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Accident and Emergency Services

Volume 515: debated on Tuesday 14 September 2010

It is a pleasure to serve under your chairmanship, Ms Clark. I understand that this is your first time in the Chair, and you are to be congratulated. Obviously, years of fierce political independence have finally paid off.

The subject today is accident and emergency provision. We have to accept that most TV hospital dramas are set in casualty departments, in the same way that most soap action seems to take place in pubs. That is not simply because they are eventful places, but because they are actually very varied places. Traditionally, every hospital has a casualty—an A and E—and it traditionally confronts a whole range of varied cases, from major trauma to self-referred cases of all kinds. Some people are anxious and simply need assurance, and some are anxious and genuinely need treatment. A and E departments also deal with the self-inflicted consequences of over-indulgence in legal or illegal drugs. Alcohol is, of course, regrettably an enormous source of business to A and E departments. Too often, the people who come there repeatedly do not get precisely the kind of treatment that they require and need. A and E departments also deal with simple things such as sprains, breaks and simple mishaps. They deal with mental health cases of all kinds—cases showing a greater or lesser degree of urgency.

What all those cases have in common is the factor of urgency. A patient either needs treatment urgently or urgently feels—which is not quite the same thing—that they need treatment. In some cases, regrettably, people are simply too impatient to seek treatment that they could get in good time elsewhere.

I have made three visits to casualty departments over the past three or four years. All of them have been different in kind. In one case, I had pins and needles in my left arm, which my wife persuaded me was an incipient heart attack. I went to casualty, was given a good grilling, and was gently diagnosed as having pins and needles in my arm. As for the second time, for reasons we will not go into, I had hit myself on the head with an iron bar. Again, I was simply checked out for a large bump and a haematoma, which had no lasting consequences—or none as far as I can tell. More critically, having had an accident in a car on the M1—I was not driving—I accompanied my daughter to an A and E department in Northamptonshire. In none of those cases did I receive any treatment, but each case was, in a sense, different. Treatment in an A and E department can be very different. It can vary from massive defibrillation to a gentle word of advice; from simply a conversation to a major life-saving intervention.

The bottom line is that A and E departments are everybody’s community back-stop. It is their security; knowing that there is one in their town is crucial to a lot of citizens. As what is in an A and E department varies, they are very hard to assess by any normal yardstick or benchmark. They require a whole formidable range of skills. The skills to deal with someone who has had a cardiac arrest differ markedly from those that might be required if someone wanders in in a confused or deranged state. A and E departments have tried to deal with this informally and internally by, to some extent, organising their work streams in different ways. My local A and E department in Southport used to have a colour-coding system. One would be told what colour one was, and attached to that colour was an expected waiting time. One knew where one was, in priority terms. There was—and there still may be—the expectation, and maybe the hope, that the patients, the users of the service, would appreciate that kind of prioritisation and understand what it is about. After all, nobody wants to wait for a long time for something they themselves have defined as urgent care. Unhappily, in many hospitals some of the customers—if I can use that inappropriate term—do not always feel that they ought to wait as long as they should, even when there are higher priority cases being dealt with.

Recently—this is where the trouble starts—within the NHS there has been an attempt to disaggregate work streams. There are two reasons for that. One is that it is thought that A and E departments are dealing expensively and inappropriately with all sorts of cases that could be dealt with better in other settings; or that doctors are referring cases to A and E departments in circumstances where references should be made to other facilities or alternatively dealt with by the doctors themselves. Secondly, there is a raft of very good research that shows that in the case of the most severe traumas, the most critically injured and sickest patients are better dealt with at a major trauma centre that is kitted out and has all the facilities and expertise necessary to deal with the problem. We all have to recognise that there is quite a lot of empirical research about survival rates that points in that direction.

The net effect of both those thrusts is that across the country there has been a downgrading of many A and E departments at many district general hospitals. Given that they are the community back-stop for many people, there is significant alarm attached to that. One notes, in Health questions and so on, that that is a common refrain. The situation is aggravated in many cases by the fact that the NHS, by and large, disowns any interest in transport arrangement. Having reconfigured services, it does not think too hard or too long about how people will get to those services. Superimposed on that is a degree of political manipulation of the proposed changes, because they are politically very sensitive. We have had an independent MP elected to this place purely on the back of the reconfiguration of such services.

