trust compared with others, such as orthopaedics, which appears to generate income for the trust. It would be worrying if such business considerations were interfering with a trust’s ability to take management decisions that might attract more consultants and registrars into an emergency department.

I want the Minister to address, first, the national issue of the shortage of emergency doctors, which is forcing difficult decisions on trust managements and, secondly, what she thinks trust managements’ best response might be. For instance, would it be better for them to wait for the outcome of the Keogh review into emergency services, rather than to take pre-emptive decisions now to take such actions as downgrading emergency services at Cheltenham general hospital?

The suggestion is not that that hospital will be closed outright, but simply that it will be downgraded so that bluelight referrals at night are diverted from Cheltenham to Gloucester. That seems like a small and not drastic change, but there have been a whole series of changes—to trauma, neonatal intensive care, children’s services and maternity—and each small change by the trust seems to justify another change. In itself, that is worrying, because who knows what will follow this decision. Will all bluelight referrals be diverted to Gloucester? In a few years’ time, will Cheltenham end up with simply a minor injuries unit for a town of 120,000 people, given that we instinctively know that had the management arrangements been different and two different hospital trusts were in existence, they would be fighting to keep the services open?

The timing of the consultation is very unfortunate, coming at just the moment of the changes to the NHS organisational structure. Perhaps I am a little cynical, but I cannot help thinking that the trust’s timing may not be entirely accidental. The primary care trust, which fought strongly to keep services at both Cheltenham and Gloucester reasonably level—it tried to serve both populations and keep a degree of equity between them—has been wound up and handed over to a clinical commissioning group that has failed to attract a single doctor from Cheltenham to serve on its board, so that a town of 120,000 people has no local voice on the main commissioning body. At the precise moment that it started—new and relatively experienced compared with the old PCT—the trust has chosen to launch changes to one of the services that is most controversial and most valued by local people, which is a very unfortunate coincidence of timing.

I want us to hear, if we can, the Minister’s real plan for the future of emergency services, and to see whether there is any long-term vision about how local MPs and people can put a case to their trusts for the preservation of local emergency departments wherever possible. We need to deliver care to people as close as possible to their homes, and not drift into a situation of its being more and more centralised in particular locations, which may enable trust managements to have a rational case for attracting more sub-specialisms and doctors to their department, but leave a town the size of Cheltenham, with 120,000 people, with a much worse service.

That is causing great alarm, particularly in the context of the waiting times that we see, even as this debate goes on, right now. In Cheltenham, the wait is 38 minutes, according to the trust’s website. At Gloucester Royal hospital, it is 68 minutes—already more than an hour—at a time when demand should actually be very low. Those emergency departments are struggling to cope, and it seems to me that the waiting times are symptoms of a rather deeper and more difficult problem that we have to tackle.

--- Later in debate ---

[Grahame M. Morris]

I think that the Government are cutting the money that is spent on the NHS, not least with the costs of the reorganisation, which I have already mentioned. That money need not have been spent. We are giving back several billion pounds—some £2.5 billion to £3 billion to the Treasury—which could be spent addressing issues such as this. There are a couple of practical points that I want to raise with the Minister later, but I give way to the hon. Member for Cheltenham (Martin Horwood).

[Martin Horwood]

I agree with the hon. Gentleman about the reorganisation of the NHS. That time and effort would have been better spent trying to work out how to deliver health care more cost-effectively. But does not he rather undermine his case when pretending that there has been a cut to the NHS budget, when an objective analysis of the actual billions spent on the NHS clearly shows that it has gone up? The difference between a cut and an efficiency saving is that an efficiency saving is returned to the NHS budget.

[Grahame M. Morris]

I did not vote for the NHS reorganisation; I spent 40 sittings in Committee trying to resist what is now the Health and Social Care Act 2012 and the damaging changes it introduces. That includes those that are about to be implemented under section 75, on the introduction of competition, which will fragment the service and add to costs and complexities. I do not, therefore, accept the hon. Gentleman’s criticism, but I will press on because I want shortly to raise a couple of issues specifically about County Durham.

Part of our responsibility is to hold Ministers and, indeed, the Prime Minister to account. On waiting times—this was one of his five guarantees—he said:

“We will not lose control of waiting times—we will ensure they are kept low.”

Other Members have quoted the King’s Fund and patient surveys, and the figures clearly show that 32 foundation trust hospitals, out of 88 acute trusts in England with an A and E unit, missed the target in the last three months of 2012. I am not sure whether Kettering was one of them, but those figures should be cause for concern for everybody, including Ministers and the Prime Minister. That is double the number of trusts that missed the target in the same period last year, and four times the number that missed it in the previous quarter.

It is therefore clear that A and E waiting times are spiralling out of control. There have been various surveys, including one conducted by the Care Quality Commission, which found that one in three people spent more than four hours waiting for treatment. It also noted a large rise in the number of patients waiting for 30 minutes or more before seeing a doctor or a nurse.

