Acute and Emergency Services
Steve Baker Excerpts(11 years, 6 months ago)
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Dr Phillip Lee (Bracknell) (Con)
NHS hospitals face mounting financial, work force and demographic pressures. The stark reality is that health care provision in the future will require consolidation of acute and emergency services in fewer locations, and an increase in the provision of chronic care in the community through locally based clinics. That is not a political choice, but a clinically driven reality. It is widely believed among those in the medical profession that the reconfiguration of hospital services can provide a powerful means of improving quality in an environment where money and skilled health care workers are scarce. In some places, reconfiguration and changes to hospital services are already a necessity, not an option.
That is the case in the Thames Valley region, of which my Bracknell constituency is part. That is why I have recently introduced a strategy proposal for the provision of health care in the Thames Valley region, in which I call for a consolidated hospital—what some have described as a super-hospital—on the M4 at junction 8/9. A “Royal Thames Valley hospital” at this location, if it is ever built, would have crucial advantages. The existing transport infrastructure means that services could be provided, within easy reach of people’s homes, to a population of the greatest possible size. This model has a multitude of benefits, which include economies of scale and sharing of medical information and manpower, and it is supported by many senior medical professionals as being the key to saving the national health service.
Nevertheless, I sense a lack of the strategic leadership that is required to deliver the change that we all need. A major stumbling-block in many hospital reconfigurations is public concern about change, and the political opposition that follows. Politicians will have to make decisions on the basis of the quality, safety and efficiency of health care, while retaining strong public engagement in decision making. That is why I have already begun to hold regular public meetings throughout the Thames Valley region.
Steve Baker (Wycombe) (Con)
As my hon. Friend knows, he has set a number of hares running in my constituency. Will he concede that a number of NHS professionals, managerial and clinical, differ with him and think that a network of hospitals is an effective and incremental way forward?
Dr Lee
I thank my hon. Friend for that intervention. Yes, I concede that some—not many—local clinicians share that view. Whenever one presents something different that is a challenge to the status quo, one will come up against vested interests, particularly in the national health service. Many of my colleagues in the Chamber need to start engaging with the public on the issue. It is coming round the corner, and we should all try to provide the political environment in which the change can take place.
I would like first to set the context, say why I support this change, and talk about the current difficulties in our health care system, and those that we will face in the future. In the past 50 years, according to the King’s Fund, the number of acute hospitals has reduced by 85% and the number of sites at which elements of highly specialist care is delivered has reduced even further. In England, general acute care is now delivered in just over 200 hospitals, and at the same time the average size of hospital has grown from 68 beds, according to a Ministry of Health document in 1962, to just over 400 beds. The average acute trust has just over 580 beds. These changes reflect developments in medical practice.
Advances in medicine and surgery have driven clinical staff and equipment to become more specialised. As skilled specialist staff are scarce and budgets are limited, services have been centralised on to fewer, larger sites, in order to ensure that patients are cared for by staff with the necessary skills and supporting specialist equipment. In addition, there has been decreasing reliance on bed rest as part of treatment; for example, most routine surgery is now undertaken as day surgery. The average length of stay in hospital is currently just less than six days and 80% of all patients have stays of less than three days.
Having surveyed both NHS trusts and the public on service change, the Foundation Trust Network found that 90% of NHS trusts said that a major change, such as a hospital merger, closure or changing the way in which services are provided, was necessary in their area in the next two years. Critically, eight in 10 trusts felt that a reconfiguration in their area would lead to maintained or improved patient outcomes which would not be possible if the change did not take place. Of those NHS trusts indicating that a reconfiguration would be necessary, 35% felt that there was a consensus locally about how this should take place. Local councillors were felt to be a barrier to service change in 49% of cases, as were other NHS trusts in 48% of cases, and MPs in 40% of cases.
Finally, market research organisation ICM’s polling of the public shows conflicting views. Four out of 10 people initially stated that they would prefer to be treated locally, but when asked to rank the importance of having services close to home versus accessing specialist care when being treated for a serious condition, more than half said that it was more important to be treated in a unit that specialised in their treatment area. That number rose to 60% if the respondent was talking about a loved one receiving the treatment rather than themselves. Three in 10 said that it was most important to have a hospital close to where they lived in such a case, suggesting that while people value the convenience and accessibility of local care, ultimately access to specialist expertise matters more where a serious condition is involved.
Demographic changes and the shifting burden of disease will require a fundamental shift from the hospital as the core focus of health service delivery to the community, to provide elective care and minor treatments from the community level in much-cherished community hospitals, and all major surgery and acute care from a central hub hospital, ideally located on a motorway.
