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NHS Emergency Care

Volume 463: debated on Tuesday 17 July 2007

It is a delight to speak under your chairmanship, Miss Begg. I am pleased to have obtained a debate on this issue as it is one of the most important things facing patients and staff in the national health service. I am delighted to welcome the new Minister, especially as this is a one-to-one debate. The huge advantage of such debates is that one gets the undivided attention of a Minister for half an hour. I am pleased that the Minister could come and I thank him very much.

Miss Begg, you and the Minister will have noticed that I am sitting bang in the middle of the Chamber. My regret about the main Chamber is that there are no seats bang in the middle so I have to sit on the Opposition side. I am sure that the Minister will have noticed that I not infrequently vote with the Government on NHS issues. I regard my job as voicing the concerns of patients and staff, both of whom I am in close touch with, to help the Government to get things right. In so many ways, they have got things right in the NHS, and I am the first to acknowledge that, but we must address the problems with emergency care.

The recent Opposition day debate on access to NHS care showed that both sides of the House recognised the problems with access to emergency care. I shall divide my contribution into two parts. First, I shall address access to emergency care. Secondly, I shall suggest a long-overdue classification of hospital emergency departments so that people will know what they will get at the end of their journey.

Access to emergency care is confusing and poorly understood, especially in areas that have lost their accident and emergency department. There are at least eight options for people who are worried about a sick child, who are sick themselves or who have a wife in the late stage of pregnancy. They can do the following: dial 999; go to an accident and emergency department—if there is one; go to a minor injuries unit; go to a walk-in centre; contact their GP, but that is only possible a third of the time because GPs are only there for a third of the hours of the week; and out of hours they can call the GP out-of-hours service or NHS Direct, or drop in to a primary care out-of-hours centre.

There are many confusing ways of accessing the service. That has been brought to light dramatically by the sad case of Penny Campbell who died of septicaemia. This week’s British Medical Journal contained a comment on that, the last paragraph of which stated:

“No one should underestimate how stressful it is to be left, as Penny Campbell was, to steer your own patient journey. Doctors can’t guarantee a good outcome but they can, and should, help patients navigate their way as safely as possible through our complex and fragmented health systems.”

I can also illustrate the point with a sad case in my own area. The parents of a seven-and-a-half-year-old boy were concerned about his intermittent, but very severe, attacks of breathlessness. They took him to the minor injuries unit because they were used to having an accident and emergency department; although we lost that department six-and-a-half years ago, people still access services inappropriately. It was 3 pm and, appropriately, they were referred from the minor injuries unit to the GP. By the time that the boy got to the GP he was much better because his problems were intermittent. The same situation occurred the next day, but out of hours. Again the family went to the minor injuries unit, which was quite wrong. They were pointed to the out-of-hours primary care centre and as there was no one there they had to phone up to make an appointment. The triage was arguably incorrect—I cannot say any more because this is under investigation by the Healthcare Commission, save that the little boy died three days later.

Where blue light accident and emergency departments have been lost, it is crucial that people understand what is in their place and how to access that. This is likely soon to be of more widespread interest, given the threats to accident and emergency departments across the country. Every potential patient, worried parent, worried husband and so on should have only two choices. If they have an accident and emergency department, they should go to it. If they do not have one, they should ring a telephone number—it should be the same number for the whole country—that will access a standardised telephone triage system.

I have recently learned that the NHS possesses exactly such a standardised, well-proven telephone triage system under the heading of NHS pathways. I tested it out in respect of that little boy who was so sadly lost. The fourth or fifth question would have said straight away that he needed to go to hospital immediately, and that would have given him his only chance.

I am sure that the Minister is aware that the system is being piloted with the North East Ambulance Service and an out-of-hours service in Croydon. Both of the trials are about to report, and the news is looking extremely good. He will be aware of the dramatic technicolour poster that NHS pathways did about the North East Ambulance Service pilot, and the extremely encouraging results that have already emerged.