In many cases, there is an attempt to think the matter through, and to soften the change and manage whatever changes are deemed necessary by means of the introduction of community facilities—walk-in centres, minor injuries centres and urgent care centres. That is a fine expression: urgent care centres. I think people respond positively to that. How and whether those changes happen in individual places seems to be a matter of chance, or certainly not a matter of clear planning. Across the country, we get a haphazard, patchwork system of urgent referral, if I can call it that. That is localism, if we can call it that. The Government have a responsibility here to set a standard. The public may accept that major trauma services sometimes require, even in these days of telemedicine, to be concentrated to be most effective. What they will not accept, and should not, is a longer journey for basic urgent care. That, sadly, can be what they get.

I want to emphasise that point by giving an extreme example in my constituency. In my town, as a result of a report that divided the spoils between two sites in a single hospital trust, children’s A and E facilities were taken 9 or 10 miles down the road to a smaller country town, Ormskirk. Adult A and E remained in the town and is still there. We have an odd configuration, with adult A and E and children’s A and E in two different places. The net effect of taking children’s A and E out of a town as large, and with as many children, as Southport was one of mass outrage. There were major demonstrations, huge petitions that were handed in at Downing street, and the kind of documents that eventually wash up on a Minister’s desk. People recognised that a genuine problem had been precipitated by ill-advised reconfiguration. Successive primary care trusts acknowledged the problem and endeavoured to deal with it. Southport and Formby PCT, when it still existed, endeavoured for some time to progress what it called a health village, which would have had a minor injuries unit. The PCT got £500,000 for it and was going to proceed with it, but, unfortunately, it was abolished, and the hopes of the people of Southport were, pro tem, crushed.

The new, successor PCT discovered exactly the same thing as the previous PCT—that there was a huge, yawning gap in service provision, which nobody could quite explain rationally and which needed to be addressed in some way. The new PCT made progress towards establishing a minor injuries, or walk-in, centre in Southport. The PCT involved stakeholders, as the previous PCT had done, as well as parents and various groups and political representatives in the town. We should bear it in mind that that was done to address only some of the issues precipitated by the reconfiguration.

It was absolutely unthinkable to people that a large seaside town would have to tell children who had had any kind of accident, such as falling over on the rugby field, hurting themselves in the street or whatever, to leave town in a taxi or in their mother’s car, supposing that she had one. People thought that that was wholly irrational, given the talk these days of bringing services closer to the community.

For two years, we spoke to the PCT. For two years, we had meetings. For two years, we planned the new centre. Then, a few weeks ago—to some extent, this is what precipitated my calling the debate—we suddenly found that the PCT had commissioned a report saying that the centre could not go ahead. It argued that the viability of the out-of-town, Ormskirk-based paediatric A and E required there not to be a walk-in centre in Southport. It argued that the costs were prohibitive and that what is done in many other places—such as Solihull, where two hospitals have exactly the same arrangement as Southport, but deal with the matter very differently and more sensitively—cannot be done in Southport.

As is often the case when someone needs a report to make their case, the PCT amassed a set of statistics, which have been questioned. It spoke to witnesses, all of whom were hand-picked to take a relatively adverse tone and not to be enthusiastic about the project. It presented shaky arguments, and as is often the case on such issues, it confused financial viability, which is a completely distinct, although important issue, with clinical safety, which is a different and separate issue. It did not bother to consult the local council’s overview and scrutiny committee. It spoke to GPs, but it did not consult the GP body. The result is that the public are absolutely baffled as to why we cannot have a sensitive and sensible set of clinical networks for children, based partly in Southport.

It is not just the public, but schools that are baffled. What do they do in the middle of the day if a child falls over in the school yard and someone has to take them not to a local facility, but to a facility outside town? In the past day, I have had constructive and helpful discussions with the Secretary of State for Health, and my views, far from being outrageous, strange and madly populist, are actually quite sane and rational, and it is legitimate that the PCT should take them into account.