In any reconfiguration of hospital services there are four drivers: quality—that is, better health care—work force, cost and access. The challenge is to try to arrive at a configuration that optimises all those elements as far as that is possible, given the complex trade-offs that exist between them. Quality considerations include access to highly trained professionals in all disciplines, compliance with clinical guidelines, and access to diagnostic technologies and other support services, as well as strong clinical governance. More recently, there has been pressure on trusts to meet challenging funding needs, which is putting greater emphasis upon operational systems and environments to work together to meet the targets and improve patient safety in acute care settings. There are also interdependencies between services—for example, withdrawal of paediatric services can threaten obstetric services, which rely on paediatricians to provide care for the newborn child.
There is wide variation in the quality of care delivered by NHS hospitals. Reconfiguring services can be a powerful means of addressing this variation. An often cited successful example is here in London. It has been estimated that the recent reconfiguration of stroke services will save more than 400 lives a year. This is through the establishment of stroke networks that have concentrated specialist stroke expertise and diagnostics in fewer units, while retaining local access to stroke rehabilitation services in local community hospitals. Other examples include vascular surgery, where the mortality rate is lower in high-volume hospitals than low-volume hospitals, and paediatric heart surgery, where there are plans to cut the number of hospitals undertaking surgery to improve outcomes.
With reference to stroke mortality rates across acute hospital sites across England, it is estimated that there would be 2,117 fewer deaths per year from stroke in England with increased ambulance services to specialist centres. That clearly demonstrates that centralisation of stroke and trauma centres would benefit a larger proportion of the population and would reduce mortality rates and thereby improve the quality of care.
Alongside those changes, there is a need to shift the location of care for older people who do not require specialist care in a hospital setting. The Royal College of Physicians estimates that almost two thirds of people admitted to hospital are over 65. People over 85 account for 25% of bed days. As we have noted, older people make up the majority of patients in hospital beds, yet many could be cared for elsewhere if appropriate facilities were available. In particular, end-of-life care illustrates the inappropriate use of hospitals. Notwithstanding recent increases in the proportion of people dying at home, many still die in hospital even though they would prefer to be cared for in a hospice or their own home. One of the challenges in this regard is to make community services available 24/7, to stop hospitals becoming the default setting because of a lack of other options.
I will move on to work force pressures. Since the application of the European working time directive to junior doctors, there has been a 50% increase in the number of junior medical staff required to fill a rota and provide 24/7 care, which many units have struggled to achieve. According to a report by the Royal College of Physicians, three quarters of hospital consultants report being under more pressure now than they were three years ago and more than a quarter of medical registrars report an unmanageable work load. I draw colleagues’ attention to the report, “Hospitals on the edge? The time for action”, which is well worth a read and should be borne in mind when discussing or defending local hospital services.
Recruiting into emergency medicine is also becoming difficult and application rates into training schemes involving general medicine are also in decline. According to the RCP, there is an increasing reliance on locums and unfilled consultant posts. That will have a negative effect on emergency care, which is vital to all. There is also an increasing recognition that services such as emergency surgery might be unsafe out of hours, and the provision of those services needs to be concentrated in fewer centres that are better able to provide senior medical cover.
Improving the quality of care often entails making available senior medical cover in some services on a 24/7 basis. That in turn means reducing the number of hospitals providing those services, to enable consultant medical staff to operate effective rotas in the evenings and at weekends. That would also reduce mortality rates, as most deaths happen on poorly staffed wards at weekends. The most contentious issues concern changes in the provision of accident and emergency and maternity services because of the importance attached to those services by patients and the public. Many of the changes derive from work force shortages, for example among consultants and midwives, making the current model of care unsustainable. That is leading to increasing differentiation in how services are provided. For example, some hospitals provide midwife-led maternity care and others no longer provide accident and emergency services at night.
I will now move on to cost. The merger of particular services, such as intensive care, A and E services and cardiac surgery, could improve quality and save money. NHS London, for example, has demonstrated that the recent reconfiguration of stroke services has achieved an improvement in quality as well as significant cost savings. The Department of Health estimates that in the last quarter of 2011-12, 10 out of 72 NHS acute and ambulance trusts were rated as “underperforming” or “challenged” on their financial performance. Of 143 foundation trusts, Monitor reports that 10 had a financial risk rating of 1 or 2—on a scale of 1 to 5, 1 being high—and that 11 were in breach of the terms of their authorisation on financial grounds. Twenty trusts have declared themselves unviable in their current form, including Heatherwood and Wexham Park Hospitals NHS Foundation Trust, which serves part of my constituency.