The other advantage of NHS pathways is that it not only advises the patient what to do, but transmits the information to the right provider and makes the transition to the provider appropriate and rapid. My plea to the Minister is to examine NHS pathways, to consider a roll-out of the system across the country, to try to get NHS Direct to use it—we must certainly get out-of-hours triage systems to use it—and to ensure that there is one phone number, widely known across the country, that everybody uses in these circumstances.

The spin-off is that the NHS pathways triage system is designed to be used by lay people. No longer do we lock up the nurses in their triage stations; we get them out doing nursing. I guess that they would prefer to be doing that, and they should be doing so. That is the first part of my argument, and I turn to the classification of hospital emergency departments.

Everybody, including the ambulance people and the GPs, should know what their local emergency department can do and can cope with. To know that, a definite classification must exist. The first such classification that I have come across was in Northern Ireland, whose acute hospital review group reported in June 2001. Three grades were involved. There are no arguments about the top two, although there is a difficulty in that some of the schemes call them level 1 and level 2 whereas others call them level 5 and level 4.

Let us consider the top two grades of hospital emergency department for the breadth of things with which they can cope. The first one is the major trauma unit, which is currently available in major centres. There can never be more than limited numbers of those. They will cope with everything—including, specifically, major trauma, burns, chest injuries and head injuries. That is the top level—no argument about that. Nor is there any argument about the second level, which is what we know as the standard accident and emergency department. It copes with all medical and surgical emergencies except burns, head injuries, chest injuries and cardiac injuries, which have to go to the major units. Those top two levels are well agreed.

The second level is probably under threat, largely because of specialisation and medical staffing problems. That makes level 3, the middle level, very important; that is why a tremendous amount of discussion is needed. I should like to read out the description of level 3 in Northern Ireland:

“a centre serving a smaller catchment population, operating in a managed clinical network with a level two service. The range of services available in each centre will vary according to local circumstances. They would have physicians, surgeons and anaesthetists available during the day and a full A&E service.”

So far, we have gone down a slightly different route in England. What in this country are now called urgent care centres—such as those in Bishop Auckland and Hexham—have lost emergency surgery in their hospitals. Not only can they not take any surgical emergencies; they cannot take all unselected medical emergencies, although they can take a number of medical emergencies. The Royal College of Surgeons has reservations about the situation. It believes that if there are to be any medical admissions at all, there must also be full acute surgical back-up; if there is an attempt to specify the medical admissions, things may sometimes go wrong.

People wish to have as much as possible locally, and as medical emergencies are far more common than surgical emergencies, people desperately want facilities for medical emergencies near to home. Just yesterday, I was speaking to Don MacKechnie, president of the British Association for Emergency Medicine. The association too, has five tiers of emergency department. Its middle tier would be the ideal. That would keep medical admissions because there would be a 24-hour A and E service, CT scanning, critical care and adequate surgical back-up. My fear is that that may not be affordable or possible, but it is what people would like.

Recently, a lot has been said about cardiac care and stroke care. We are not yet in the ideal world of being able to offer emergency angioplasty and reboring of the arteries to everybody who has a heart attack. Until we are in that situation, it will surely be far better for paramedics to give clot-busting drugs rapidly to patients with acute heart attacks. In that way, they will get the drugs within minutes, and then go to the local hospital rather than travelling miles and miles to the nearest unit that could do the revascularisation. If reorganisation is seen as a quick fix for financial or staffing purposes, the danger is that it could go ahead before replacement facilities are ready. Such facilities must be ready before changes are made.

I have covered the top three levels. The lowest level is the minor injuries unit, led by nurses. Having lost our A and E department and got a nurse-led minor injuries unit, my area has discovered that although that unit is good for minor injuries, that is absolutely all it can cope with. That is not enough. The name is wrong; the unit has to cope with minor illnesses as well as minor injuries. The president of the British Association for Emergency Medicine agreed with that. He also agreed that the presence of a doctor in such a minor injuries unit would increase the range of patients who could be seen. That is why I am delighted that at home the primary care trust and acute hospital trust have agreed to trial a doctor at our minor injuries unit to study whether such an arrangement can be self-supporting and cut down on the people who go to the A and E department by avoiding unnecessary journeys and unnecessary admissions. That is crucial.