The PCT’s report set out to answer a fundamental question, although, significantly, it failed to answer it: if a mum or grandmum finds that a child whom they are caring for on that day has fallen over and hurt themselves, and they think that an urgent attempt should be made to get the medical advice that is probably required, why the heck should they have to think through getting an expensive taxi, finding a neighbour to ask for a lift or doing something else that most people in less deprived areas do not have to do? I use the word “deprived” quite deliberately because although Southport might not be defined as generally deprived, we are deprived of a resource that is widely available elsewhere.

I hesitate to argue with clinicians, and I do not know a great deal about clinical matters, but I do know something about logic, and I am fairly confident about what I know. I am confronted here with the perverse argument that if we are to have a state-of-the-art clinical facility outside town—it is suggested that it must be there because it needs to be a specialised, full paediatric facility—that can dedicate itself to playing an important role in dealing with certain things, we cannot have run-of-the-mill care in another place to deal with the ordinary hazards of childhood life. We are told that if services are to be centralised in Ormskirk, it is necessary to have no services anywhere else. That does not follow at all, because it contradicts one of the basic premises of moving A and E services in the first place—that they should not be bogged down by, or confused with, minor injuries services and that they should be fielded closer to home.

It has been suggested that if what I am saying is the case, people should have nothing in Southport and should simply go to their local GP, but that presupposes some important things. It presupposes that every GP offers the kind of service that I have outlined, which is not the case. It also presupposes that everybody has a GP. People might or might not know this, but Southport is a seaside town, and a number of children arrive every week and every weekend simply to enjoy themselves. They do not have a GP in town. If they hurt themselves on the beach, they do not expect to be told, “I’m sorry, there’s nothing in this town for you. You have to go somewhere else.” That is an absolutely absurd scenario. Southport should provide assurance, triage and a diagnostic base for the worried mum, grandma or teacher who does not necessarily need a blue-light service, but who, in most other parts of the country, would be the sort of person to turn up in A and E.

The people of Southport are no longer uninformed about the issue; they have an intelligent grasp of what is required, but they have difficulty getting their point across to the NHS quango that disposes of the resources and commissions the facilities. The general direction in the country should not be that clinical networks are designed on the assumption that children, patients and parents will travel indefinitely—at any time, to any place—but that clinicians should not.

I do not need it spelled out to me that there are constraints on finance in this age of austerity; finance is always an issue. Equally, it is perfectly valid, particularly in paediatrics, to say that there are chronic staff shortages in various parts of the country. The lady who did the report that was so useful and helpful to my local PCT told me that the situation is so critical in paediatrics that any new facility is almost a threat to any existing facility. However, that presupposes that the provision and availability of staff, as well as demands for them, are the same right across the country. I would take some convincing that we cannot staff a modest facility in Southport and that we must sacrifice any basic care just to keep a unit down the road going.

There is a genuine need for local commissioners to think further about this issue, and, encouraged by my discussions with the Secretary of State yesterday, I am convinced that they will. I am convinced that some of the points that I have tried to get across today have got across—albeit the hard way—to local commissioners. There are, however, two important general issues, on which other Members might wish to comment, that arise from that case and from others with which I am familiar.

First, there is the general issue of standards. Where, amid all the reconfiguration that is going on across the country—we think that we understand some of the rationale behind it—is the baseline standard for urgent care that we can expect and accept in the UK? Clearly, it will vary between urban and rural populations, and with the age of populations; demographic factors will kick in. We set standards for waiting, and most of us believe that such a standard should be set, although as hon. Members will appreciate, there have been all sorts of problems with the gaming that sometimes results from that, and with the difficulties generated. We should also set a standard for access; I am afraid that we are forgetting that in all the reconfigurations across the country that have been carried out on the basis of clinical advice. Someone cannot wait for a service that is simply not there. That is one issue raised by the Southport situation, and others.

The second issue, which is also absolutely pivotal, is democratic accountability. What levers does a community, which ultimately pays for the local NHS in one form or another, have when its requests and demands persistently, and in some cases unreasonably, go unheeded? I am not calling for some type of naked populism; I can understand the concern of anyone in the NHS. We all tend to do things on the basis of what the crowd may or may not call for in all circumstances, but the NHS trusts are often confronted with a tension between how they want to deliver a service and how the population wants to receive it. That is certainly the case with paediatrics in the Southport and Formby area.