One of the most comprehensive reviews for clinical and financial evidence was Lord Darzi’s review of the NHS. He argues that future technological advances will result in an expanding number of diagnostic tests and therapies that could be provided more cost-effectively in a smaller number of regional specialist centres, such as the one I have suggested for junction 8/9 on the M4, rather than a large number of low-volume district general hospitals, which is currently the pattern in large parts of the country. For example, the Audit Commission has identified 25 operations or admissions and estimated that 75% of surgeries should be carried out as day cases. It estimates that if all trusts achieved an average 75% day case rate across these procedures, at least 390,000 bed days could be freed up. That would save £78 million, based on £200 per elective patient bed day.
Lord Darzi further explains that minimally invasive techniques will continue to improve. In the next 10 years, endoluminal surgery—entering the body through its natural holes, such as the throat—will become the standard method for treating many complex cases. Better diagnostics will also help most surgery to become non-invasive. Minimally invasive surgery means smaller scars and less risk of post-operative infection, which means patients will also recover more rapidly.
Furthermore, there is an argument for reducing the number of administrative staff required, which will be more cost-effective and save money that could be better spent on the quality of care. Hence, reconfiguration can deliver improvements in quality and safety without significant additional cost.
There are strong political and policy pressures to sustain, and where possible increase, local access to services, particularly those needed in an emergency such as A and E and maternity care. We have an ageing population, and the majority of hospital users will rely on public transport to take them to hospital. Transport systems will have to be put in place so that people can access the central hub hospitals.
How do we achieve the utopia I am seeking in the location and structure of national health service hospitals? I fear that we will need something that we do not currently have: some central direction. This project will take many years to achieve, and we need a cross-party committee to draw up a plan that applies to the whole of England and Wales, so that we can decide where the hospitals, including the community hospitals, are required. If we do that, I am convinced that we will be in a position to deliver the best care in the western world to all our constituents.
Oral Answers to Questions
Steve Baker Excerpts(12 years, 1 month ago)
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Mr Lansley
That is complete rubbish. The legislation is absolutely clear that it does not lead to privatisation, it does not promote privatisation, it does not permit privatisation and it does not allow any increase in charges in the NHS. It simply creates a level playing field so that NHS providers will not be disadvantaged compared to the private sector, as they were under a Labour Government.
Steve Baker (Wycombe) (Con)
The present Wycombe hospital consultation has proceeded with a number of hiccups, not least because of the false sense of local accountability engendered by Labour’s top-down system of health management. Will the Secretary of State meet me and a small delegation of my constituents to discuss how things will improve under his reforms?
Mr Lansley
Of course. I will be glad to meet my hon. Friend and his constituents. I recall how he has been an advocate on their behalf in the past and a vocal advocate of services in Wycombe. I emphasise to my hon. Friend that we are looking towards not only the clinical commissioning groups, but the local authorities injecting further democratic accountability so that in his constituency and those across the country we see much greater local ownership and accountability for the design of services.
Oral Answers to Questions
Steve Baker Excerpts(12 years, 6 months ago)
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Mr Lansley
I welcome the hon. Gentleman to the Opposition Front-Bench position. We are looking forward to the exchanges with him and his colleagues, including during questions today.
Twenty-two trusts have told us, in the course of our looking at where the impediments are to their financial sustainability for the future, that the nature of the PFI contracts entered into by the previous Government is a significant problem in this respect. It is absolutely right for the NHS to build hospitals, which is why we are, for example, building a new hospital at Whitehaven in the hon. Gentleman’s constituency. [Interruption.] I beg his pardon—in the constituency of the hon. Member for Copeland (Mr Reed); we are building so many new hospitals. The nature of the PFI projects we enter into must be to provide value for money and be sustainable in the future. That is something that the previous Government failed to achieve.
Steve Baker (Wycombe) (Con)
3. What representations he has received on the reorganisation of urgent care in the past six months.
The Minister of State, Department of Health (Mr Simon Burns)
A search of the Department of Health’s database revealed that 131 items of correspondence, and five parliamentary questions relating to the reorganisation of urgent care were received in the past six months. In addition, I have received three requests to meet MPs on this subject.
Steve Baker
Wycombe hospital is currently going through a consultation on a change to urgent care services, and it is doing so in the context of the betrayal felt after “Shaping Health Services” in 2004, which removed our accident and emergency department. I would like to escape this cycle through mutuality. What is the Government’s position on mutuality? Will the Minister join my call for directly owned community health services?
