Accident and Emergency (Westmorland General Hospital)

Tim Farron Excerpts

Wednesday 23rd June 2010 Westminster Hall

[Tim Farron (Westmorland and Lonsdale) (LD)]

It is a pleasure to serve under your chairmanship for the second time in an hour, Mr Benton. I wish to express my gratitude for the opportunity to make the case for my local hospital.

The Westmorland general hospital in Kendal sits almost exactly at the geographical centre of the area covered by the University Hospitals of Morecambe Bay NHS Trust. It is one of three hospitals serving the area, along with the Royal Lancaster infirmary and the Furness general hospital at Barrow. Westmorland general hospital serves, in Cumbria: the Lake district, the western part of the Yorkshire dales, South Lakeland district and the southern part of the Eden district. In north Lancashire, it serves large swathes of the Lune valley.

For all those areas, Westmorland general is the closest and most accessible hospital. Indeed, it was built in 1992 expressly to serve those communities as a district general hospital. At that time, it provided full accident and emergency services and acute provision. Since 1992, the population of Westmorland general hospital’s catchment area has grown significantly in comparison to the populations of the other hospitals at Lancaster and Barrow. However, the past 18 years have seen the steady removal of key services from Westmorland general, culminating in the loss of medical emergency services in August 2008.

Since 2008, anyone suffering a suspected cardiovascular emergency, a heart attack or a stroke in the Westmorland general catchment area has been taken by ambulance to Lancaster or Barrow instead. The majority of local health professionals opposed that decision throughout the consultation process in 2006, as did the overwhelming majority of the local population. I presented a petition to this place, with 27,000 signatures opposing the proposals. There were 7,000 responses to the formal consultation, almost all of which opposed the proposal. Some 6,000 people joined a march in opposition to the cuts and 4,000 of us joined a human chain around the hospital to protest. I am proud to have been involved in all of those actions, as they were a key mark of the strength and vitality of our communities and of the clear awareness of the immense danger that the proposals pose to tens of thousands of residents and visitors. The campaign went on for almost three years, but in August 2008 the medical emergency provision closed.

Trust managers—I would say disingenuously—attempted to convince the previous Labour Administration that the opposition to the proposals was simply a case of an emotional and uninformed public and MP against an informed and clinically astute medical community. I can assure the Minister that that is absolutely not the case—it is, indeed, nonsense. As I have already said, the majority of local medical opinion was opposed to the closure. There were some doctors who supported the closure of emergency services, but there were barely any of those who were not also some sort of trust manager, and therefore sticking to the party line. I am seeking the Minister’s help to ensure that safe emergency provision is reinstated for residents and visitors to South Lakeland, the lakes, the dales, the northern part of the Lune valley and the southern part of the Eden district.

The resident catchment population for the Westmorland general hospital is 123,973 individuals, rising to 157,513 when one factors in resident visitors. For the Royal Lancaster infirmary, the resident catchment area is 143,500, rising to 161,886 when factoring in resident visitors. For the Furness general hospital catchment area at Barrow, there are 71,800 residents—78,093 when factoring in resident visitors. The catchment populations of Lancaster and Westmorland are roughly identical, with the catchment area of Barrow less than half their size. An additional factor, of course, is the vast number of non-resident visitors in the Westmorland general hospital catchment area visiting the lakes and the dales, who are as likely as anyone else to fall ill and need emergency treatment. That means that, for most of the year, there will be significantly greater numbers of people in the Westmorland catchment area than in that of either of the other hospitals in the trust area, yet Westmorland general is the only one without medical emergency facilities.

The area served by Westmorland general is much more rural and sparsely populated than the rest of the trust area. Barrow has 10.2 people per hectare, Lancaster 2.81, and Westmorland just 0.6. Many parts of my constituency already face vast distances and a significant trek to get to Westmorland general hospital, but to now force people to go all the way to Lancaster or Barrow is a significant threat to patient safety.