The Minister might advise me to the contrary, but I do not think that that tension will necessarily go away if GPs hold the purse strings; it may just appear in another form. All clinicians, I think, have a predilection, for a combination of personal, genuinely clinical and philanthropic reasons, for delivering any care in an optimal clinical environment, and we cannot afford that everywhere. To some extent, that will always conflict with access issues. I sometimes think that doctors’ heaven would be a massive all-capacity ward in the middle of Birmingham, with expressways joining the city to all parts of the UK in under 20 minutes. That is the implicit model behind some of the thinking that I have heard. In the real world, however, we cannot get that, but there is another way of doing things: having well-understood clinical networks with appropriate protocols. Designed in the right way, such networks can be just as safe. In their absence, we will get continual tension between communities and the local NHS on such issues.

I genuinely think that there is a democratic deficit of sorts here. If I may hark back to the subject without it being too tedious for hon. Members, who may have lost interest in the topic—I hope that they have not—a genuine tension can be almost felt in my constituency. Over the past few years, what we have had is not no expenditure but too-large Darzi clinics, which we struggle to fill; people wonder how they came about. Equally, there is something that we dearly want, and the PCT has twice let us down over it. One can stop any individual in the street in my town and hear their anger about the facilities that they would like. They are not asking for utopia; they are just asking for obvious deficiencies—in children’s services, in this case—to be corrected. I simply ask: why does this have to go on?

It is a pleasure to serve under your chairmanship for the first time, Ms Clark. I congratulate the hon. Member for Southport (Dr Pugh) on securing the debate, on what I think we all agree is an incredibly important topic. The Minister will be pleased to hear that I do not want to detain the House for too long, but I do want to question him on the provision of accident and emergency services in Hartlepool.

The Minister will no doubt recall that just before the summer recess we had an important debate on the provision of hospital services in the north-east, and I obviously focused on the University hospital of Hartlepool. I was pleased to hear the Minister say that, regarding the future of Hartlepool hospital,

“there are currently no plans to close it”.—[Official Report, 27 July 2010; Vol. 514, c. 232WH.]

That statement was very welcome, but less than 24 hours after the Minister had uttered it the local press leaked the information that the University hospital of Hartlepool accident and emergency services, in their current guise, would close. The manner in which that was communicated was not conducive to providing any reassurance to my constituents about the future of health services. This was all part of the proposed changes, which had their origins in the Momentum programme, with which the Minister will be familiar, with some provision being transferred to the new minor injuries unit—the One Life centre in the heart of town. That is very welcome, because more people in Hartlepool will be treated for a wider range of ailments closer to home, and it brings into play the notion of more community-based health services, which is encouraging because Hartlepool needs and deserves first-class community-based provision. However, as part of the proposals, some provision, particularly for the more serious type of case seen in accident and emergency, would be transferred about 13 miles away to the University hospital of North Tees.

As I listened to the hon. Member for Southport it struck me that the model of health care in his area—a two-site trust, in Southport and Ormskirk—is very similar to my situation in the North Tees and Hartlepool NHS Foundation Trust. Moving more serious cases to North Tees is very unwelcome as it is detrimental to my constituents. As I have previously mentioned to the Minister, I know that there is a balance, and often a conflict, between providing state-of-the-art specialist medical care in a centralised setting and ensuring that all communities have access to services. The hon. Member for Southport mentioned that in his opening remarks. For many of my constituents, North Tees is not easy to get to. It might appear to be only about 13 miles away, but it is a lot further away in many people’s perception, particular that of people who do not have access to a car. Car ownership in my constituency is below the national average. I therefore suggest that there would be a disproportionate reliance upon ambulance services. Is that appropriate? Is that what the Department wants? I am interested in hearing the Minister’s thoughts about the relationship between accident and emergency and ambulance services.

I understand that the North East Ambulance Service had not been informed in advance in July of the proposed change to A and E. The change would impose greater pressure on that service at a time when we need to be thinking about how we put pressure on public services, and I cannot suggest that the change would help to secure safe and effective access to accident and emergency services. I am also concerned that the proposed move will accelerate the closure of the hospital in Hartlepool, despite what the Minister said in July.