Mr Burns
The Government have supported the right to request, which has enabled 45 staff-led social enterprises to be established. This policy has supported approximately 25,000 staff into social enterprises, with contracts of roughly £900 million. NHS staff have been assisted by a wide-ranging programme of support from the Department.
NHS Future Forum
Steve Baker Excerpts(12 years, 11 months ago)
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Mr Lansley
I am sorry the hon. Gentleman tried to characterise that as he did. The joint committee of primary care trusts is conducting a consultation. The Government are not doing it; I am not doing it; the committee is doing it, and the consultation closes on 1 July. People across the country are quite properly making representations to the consultation, including on the Royal Brompton and other units. The committee has not made recommendations to me; it will come to its conclusions after that consultation, which has absolutely nothing to do with the structure of the proposals I am referring to today.
Steve Baker (Wycombe) (Con)
My constituents will not be interested in hard left, old school scaremongering. They simply want to know whether the Bill will put local health services under a greater degree of local control.
Mr Lansley
My hon. Friend will know that many of us in the House were deeply frustrated in the past that Ministers would say at the Dispatch Box that primary care trusts were responsible for local decisions, and then nobody found locally that the PCT was in any practical sense accountable to them or the population they represented. In future, there will be proper accountability: clinical accountability through the commissioning groups and democratic accountability through local authorities.
Oral Answers to Questions
Steve Baker Excerpts(13 years, 2 months ago)
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Rehman Chishti (Gillingham and Rainham) (Con)
14. What steps he is taking to improve NHS cancer services.
Steve Baker (Wycombe) (Con)
17. What steps he is taking to improve NHS cancer services.
The Minister of State, Department of Health (Paul Burstow)
We published our cancer strategy in January, which set out a range of actions to improve cancer outcomes and cancer services. We set out our plans to improve earlier diagnosis, access to screening, treatment and patient experience of care.
Paul Burstow
My hon. Friend is right to draw attention to that survey, which has produced invaluable data. More than 65,000 patients took part in the 2010 survey, and it is proving to be an invaluable tool in enabling trusts and commissioners to identify areas where there is scope for improvement locally. The cancer strategy that we published in January commits us to repeating such a patient experience survey, and we are exploring the options at the moment.
Steve Baker
What is the Government’s policy in relation to those charities that provide indispensable services to cancer patients and their families? I have in mind, in particular, Macmillan and Marie Curie.
Paul Burstow
My hon. Friend is absolutely right to describe the contribution of Macmillan, other cancer charities and, indeed, charities in the health sector more generally as indispensable. I recently had the pleasure of visiting Macmillan’s headquarters, where I did an online chat with a number of cancer sufferers and their families and saw the helplines and other support services that it provides. In our cancer strategy, we are very clear that such charities have an invaluable role to play.
Horton General Hospital
Steve Baker Excerpts(13 years, 11 months ago)
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The Minister of State, Department of Health (Mr Simon Burns)
I congratulate my hon. Friend the Member for Banbury (Tony Baldry) on securing this debate on the future of Horton general hospital. I know that he has campaigned vigorously in support of the hospital for several years, and I am sure that his constituents appreciate both his hard work and his dedication to protect good local health services in his constituency. I also pay tribute to the NHS staff across the whole of Oxfordshire, who provide such first-class care for his constituents.
As my hon. Friend will know, the Secretary of State has visited his constituency a number of times, and has seen for himself the excellent work carried out daily at Horton general hospital. I would be delighted to accept my hon. Friend’s offer to visit Horton myself, so that I, too, can benefit from knowledge of the experience that his constituents enjoy.
Steve Baker (Wycombe) (Con)
I, too, congratulate my hon. Friend the Member for Banbury (Tony Baldry) on securing this debate, and I note the Minister’s diligent concern for Horton hospital. Will he consider the case of Wycombe hospital, which is somewhat further down the route upon which the Horton had embarked, and our local services?
Mr Burns
I am grateful to my hon. Friend for drawing that to my attention. Given the constraints of time in this debate, if he were to be kind enough to write or to come and see me, I would be more than happy to discuss the situation with him.
My hon. Friend the Member for Banbury referred to the decision made by the board of Oxford Radcliffe Hospitals NHS Trust on Monday this week to maintain 24-hour paediatric services and a full obstetrics service at Horton general hospital. That is good news, and thanks in no small part to the strong opposition mounted by local GPs, clinicians and the public to the trust’s original plans that were proposed in 2007. In addition, my hon. Friend and my right hon. Friend the Prime Minister—in his constituency role—my former hon. Friends Tim Boswell and John Maples, and my new hon. Friends the Members for Stratford-on-Avon (Nadhim Zahawi) and for South Northamptonshire (Andrea Leadsom), should be congratulated on the determined way in which they have fought for their constituents in seeking to stop the original proposals, which would have meant paediatric in-patient services moving from the Horton to the John Radcliffe hospital in Oxford, with the problems that that would cause for their constituents.