If one had a heart attack in Hawkshead, it might take an ambulance half an hour to arrive. The fastest time it would then take to get to Lancaster hospital would be an hour, but it would be more likely to take 90 minutes. The average patient suffering a heart attack would therefore arrive at Lancaster’s coronary care unit some two hours after they had dialled 999—if they survived. It would take 37 minutes to get to Kendal, rising to 45 if the traffic was sticky. The same, give or take a minute or two, is true for people who fall ill in Chapel Stile, Elterwater, Grasmere or Coniston. It takes 46 minutes at best—it is more likely to take an hour and a quarter—to get from Ambleside to Lancaster, but less than 20 minutes to get to Kendal.

We all know about the golden hour following a heart attack, during which a patient must be stabilised. After the hour is up, the chances of a patient dying or suffering permanent damage rocket. Anecdotally, I know of a great number of deaths that occurred as a consequence of the decision to close down emergency medical services at Westmorland general hospital. I know, from talking to ambulance service staff, that patients have died in the back of ambulances en route to Barrow or Lancaster, but that they would have survived had they been allowed to be taken to Kendal. Such deaths do not show up in statistics, because no one officially dies in an ambulance—they are only designated dead on arrival. I encourage the Minister to dig as deep as she is able to uncover hard evidence of that through coroners’ reports and other similar material.

All acute medical crises have better outcomes the sooner they are treated by a full medical team, a doctor and specialist nurses situated in a fully equipped resuscitation room. It is criminal to reconfigure acute services to lengthen the time that dangerously ill people have to wait before receiving life-saving treatment, especially given that Westmorland general hospital had an excellent record of managing the initial stages of heart attacks and other life-threatening acute cardiac emergencies. I invite the Minister to look at the official statistics, which show clearly that timings at Westmorland general for patients receiving vital treatment were significantly and consistently better than at Lancaster or Barrow. Outcomes were also excellent.

It is not the case that Kendal operated at a lower level or standard than the other two hospitals. Cutting-edge coronary care units are equipped to provide angioplasty services, but the nearest such unit to Morecambe bay is in Blackpool, which is well outside the trust area. It is important to spell out that neither Lancaster nor Barrow provide that function. Indeed, although the expertise and the level and standard of service provided by the coronary care units at Lancaster and Barrow are excellent, they are no more advanced and no better in terms of outcomes, patient experience, safety or survival rates than those that were available at Westmorland general hospital in Kendal just 22 months ago.

Expert opinion suggests that, where it is appropriate, a patient should be thrombolysed by a trained paramedic at the scene before being transported to the nearest specialist centre. In order to allay my fears and those of my constituents, the hospitals trust negotiated with the North West Ambulance Service to provide an additional ambulance service for South Lakeland and a number of additional paramedics to compensate for the closure of acute services at Westmorland general. Those promises were kept, but the figures clearly show that the administration of thrombolysis at the scene almost never happens in South Lakeland. Indeed, in the first six months of operation, only four instances of thrombolysis took place outside a hospital in the south lakes. In the other 95% to 99% of cases, the patient is left waiting at least 30 minutes longer for their treatment than they would have when the Westmorland general’s coronary care unit was open. I can only speculate why that is so—it may be due to a lack of training or a lack of confidence. A paramedic is now being asked to perform the same function alone in an immensely stressful situation, possibly in the presence of distressed relatives, that only 22 months ago would have been performed by a team of experts and experienced coronary care nurses in a specialist unit. I do not blame the paramedics for not thrombolysing, but I blame the trust management for pretending that this practice could ever have been a safe alternative to a coronary care unit at Westmorland General hospital.

There are additional dangers to patients as a result of this decision. Because more than 90% of ambulances from the south lakes now have to make the journey to Lancaster or Barrow to deliver a patient to hospital, the south lakes ambulances tend to be at least 30 minutes further away from their next emergency call than they used to be. That had to have a dramatic effect on response times, and indeed it has. However, some of this lengthening of response times has been covered by the presence of our outstanding volunteer first responder teams, who will usually get to the scene of an emergency before an ambulance and in some cases more than an hour before an ambulance, thus making it appear that the ambulance service has met its response time target when in reality it has not.