I, like the hon. Member for Southport, am no medical expert, but it seems to me, as I think it struck him, that accident and emergency services are the centrepiece of a modern district general hospital. Related and interconnected services such as emergency care, surgery, resuscitation units and cardiac response teams, link up to ensure that specialist teams work closely together, both figuratively and literally, to provide the highest-quality service for the patient. In many cases, depending on the nature of the complaint, a patient presenting at A and E will result in the use of more specialist and complex medical teams that complement what might have been done in A and E. Again, that is welcome.

As to what is proposed at the University hospital of Hartlepool, the potential loss of A and E would mean that more specialist teams and complex medical interventions would move away from Hartlepool. That would be at a time when there remains considerable confusion and uncertainty about the future of hospital services, as we outlined in the debate in July. As the Minister is no doubt aware—I imagine he will recall it well—a decision was made early in the Government’s life to cancel the funding for the proposed new hospital to serve the communities of Hartlepool, Sedgefield, Easington and Stockton. Whereas, before, the Momentum programme culminated in the opening of a new publicly-funded hospital in the borough of Hartlepool, the Government’s recent decision on funding means, as I said in the July debate, that there is a big risk of services migrating away from Hartlepool and failing to return—without the prospect of a new hospital.

As the hon. Member for Southport said, you cannot get much bigger and more symbolic than accident and emergency, in the matter of reassuring a community about health services. I hope that the Minister will provide more information. Does he share my fear that the loss of an accident and emergency service will put a question mark against the long-term viability of a modern district general hospital? I should in particular be interested in any guidance that his Department provides about the relationship between accident and emergency and related services in a modern hospital.

As I mentioned, all that I have described is taking place against a backdrop of uncertainty and confusion about the future of health services in Hartlepool, because of the Government’s decision. I am concerned in particular about the confusion that the movement of accident and emergency will produce. I welcome, and would reiterate, the comments of the hon. Member for Southport about what happens if there is an accident.

At the moment there is relative simplicity and understanding. Someone who has an accident can feel reassured that they can present themselves at Hartlepool hospital’s A and E. However, although I welcome the introduction of the new One Life centre, I think that adds confusion to the mix. If, say, a child has an accident and bumps their head—which has happened to one of my children—or if, as has also happened, someone drops a lead bar on their head or gets pins and needles in their left arm, what happens then? Where should a Hartlepool constituent go? Should it be to the One Life Centre, the University hospital of Hartlepool or the University hospital of North Tees? As I asked before, what happens when those people do not have a car? Should we rely on the ambulance service? Should we rely on NHS Direct to give the first pointer about where to go? I suspect there is considerable confusion about the future of NHS Direct. In my part of the world, the north-east of England, there is a new provision—the 111 number that is part of the County Durham and Darlington NHS Trust. However, that is not particularly close to my constituency. What will happen—when will that be rolled out?

In all that is happening there is considerable local disruption and national uncertainty. I am concerned that the new service will not bed in properly and effectively until people are fully reassured that they know where to take their loved ones in the event of an accident. I was taken by the point that the hon. Member for Southport made about schoolchildren. Where would a teacher go if an accident happened at a school in Hartlepool this morning? I am not convinced that the acute trust in Hartlepool has sufficiently clear and robust communication plans to enable it to provide reassurance. Can the Minister do anything else to assist?

I pay tribute to Councillor Stephen Akers-Belcher, who chairs Hartlepool borough council’s health scrutiny forum, which, in the summer, challenged and questioned the trust management on the issue in question. I am pleased that as a result of that intervention both minor and major injuries will continue to be seen by medical staff at the University hospital of Hartlepool. The scrutiny forum will closely evaluate how the proposed changes to A and E are managed. That is a good example of councillors holding the local NHS to account, which relates to the point that the hon. Member for Southport raised about the democratic deficit.

The fact remains that there is considerable confusion and uncertainty about the provision of health services and A and E in Hartlepool. While that persists it is not a good idea to move accident and emergency services away from Hartlepool. I should welcome the Minister’s comments, and hope he will ensure that despite the confusion and uncertainty he will provide my constituents with the best possible access to accident and emergency services.