Following the rejection of the original plans in 2008 by the independent reconfiguration board, Oxfordshire PCT set up the better healthcare programme to develop proposals on how safe, long-term services at Horton might be delivered. It established a community partnership forum to ensure wide engagement with the local community, which included representation from local GPs, patients, the public, Horton general hospital staff, councillors and Members of the House. I am aware that my hon. Friend the Member for Banbury played a long and active role in those deliberations.
I am pleased to note that local engagement has been such a key part of the better healthcare programme. I understand that the community partnership forum has been involved throughout, and that frequent briefings were held with GPs and the practice-based commissioning consortia. Clinical staff at Horton general and John Radcliffe hospitals have also been involved, to ensure wide clinical engagement.
The model of care that emerged from the better healthcare programme was for consultant-delivered paediatrics and obstetrics services to remain at Horton general. That will mean less reliance on middle-grade doctors, and result in Horton continuing to provide local, high-quality paediatric and maternity services. The Oxfordshire health overview and scrutiny committee agreed with that model.
In March, the proposals developed to implement that model were presented to a clinical review panel. The panel consisted of local GPs, representatives from the Royal College of Obstetricians and Gynaecologists, the Royal College of Paediatrics and Child Health, the Royal College of Anaesthetists, Cherwell district council and a PCT board member. Although I understand that the panel had some concerns, it concluded that the proposals were clinically safe and deliverable. Now that the PCT and trust boards have decided to go ahead with these proposals, the next step is for the trust to develop an implementation plan. That will involve recruiting the required number of additional consultants.
I am pleased that Oxfordshire PCT and South Central SHA have both assured me that the better healthcare programme has passed the four tests set out by the Secretary of State, which have been a strong feature of the way the programme has been organised. As my hon. Friend will appreciate, the four tests to which I refer are the new tests that the Secretary of State has laid down to ensure that when reconfiguration proposals are made, local GPs and clinicians—and local communities—are fully consulted before any decisions are made, so that they can have a say in the health care that they need.
My hon. Friend asked a number of questions that I will seek to answer now as far as I can. He asked about the timetable for the transition to GP commissioning and the future role of primary care trusts. As he knows, we have only been in government a matter of weeks and a tremendous amount of work needs to be done to begin to realise our vision for an NHS based on putting patients first so that quality of care is the priority in the service. In that context, we will set out our vision for the national health service shortly. Until we do, I am not in a position to respond in detail to those two specific questions.
My hon. Friend asked about the independent NHS Board. The board will set outcome objectives, allocate resources and provide commissioning guidelines free from political interference. Again, I beg my hon. Friend’s patience as we will set out further details of the NHS Board shortly. I am sure that he appreciates that I cannot go into detail at this stage and while we are putting together our proposals to bring before the House and the nation.
My hon. Friend also raised the idea of an initiative to bring together an alliance of general hospitals to help provide the best integrated primary, community and hospital care. Like him, I believe that it is vital to have first-class integrated health and community services, and I assure him that we are looking at how we might best achieve that.
I applaud the determination that my hon. Friend, and my other hon. Friends—I am pleased to see them in their places tonight—have shown in their championing of local services in Banbury and in other areas affected by these proposals. His constituents, like those of all hon. Members, deserve good local health services that have the full support of local GPs, clinicians and the local community and provide the highest standards of quality and care. By seeking the support of GPs and local people for any changes made, by basing any changes on clear evidence, and by ensuring that all changes improve patient choice, the enhanced services in Oxfordshire will inevitably lead to better care for my hon. Friends’ constituents, not only in that area but in those parts of south Northamptonshire and Warwickshire that form part of this hospital area.
In conclusion, I am pleased that the plans that have finally been devised through local involvement and commitment have solved a potential problem. It shows that, by consulting with local stakeholders and the local community, one can achieve the sort of configuration that meets the needs of local people as well as the needs of a local national health service. In particular, I congratulate my hon. Friend on his tremendous work and the leadership that he has provided in ensuring that the local community, working together, achieved the successful outcome determined last Monday. I wish him and the local health service in Banbury and the surrounding area every success in ensuring that these proposals work, and work well, for the benefit of the local community.
Question put and agreed to.