To illustrate the situation, I will use one example. In December I went on shift with one of Kendal’s ambulance crews. We responded to a 999 call from a man in his late 80s who had presented with chest pains. He lived roughly a mile from the Westmorland general hospital in Kendal, which 16 months previously would have been able to receive him and treat him. Instead, we had to drive this patient past the Westmorland general hospital on the A65 and take him down the M6 to Lancaster. The patient was clearly afraid and the paramedics were clearly appalled at having to take a potentially dangerously ill person so much further to receive treatment. His frail wife was left behind in Kendal, with no prospect of being able to visit her husband in the coming days, as she would have been able to do at the nearby Westmorland general hospital. Even with blue lights flashing and sirens blaring, it still took us 45 minutes to reach Lancaster’s A and E department. The nature of Lancaster’s traffic system means that, even when other road users pull over in unison to allow an ambulance to pass, it is barely possible to go above more than 15 or 20 mph as a driver attempts to negotiate the traffic.

We stayed with the patient for more than an hour until he was safely admitted and then we left to return to the ambulance station in Kendal. From getting the 999 call to returning to the base and being once again available for the next emergency call, it had taken almost three hours. If we had been allowed to take the patient to Kendal, we could have been back at the base, out and ready to help the next patient in just half an hour.

Again, I can only speculate as to the motives of the trust management who were behind the closure. At the time, financial motives were cited, although those financial pressures have actually alleviated significantly. Mostly, clinical reasons were put forward for the closure, but those clinical reasons were seriously flawed. The solitary piece of clinical evidence used by the hospital trust and the PCT to justify their decision was the Royal College of Physicians’ guidance notes from 2002, which included a recommendation that consultants in acute medical care should not straddle more than one hospital. To follow that guidance to the letter would mean closing acute hospital medical services at either Lancaster or Kendal, so the trust chose to close services at Kendal.

However, the guidance is just that—it is guidance. It is not an edict. Indeed, in an answer to a written question from myself to the former Secretary of State, Patricia Hewitt, it was confirmed that that guidance was only one of a range of considerations that had to be weighed up when trusts were deciding how best to deploy acute medical resources and, crucially, that many trusts, especially in rural areas, had chosen to acknowledge the guidelines but had also chosen to continue to operate the relevant coronary care unit, because of the greater importance of ensuring adequate treatment for patients within the golden hour.

We can look at the example of Fort William hospital, where GPs are recruited to fulfil a cardiac role within the hospital. They are well trained to manage cardiac emergencies, independently if necessary. At Westmorland general hospital, the answer could be to recruit a medical registrar—a grade doctor—and to ensure the presence of such a registrar around the clock with sufficient supporting cardiac-trained nursing staff. The reality is that, before the loss of coronary care services at Westmorland general, a consultant would very rarely be present during the acute stages—as is the case with most other coronary care units—and that the senior house officer or registrar would manage just as well as a consultant. One only needs to look at the outstanding performance indicators from the coronary care unit in Kendal until 22 months ago to see that.

As the Minister will be aware, local geographical and territorial politics can often be just as significant as party politics. In our case, the rural catchment area for Westmorland general seems to have been squeezed out by the more urban interests of the two districts either side of us. That is despite our large and often larger population.

I quote what a senior trust representative told Kendal town councillors when the closure proposal was made. He said:

“We had argued for 10 years with our administration that acute medical services should be transferred from WGH to Lancaster. They had resisted it but when the financial crisis occurred, we saw our opportunity. We recognise that the Consultation process was defective and we argued for accurate costs to be included but the final decision was the one we wanted. That is all that matters.”

I do not have time to give full details of the flaws in the process that led to the closure of Westmorland’s emergency service. Instead, I have chosen to make an outline case for such provision to be returned. In answer to my question about cancer services on 9 June, the Prime Minister made it clear that the present Government do not follow the “one size fits all” mantra of the previous Government that big is always beautiful. I know from his visits and those of the Deputy Prime Minister to Westmorland that they are particularly supportive of our cause.

As someone who lives in the south lakes area and whose family and friends rely on local services, I simply want the safest and most appropriate emergency care for our communities and the hundreds of thousands who visit our communities each year. I ask the Minister to do all that she can to ensure that emergency services are restored to Westmorland general as a matter of urgency.

[The Parliamentary Under-Secretary of State for Health (Anne Milton)]

Thank you for calling me to speak, Mr Benton; we seem to have spent a fair bit of time here today.