This has been an interesting debate and I commend hon. Members on their contributions. It is clear that accident and emergency is close to all our hearts. I am particularly blessed with two very good district general hospitals—one is at Torbay and the other is the Royal Devon and Exeter hospital. I am extremely fortunate. However, there are three minor injury units in the smaller towns of Newton Abbot, Teignmouth and Dawlish. The challenge for me is in many ways an echo of the points raised by my hon. Friend the Member for Southport (Dr Pugh). Clearly, the issue is access. I am concerned to ensure that we use the minor injury units to their fullest extent. For my constituents the journey to Torbay or the Royal Devon and Exeter is quite a long one. My concerns, on which I hope the Minister will look favourably, are that we should think about making better use of the minor injury units. If we do so, we shall help the overall NHS budget very much.

I do not know how many people realise that the number of people who attend A and E is growing faster and faster. In just the past three months of this financial year, 5.49 million people have been seen at A and E. Mathematically, extending that over the year gives a figure of 22 million people visiting A and E throughout the country. That breaks last year’s record of 20.5 million. Such a figure would mean 40% of the population visiting A and E at least once, assuming that each individual who visited was responsible for only one attendance. That is a huge figure. The challenge for the Government and the country, given the current economic climate, is how we afford that. One of the issues is the number of people who inappropriately attend A and E—not through any fault of their own.

Just going through the door at an average hospital costs the NHS £100. By comparison, the average cost to go through the doors of a minor injury unit is £50. Those figures are averages, but the cost differential is significant.

The hon. Lady has mentioned the statistics and the increased number of inappropriate self-referrals. She is probably also aware, because she is extraordinarily well informed on the issue, that GPs are referring more people than hitherto to A and E. Therefore primary care—the GP setting—is not the answer. The answer is probably the minor injuries unit.

I thank the hon. Gentleman for that valuable contribution; I agree with the earlier comments that the answer is probably an appropriate network of different provision. However, we need that to be clearly signposted. That is the way forward.

The challenge for the Government and the Minister is to quantify the percentage of people who present at A and E who would be better dealt with in, for example, an MIU. People have tried to quantify that, but the figures vary wildly, from 60% to a more modest 10% to 30%, which is the latest finding of the Primary Care Foundation. Further work on that would be very worth while. However, the Minister could sensibly consider several steps now, even before that investigative work, to examine how we can manage A and E attendance more effectively. The figures show that 20% of presentations at A and E are alcohol-related. We all know that is a huge burden on the NHS and the country as a whole, because of crime and other issues. Minimum alcohol pricing and improving education in schools might make a significant difference to the Minister’s problem.

Secondly, I suggest that the Minister and his colleagues consider the availability of other services, such as dental care, in communities. Often, it is because there is not adequate NHS dental care that patients present themselves at A and E units. A and E services are cheap, they are there, and they are now. If we could fix that situation it would make a big difference. Such problems cannot be the right reason to attend A and E. Although the PCTs have tried to assist the public’s understanding of where to go for which service, it is abundantly clear that they have failed. People know about 999 and A and E, and that is where they go. We need to find a much more effective way of educating them. I commend the Minister on the commencement of the 111 service, which is excellent, if we can educate people to use it appropriately.

The Minister might also like to take into account how we give prominence to and promote MIU services. However, to do it effectively we need to ensure that across the country everyone knows what the service is and that it is consistent—for example, that opening hours are consistent. In my constituency, it depends on which MIU someone attends; if they turn up at Dawlish after 6 o’clock, the door will be closed, but that would not be the case if they turned up at Newton Abbot. It is equally bizarre that for someone who needs an X-ray, the X-ray unit is not coterminous with the MIU opening hours. Those are exactly the sort of things that put people off going to an MIU. In that regard, some steps forward would be extremely helpful.