To conclude, there should be clear pathways for accessing emergency care and we should beware of drastic reconfigurations before replacement facilities are in place. In all reconfigurations, we should remember the needs and wishes of patients. I finish with two quotes. In 2004, Andy Black, a well known health service management consultant, wrote in the British Medical Journal:

“If the price of moving the complex emergency to an appropriate centre of expertise is that it is accompanied by another 9 or 10 patients who are not complex acute cases, another set of problems is launched.”

I commend to the Minister the Department of Health document “Keeping the NHS local”, published in 2003 and added to in 2004. At last, the document recognised that big is not always best and that patients want more, not fewer, local services. In describing the pilot sites, the document stated:

“The objective is to provide as a minimum a ‘first port of call’ (a service able to receive and provide assessment, initial treatment and transfer where necessary).”

That is indeed the minimum. Anybody requires a pathway; we talk about the patient journey. For a patient journey, a route map and a destination are required. At the moment, I contend that patients in areas that have lost A and E departments have neither a route map nor a firm idea of their destination.

I congratulate the hon. Member for Wyre Forest (Dr. Taylor) on securing this debate. I also thank him for all his work on health, which is done in a bipartisan spirit, and for his contribution to policy formation and furthering debate. Before I move on to the hon. Gentleman’s specific points, I should like to spend a moment on the national context and reflect on the transformation, in recent years, in access to both urgent and emergency care delivered by the NHS.

More and more patients in A and E departments are receiving timely access to quality care. In 2003, almost a quarter of such patients waited for more than four hours; in contrast, in the year 2006-07, more than 98 per cent. of patients were seen, diagnosed and treated within four hours of their arrival at A and E. The ambulance service and its staff also provide an excellent service day in, day out—saving lives and caring for patients.

In 2006-07, 1.3 million category A patients—those with potentially life-threatening emergencies—received a response within eight minutes. That compares with a figure of 710,000 for 2001-02. A recent patient survey showed that 98 per cent. of patients were satisfied with the ambulance service—one of the highest ratings for any NHS service. The 2006 National Audit Office report on out-of-hours care also confirmed that we are making progress towards providing good round-the-clock GP out-of-hours services. The report found that patients’ experiences of such services are generally positive: eight out of 10 patients are satisfied with the service, and six out of 10 rate the service as excellent or good.

We have also put in place national quality requirements for out-of-hours providers, setting standards for the delivery of care so that patients can be assured that their clinical needs should be consistently met. Services are being provided closer to home by GP practices, pharmacies, ambulance clinicians, community hospitals, NHS walk-in centres and minor injury units, rapid response teams and new technologies. NHS Direct provides a 24-hour information service to patients. In May of this year, it recorded its best ever performance scores for access to the phone line—how quickly a call is answered—and for clinical triage.

As the hon. Gentleman said, we should ensure that when patients need to go to hospital they should go to a facility that is best equipped to meet their needs. For some patients with particular care needs, the equipment, facilities and expertise required to deliver their care safely may be provided in a more specialist centre. As Roger Boyle, the national director of heart disease and stroke, said in his recent report:

“Going via a local A and E can add a delay that can mean it is too late for the patient to benefit from the newest drugs and procedures.”

I wholeheartedly agree with the hon. Gentleman about how important it is for people to have straightforward information, clearly communicated, about what to do in an urgent or emergency situation and to be aware of the options available. That is all the more important given the wide range of urgent and emergency care services that are now available. People have consistently told us that they want more convenient local health and social care services. In particular, they want different services more closely integrated to meet their needs.

The NHS has made progress in that respect. When people have an urgent or emergency care need, they now have a number of access routes: they can call 999 or visit an accident and emergency department, a minor injuries unit or a walk-in centre. Alternatively, they can make a same-day appointment with their GP or call NHS Direct or their local out-of-hours primary care service. The configuration of those services will vary from place to place so that they are responsive to people’s needs and take account of local circumstances. It is important that those services work closely together everywhere to provide an integrated service for the public, for example using technology to patch telephone calls through to a single assessment team.