In my area, The Northern Echo is campaigning on this issue, highlighting the alarming rise in the number of patients in the north-east waiting more than four hours for treatment. That number has almost trebled in the past 12 months. The paper has disaggregated figures from the Department of Health and found that more than 1,000 patients have waited longer than the target time, including 536 in County Durham and Darlington. Compared with 12 months ago, the number of patients waiting more than four hours has increased by 200% in County Durham and Darlington. South Tees and York have also seen increases in excess of 200%, compared with the previous year. However, at the Newcastle foundation trusts, the percentage increase is a staggering 630%. Alarm bells should be ringing for Ministers, because those figures are quite dreadful.

I was concerned by the Secretary of State’s responses at Question Time. One disturbing characteristic of this Government is that they are not taking responsibility or coming forward with proposals to address these issues. Specifically, in response to a question from my hon. Friend the Member for Manchester Central (Lucy Powell), the Health Secretary said:

“We are looking at the root causes of the fact that admissions to A and E are going up so fast”

—I think he quoted a figure of an additional million. The factors he blamed were that

“there is such poor primary care provision…changes to the GP contract led to a big decline in the availability of out-of-hour services…and…health and social care services are so badly joined up.”

He added:

“That is how we are going to tackle this issue”.—[Official Report, 16 April 2013; Vol. 561, c. 168.]

That really is not good enough. Indeed, Dr Laurence Buckman, who is chair of the British Medical Association’s General Practitioners Committee, has been quite dismissive and scathing about the Health Secretary’s decision to blame the increase in A and E numbers on the changes to GP contracts. He said it was “impressively superficial”—[Interruption.] Well, that is what the man said, Minister. He said that the decision was not based on any evidence. He went on to say:

“Most GPs were not providing personal access out of hours anyway; it was provided through a variety of out-of-hours routes and that has been the case for the past 30 years, so it would be nonsense to suggest that because GPs haven’t been personally responsible since 2004, therefore casualty is full of people. That is just such fatuous nonsense. I question the wisdom of the people briefing the Secretary of State.”

I tend to agree with him.

There is no magic bullet. With a complex organisation such as the NHS, we need a broad-spectrum antibiotic; we need to apply a number of measures. The fragmentation of the service is certainly contributing to the problem. There is also the issue of people not having access to their GP within 48 hours. Like many Members, I have, unfortunately, had experience of close family members and constituents being left with little alternative but to go to A and E, when the GP could have addressed the issue, had they been available in a reasonable period. This issue therefore requires a team effort.

I am also concerned about what the RCN is saying about the reduction in the number of community and district-based nurses, and I hope the Minister will refer to that. Information provided through freedom of information requests shows that the number of nurses in communities who are part of the rapid emergency assessment and co-ordination teams and the rapid response teams that help to keep elderly people, in particular, out of hospital, has been dramatically reduced.

--- Later in debate ---

[Mr Reed]

I note that the Minister prepared an answer, and I am grateful for that.

Major accident and emergency units—type 1 facilities, nationally—have missed the target for at least the last six months, and all A and E units, including minor incident units, have not hit the target for 12 weeks in a row. If anyone needs help analysing the figures, I would be happy to oblige. They are easy to find and they reveal some interesting points. For example, I wonder whether hon. Members know that only one trust with a major accident and emergency unit in England has hit its target every week since the Secretary of State took his position. That is relegation form, and if this were a football match the cry from the crowd would be “You don’t know what you’re doing.”

Before the Minister attempts yet again to dismiss those statistics, I hope she will take a moment to attend to what has been said by the chief executive of the Royal College of Nursing, by Dr Clifford Mann of the College of Emergency Medicine, and by David Behan of the Care Quality Commission. Earlier this month, Dr Peter Carter, of the Royal College of Nursing said:

“These figures are yet more proof of a system running at capacity, and patients are suffering as a result. Our members are regularly telling us that pressure on the system is rising while staffing levels fall, and as a result any increase in demand results in unacceptable waits for patients who are already going through a difficult time.”

Dr Clifford Mann, of the College of Emergency Medicine said:

“We are seeing...ambulances queuing outside departments, and patients waiting too long on trolleys before they can be admitted to hospital.”

The Care Quality Commission said:

“It is disappointing that people have said they have to wait longer to be treated than four years ago. People should be seen, diagnosed, treated and admitted or discharged as quickly as possible”.

Like me, the Royal College of Nursing, the College of Emergency Medicine and the Care Quality Commission will be appalled that the key performance indicators for the NHS, such as A and E waiting times, are getting steadily worse. In the past six months, 582,811 people waited more than four hours in major A and E units, compared with 420,921 for the same period in the previous year. That is an increase of 161,890 people. That is not silly: it is a question of people’s lives. Those figures relate to people in need who did not get treatment in the time when they needed it. They represent more than 500,000 extra waiting hours in one year. People will find it hard to stomach the fact that there are now about 5,000 fewer nurses than there were in 2010, at a time when, as hon. Members on both sides of the House have mentioned, demand in our A and E units is increasing.