If I may, I shall take the opportunity to refer to a couple of helpful things that my local health community is doing in my constituency. First, in Torbay hospital, local GPs attend A and E at the point of entry, so, rather than going through standard A and E routes, some patients see GPs, which reduces costs. The second good initiative in my constituency comes from our mental health practitioners recognising that, often, a stay in hospital is extended because someone has the symptoms of depression. Devon Partnership NHS Trust, which is responsible for mental health care in my constituency, has placed mental health care practitioners in hospitals to assess individuals, and, as a result, is beginning to reduce the time that individuals stay.

I am grateful to hon. Members for their contributions and to the Minister for his attention. I commend to him the idea of looking further at consistency in MIUs, how to reduce alcohol-related admissions, using mental health care practitioners to reduce the length of stay in A and E, and making other services, such as dentistry, available, as they should be, to avoid people unnecessarily going to A and E.

On alcohol-related admissions, which the hon. Lady mentioned twice, one problem that besets many A and Es is repeat customers—chronic alcoholics who appear again and again. Clearly, alcohol pricing would make little difference to them, so a linkage between A and E and other services in the community is normally required in those contexts. In many parts of the country, that linkage simply does not exist, which creates repeat custom for A and E.

Thank you, Ms Clark. This is my first time in this Chamber, and I hope I succeed as well as you will no doubt succeed in the Chair. I congratulate my hon. Friend the Member for Southport (Dr Pugh) on securing the debate.

In Burnley, we have been fighting for over three years to resolve a major problem with our A and E. I shall give a brief history of the area, which is Pennine Lancashire and includes Burnley, Pendle and Rossendale. Not many years ago, we had five hospitals. That was reduced to one, which was a very successful, well-loved and well- thought-of hospital—Burnley general. Over the past three years, it has been decimated, and the A and E has disappeared. The hospital covers an area—Burnley, Pendle and Rossendale—with a population of more than 250,000, and the A and E services have been moved to the Royal Blackburn hospital, which is brand new, built in Blackburn, and, I believe, built for the area that Blackburn covers. It is attempting in some way, shape or form to cope with the extra influx of people travelling over from Burnley.

Our A and E was changed to an urgent care centre. What an “urgent care centre” is, nobody seems to know. I certainly do not know, and when people ask me what “urgent care” means, I say, “Well, if you need it urgently and you need some care, that’s where you must turn up.” They say, “Well, what’s the difference between that and an A and E?” That debate is still going on in Burnley, and it is a question that I have asked the chief executive of the trust to answer, without much success.

This started three years ago with the “Meeting Patients’ Needs” study by Sir George Alberti, who decided that the 250,000 people in Pennine Lancashire did not need an A and E and it could be transferred comfortably to Blackburn. The vast majority of the 250,000 do not feel that they have had their needs met in one way, shape or form or even at all. Royal Blackburn hospital is constantly overwhelmed and permanently on red alert. On one occasion, it had to close the A and E due to being swamped with what I would class as patients or, as my hon. Friend the Member for Southport said, customers—

Indeed. People turning up at A and E were being either stored in ambulances or transferred to Lancaster, and, in one case, a gentleman came to me who had been transferred to Bury. On arrival in Bury, in his carpet slippers and cardigan, after taking his wife initially to the A and E unit in Burnley, he was told that she was being kept overnight and he could go home. When he questioned where he was, they said, “You’re in Bury.” He said, “I only went to Burnley, how the hell have I finished up in Bury? How do I get home? I’ve got my carpet slippers on, I’m in my cardigan and I’m 76 years old.” He was pointed to a taxi, which took him home at great expense. That is an example of what is happening with an A and E unit that was built some 35 miles away from the outskirts of Pendle and some 15 miles away from Burnley—the area that it is supposed to support. How on earth can it cope with the extra work? It cannot. If it could, it would not be on red alert permanently.