I congratulate my colleague the hon. Member for Westmorland and Lonsdale (Tim Farron) on securing this debate. I know that the future of Westmorland general hospital is a matter of long-standing interest and concern to him. He spoke with passion—and some frustration, because he has clearly been fighting a long and hard campaign. As a constituency MP, I have engaged in not dissimilar exercises in connection with a community hospital and a large acute trust hospital. I possibly lost one, but won the other. I know how passionate he must feel—and how passionate his constituents feel, which is demonstrated by the size of the petition that he presented.

I know how important hospital services are to local communities, and how worrying it can be to local people when services are moved. The fact is that change has not always been well managed in the NHS. I assure my honourable colleague that the Government are determined to do these things differently, and to get local populations behind changes in the NHS. We believe that the best decisions are local and that change should be driven by local clinicians and not imposed, top-down, by politicians or decided behind closed doors by managers. That is why we introduced an immediate moratorium on new or pending service reconfigurations.

The Secretary of State for Health has made it clear that all proposed service changes must now pass four crucial tests. First, they must have the support of GP commissioners. Secondly, public and patient engagement must be strengthened; that was at the hub of my colleague’s words. Thirdly, there must be greater clarity about the clinical evidence base for any proposals—a matter also mentioned by my honourable colleague. Fourthly, proposals must take account of patient choice. As a result, the local NHS will have to make its proposals more transparent to the public, more responsive to the views of the clinical community and more firmly grounded in robust clinical evidence.

In the case brought to the House by my honourable colleague, it means that there may be new opportunities for local debate, with new clinical judgments on how services should operate. However—my colleague will be disappointed to hear me say it—this is not an opportunity to revisit reconfigurations that have already been completed. That simply is not possible. That means that the 2006 review will not be reopened, and that the decision will stand. However, I note my honourable colleague’s concerns about valuation and patient safety; the Department of Health has raised them with the primary care trust and the local NHS trust. In case I forget to say so in my concluding remarks, I know that a Health Minister will be happy to meet my honourable colleague.

I understand that following a full public consultation, Cumbria county council’s health and well-being overview and scrutiny committee approved the changes; they were not referred to the Secretary of State for review by the independent reconfiguration panel.

[Tim Farron]

The overview and scrutiny committee did indeed rubber-stamp the proposals, but its process was deemed flawed by an investigation by the independent health commissioner because it did not take any evidence from the non-trust side. It was a completely loaded investigation.

[Anne Milton]

I thank my honourable colleague for that clarification, and it highlights so well what happens when things cease to have public trust and confidence.

My honourable colleague has made the case for acute services to be reinstated at the Westmorland. The NHS trust tells me that the coronary care unit had to be closed on the grounds that it was no longer sustainable or safe. There is an increasingly difficult balance to be drawn between services that are local and accessible and those that have a significant throughput to ensure that clinical safety is maintained. A service might have been safe in the past, but that does not necessarily mean that it will be safe in the future. I understand that, on average, the service treated only three or four patients a week, and that level of throughput is simply not enough and potentially puts patients at risk.

--- Later in debate ---

[Tim Farron]

I have two quick things to say. First, will the Minister investigate what evidence there was at the time of the closure for the Westmorland general unit to be deemed less safe than the other two units that we have mentioned at Barrow and Lancaster? Secondly, will she conduct an assessment of the position with regard to the safety of patients now? In other words, what impact has the closure had on the safety of patients or visitors within the South Lakeland area?

[Anne Milton]

There are two issues here: what happened in the past and what happens in the future. The concerns that my honourable colleague has about safety in the future will be examined, and I am sure that Department of Health officials will help with that. I understand that Professor Roger Boyle, the national director for heart disease and strokes, has said that he does not believe that reopening the cardiac unit will be best for the local people, so that should be borne in mind. He feels that it would not be feasible to provide primary angioplasty for severe heart attacks at the Westmorland. He also thinks that for less severe heart attacks, Westmorland cannot provide the most appropriate care, such as early referral for intervention. However, I do recognise my honourable colleague’s legitimate concern over the use of pre-hospital thrombolysis, and over the fact that it is low in Cumbria. Clearly, more work is needed to ensure that heart attack patients in Cumbria get the best possible treatment.