One way to get the figure down—it has been touched on already in the debate—would be to offer services for people with non-emergency ailments, so that they do not feel the need to travel to an A and E department. However, instead of NHS Direct being used as a tool for easing pressure on A and E departments, the roll-out of NHS 111 has turned into a trade marked Government shambles. Patients calling the new 111 service wait hours for advice. One patient waited 11 hours and 29 minutes for a call back. No wonder they feel that they have to go to A and E, when they cannot trust a telephone service with such an inadequate response rate.

Accident and emergency departments are a litmus test, or a barometer, for the performance of the NHS as a whole. If people are waiting in A and E, it means that there are too few beds or too few staff to cope with demand. That is just a fact of health service planning. If there are too few beds, it is because community services are being cut and patients who should be at home are kept in hospital. That reverberates back through the entire system. If patients who could be at home are in hospital, beds are occupied. If beds are occupied, A and E staff cannot admit patients. If A and Es are full, paramedics cannot hand over patients. If patients are queuing in the back of ambulances, those ambulances cannot respond to a potentially serious call-out. One failure leads to another. Each compounds the other. That is what is so serious about the debate. It is not just about the patient sitting in A and E for hours on end; the statistics I have highlighted show much more than that—the experiences of patients throughout the entire system.

[Martin Horwood]

In my remarks I suggested another possible factor in the current problems of emergency departments: the difficulty in recruiting emergency doctors. That may have something to do with the attractiveness of emergency medicine as a specialty—the long hours, and so on. However, it also obviously dates back to the training numbers that I am afraid prevailed under the Labour Government. Does the hon. Gentleman accept that there may be some such responsibility, dating back several years, in relation to attracting sufficient numbers into training for emergency medicine?

[Mr Reed]

I expect the Minister to talk about new doctors in the NHS when she replies to the debate; and, of course, we trained those doctors. We commissioned, paid for and put in place the training of those doctors, so I take what the hon. Gentleman says seriously. I also commend him for being the only Member of Parliament from either of the coalition parties to attend the debate to defend the Government’s record.

The statistics highlight more than the simple numbers: they show the experience of patients throughout the system. One person waiting in A and E can reflect one person in a bed on a ward and another waiting at home for an ambulance. I hope the Minister will acknowledge and accept that, and explain what the Government plan to do. It is essential that they explicitly acknowledge the problems faced by accident and emergency in England. Constant denials do them no credit. They must acknowledge the scale of the problem before any solutions can be introduced.

The NHS in England is completely different from the NHS in Wales. I expect the Government will be tempted to compare the two, but I want to address the issue head on. The reality is that Welsh Ministers are dealing with a £2.1 billion real-terms cut to their budgets. Yet, despite that, they have still managed to protect NHS services. There are now more GPs working in Wales than in 2010, and the number of nurses, midwives and health visitors has remained consistent. That is in stark contrast to England, where nurse numbers are falling. I am sure that hon. Members who have heard such tired comparisons over and over would be interested to know that there are differences in the way A and E waiting times are measured in the two countries, and in how frequently performance is measured.

Before any comparison is made—and I hope that none will be—I want to point out that it is misleading to try to make a direct comparison. However, it is fair to say that all parts of the UK are experiencing increased pressures on A and E. The key difference is that in Wales, Labour are doing something about it, whereas in England the coalition is sitting on its hands. In Wales, 270 additional beds were opened this winter to cope with demand, easing pressure throughout the system. The Welsh Government have also agreed an all-Wales action plan for unscheduled care, which means that health boards must ensure that they have sufficient capacity to meet demand.

Will the Minister inform us today what the Government plan to do to help A and E services in England? When and where will they start to provide such help, and how much will it cost?

That aside, will the Minister also answer a few important questions on A and E waiting times? First, will she explain why, when demand is clearly so high and the current services are at breaking point, the Government have handed P45s to almost 5,000 nurses? Will she also explain why the Secretary of State chose a period of intense demand and structural reorganisation to roll out the 111 service when it was clearly not ready to be rolled out?

May I tempt the Minister to speculate on the causes of that rise in A and E waiting times? Does she agree that a combination of inadequate staffing levels, a distracting reorganisation of the NHS and deep cuts to council care budgets is the principal reason for the sharp increase in A and E waiting times? If she does not agree that they are having a major impact on the NHS, can she explain why the Government think that fewer nurses and a distracting reorganisation have improved services?

The problems that others and I have outlined today are well known to many, but they are still sadly neglected by the Government. Despite its imperfections and its many real challenges, the NHS remains one of the best models of national health care in the world. It is filled with dedicated professionals who believe passionately in the aims and values of the service, but it is clear that an expensive, unwanted and unloved reorganisation, combined with Government-induced staff shortages, are causing and have caused deterioration in performance. That is unfair on health care professionals, and, far more importantly, it is unfair on patients. I look forward to the Minister explaining in detail how her Government intend to get a grip and bring all A and E services in England back up to national standards.