It is important, too, that people who need to contact services by telephone need to make only one call, as far as possible. That was the hon. Gentleman’s point. They should not have to repeat basic information to different providers, and nor should they be uncertain about what number to ring. NHS Direct provides a national number that people can ring around the clock to get an assessment of the urgency of need, and works closely with other providers. Similarly, 999 is available to assess and prioritise calls and respond to emergencies.

Whichever route the patient or carer chooses to take in accessing care, they should have the urgency of their need assessed consistently and rigorously at their first point of contact with the service, and should then receive an appropriate response. I am desperately sorry about the case that the hon. Gentleman outlined that affected one of his constituents. He rightly said that it was subject to an investigation by the Healthcare Commission, so I will not make any more of that. The patient should receive an appropriate response, whether that is advice on self-care, referral for a GP appointment or an immediate emergency response, such as an ambulance being dispatched.

The hon. Gentleman is right to point to some of the promising evidence that is emerging from the piloting of the NHS pathways project in three areas. We will and must wait until we have properly evaluated those pilots, which we hope to do later this year. It would be inappropriate for me to comment further on the potential for wider use of NHS pathways, but I agree with the hon. Gentleman that the evidence so far is promising. We will keep him informed of the progress that we make as time progresses.

The hon. Gentleman also raised the need for clarity about the range of services that are provided for people to address their urgent and emergency care needs. In each local health care community, patients, staff and the public need to understand clearly what they can expect from urgent and emergency care services. Local services should be planned and delivered safely and effectively in a way that is responsive to people’s urgent and emergency care needs, but the local NHS is in the best position to understand the needs of local health care communities and can work with them and other stakeholders to plan, develop and provide services that best meet the needs of the local population. I congratulate the hon. Gentleman on the role that he has played in initiating the doctor-led unit in his local hospital. We will be watching its impact and progress with great interest.

The national review announced by the Secretary of State for Health on 4 July will seek to build on recent improvements in access to services, including emergency care. I hope that under Professor Sir Ara Darzi’s leadership a major focus of the review will be discussing and working with NHS staff to determine how the safest and best quality care can be provided. He has already made a promising start with the publication of his review of services in London, which was already in progress. The national review will seek to put the patient first and the public’s views will be very important.

As the hon. Gentleman knows from his experience, access to emergency care is an emotive issue and it will be vital to discuss with people how the NHS can provide the best possible care and what that will mean for local services. He also mentioned another sad case, that of Penny Campbell. He will know that we have issued directions to PCTs in response to that case, instructing them to review arrangements for transferring information between clinicians, which was a contributing factor in Camidoc’s failure to respond effectively to her needs. As I have said, he has a point when he says that the access to emergency and urgent care can be confusing. There will always be a slight tension between offering people choice, depending on the severity of their condition and clarity of access. We need to be clearer with people about what they should do when they have an urgent need. My officials are working on some ideas to make that simpler. He mentioned a number of such ideas, including the experience in Northern Ireland and NHS pathways.

As the hon. Gentleman says, the NHS needs to take advantage of developments in technology and medical practice. We believe that the local NHS is best placed to understand the needs of local health care communities and to work with other stakeholders to plan, develop and provide services that best meet the needs of their local population, ensuring appropriate, timely and safe access to care and ensuring that the different services that are available are clearly communicated and understood. We do not believe that there is a one-size-fits-all approach that we can impose from above.

I thank the hon. Gentleman for securing the debate. I hope that we agree that people need timely access to appropriate care when they have an urgent or emergency care need. Progress has been made, but we need to make more progress on some of the issues about clarity of access and proper diagnosis that lead on from the sad cases that he has highlighted. We are determined to do so. When patients contact an urgent or emergency care service, they need the most appropriate response from the most appropriate professional at the right time, in the right place. Of course, the way in which that happens will not be the same in every area, and those planning care will have to take into account their local populations and health needs to provide the most responsive service to meet local requirements. Making the most of opportunities and medical and technological advances is also crucial. What is important is that the NHS continues to ensure that patients receive the highest standards of patient care.

Question put and agreed to.

Adjourned accordingly at three minutes to Two o’clock.