I understand that the trust is listening to my honourable colleague’s concerns and that it is looking to increase the number of cardiologists from three to five across the regions. Those clinicians will be based at the Royal Lancaster infirmary and the Furness general hospital, but they will help to build extra capacity in the treatment of outpatients. That might not be enough here and now, but it is something that my honourable colleague can take away.

I understand that there has never been an accident and emergency department—whatever that means in this day and age—but I am also told by the NHS trust that there would be insufficient volume of patients going through Westmorland to sustain a full A and E department. An A and E department has to have back-up services, such as intensive care and CT scanning, to support the unit, and the Westmorland is not in a position to provide those facilities. The trust’s argument, therefore, is that it is safer for patients to access those services at Barrow or Lancaster, and I appreciate that that is fundamental to this debate and will be fundamental to ongoing discussions, because my honourable colleague believes that the opposite is the case.

My honourable colleague also mentioned travel times, and I am told that the North West Ambulance Service advises that across Cumbria, the average time for it to get to the scene is 10 minutes. He might dispute that, but that is what I have been told. The average time on scene assessing and treating a patient is 20 minutes and the average time from Kendal to Lancaster under normal driving conditions—not with blue lights—is 20 to 30 minutes. I acknowledge that patients on the far reaches of his constituency have further to travel.

[Tim Farron]

I simply reiterate my earlier point: in rural areas, the bulk of those times record the time that the first responder arrives—the ambulance probably arrives another 20 minutes later.

[Anne Milton]

And let us pay tribute to first responders; I have them in my constituency and they do a fantastic job.

[Tim Farron]

Indeed.

[Anne Milton]

It is not always about the time spent getting to the hospital, but the treatment in the first crucial half hour or so.

Provided paramedics can reach the patient quickly, they can provide treatment and stabilise them en route, which is often preferable, and then go to a hospital or an A and E department further away. However, the expertise has to be provided by the ambulance staff. “Dead on arrival” incidents would be reported, and NHS Cumbria has advised me that no such cases have been reported in the past 18 months, but the hon. Gentleman may have data that goes back further.

Unfortunately, when it comes to serving rural populations, the NHS has to balance what is safe with what is desirable. This is very tricky and it is held in the balance. There is no doubt that across the country the NHS is facing considerable challenges, and the local NHS in Cumbria is no different from any other. We made an historic decision, as a coalition Government, to protect health spending during this Parliament and to secure the front-line services that our constituents value so highly, but it is clear that local health services need to change and to become more efficient to secure their long-term future. That will not always be a smooth process; there will be tough calls to make in the future, as there have been in the past, but a clearer and more open process, led by clinicians and putting the local people firmly in the picture, will, I hope, reduce the anxiety that my honourable colleague has spoken about today. I hope that it will also build the trust that we need around such decisions. That is how we can achieve higher standards and better outcomes.

I said to my honourable colleague that I am sure that the Minister will be happy to meet him. The question is: how does my honourable colleague move forward with his constituents and how do we ensure that, even if we cannot right what has happened in the past, we move forward constructively? This is just a suggestion, but if he and local GPs formed a small informed group to work with the trust, I would hope that the local NHS organisations could take into account some of his concerns about the future of health services. What matters now is what happens in the future. I hope that they can provide the service that he wants to see.

[Tim Farron]

I am grateful to the hon. Lady for giving way so often. Would that include the possibility of the local GP community, should they so wish, moving towards something akin to the Fort William situation that I mentioned earlier?

[Anne Milton]

I thank my honourable colleague, but I am always very nervous about stepping outside my pay grade. The crucial thing now is how we and local MPs who have fought closures and reconfigurations move forward constructively; and we cannot reopen what has gone in the past. Local GPs and clinicians forming a group to work with and alongside the local primary care trust could ensure that good and improving decisions are made about NHS services.

It is not always about how close someone lives to a hospital. Across his constituency, life expectancy will vary by 10 years or more, and that has nothing to do with proximity to the hospital, but with deprivation. The issue of health care is much wider than this debate. There is an open door for my honourable colleague, so he feels that he can get the access to Ministers; I hope that will restore his trust and the trust of his local community.

Question put and agreed to.