The misunderstanding over what A and E and urgent care are is a big concern, and I understand that the Government are looking into renaming urgent care in future, which may make it easier for people to understand. I accept that we do not need to go to a major A and E unit for a cut finger, a stitch or something like that, but major traumas happen. In fact, a major trauma happened in Burnley when an old lady parking her car in a car park that was less than 100 yards from the entrance to the hospital got her foot jammed in the car pedals and crashed into another car. Burnley hospital refused to treat her. The hospital entrance was less than 100 yards away; they brought out a blanket and covered her up, and sent 15 miles for an ambulance to take her to the A and E in Blackburn. That old lady said to me, “I wasn’t badly injured. All right, I was shook up, I’d got my foot jammed in the pedals and I’d banged my head. I’m sure a hospital this size—a hospital I’ve been proud of all my life in Burnley—could have treated me for something like that.” But, they sent an ambulance 15 miles to pick her up, took her to Blackburn to give her a check over and sent her home under her own steam. In this day and age, 2010, when not many years ago men were walking around on the moon, that is outrageous. It is totally unacceptable. Either the urgent care unit should advise people what it does at the hospital and if it is prepared to do it, or the whole A and E facility should be transferred back to Burnley.

Following on from that point, I have stood behind a campaign table outside Marks and Spencer every Saturday morning for more than 107 weeks. A petition of 25,000 names has called for our A and E unit to be brought back. We have the support of almost all our GPs, the people of Burnley and the borough council. When Sir George Alberti conducted a study, he was supposed to consult all the relevant people in the area. He consulted the borough council, and I sat in on the meeting as leader of that council. However, there was no consultation; we were presented with a fait accompli. It was almost as if he was saying, “We are moving the A and E to Blackburn and that is that.” When we asked him why, he said that in his view people in Burnley would be better served in Blackburn. I have to say that the hospital in Blackburn is fantastic. It is brand sparkling new, except for the A and E unit, which is an oversized portakabin that is stuck outside and not yet incorporated into the hospital. Therefore, the people of Burnley, Pendle and Rossendale have an appalling service. My hon. Friend the Member for Pendle (Andrew Stephenson) is also supporting our campaign to get the unit back to Burnley.

I am delighted to say that Burnley has a brand spanking new £30 million extension to the maternity unit, which has a birthing suite and all the related facilities, and we welcome it with open arms. Adjacent to that is a children’s ward, but that is now being closed down and moved to Blackburn, so we have all the facilities in Burnley for newborn babies but none for children. A child is classed as such from three months upwards, so if they are unwell when they are born they will only be treated in Burnley for three months. Thereafter, the parents will have to trail them to Blackburn, which is 15 miles away, and many of them, as the hon. Member for Hartlepool (Mr Wright) says, do not have cars. What happens to a young mother who has two children? Her husband or partner may be working or she may be on her own. How does she manage to take one of her children to Blackburn when she does not have transport? The hospital says that there is a minibus that runs from one hospital to the other. It is a joke.

My hon. Friend is clearly aware of the irrationality of the problem. However, he might not know that in Southport and Ormskirk, the paediatric department and the children’s A and E was moved to Ormskirk because that was where the maternity suite was based and it was felt that it was essential for the paediatric and maternity suites to go together. That is completely the opposite argument, and we are only about 40 miles away from one over in Lancashire.

My hon. Friend makes a good point. The children’s ward is moved from one town to another because that is where the maternity suite is based. In Burnley, the children’s ward is being moved to make way for a maternity suite. It is hard to make any sort of sense of how all this is configured, who has dreamed it up and what they are going to do about it. To say the least, I am confused, and I have been involved in such matters for a long time. How on earth are the people of Burnley, Pendle and Rossendale supposed to know what is going on?

The movement of the children’s ward might not be totally linked to the A and E unit, but, none the less, it is being done against the wishes of the people and the new guidelines that have been laid down by the Secretary of State. The Secretary of State makes it quite clear that the borough council, the GPs and the people of the town have to agree to such a move. Of the 66 GPs whom I wrote to, more than three quarters have replied. One is totally in favour of the proposal, but that is because he sits on the health board, three are neutral about it and the rest are vehemently against moving not only the A and E unit but the children’s ward as well. The borough council has moved a motion opposing the proposal and the people of Burnley have signed many petitions against it.

We in Burnley demand that the children’s ward not be moved. I urge the Secretary of State to put a stop to such a proposal. Having said that, the trust is totally oblivious to such objections. I have challenged the trust to stop the move, and it is almost as if it says, “We are moving it and we don’t care what anybody says.” The trust seems to think that it is more powerful than anyone, and it takes no interest in what the people, the patients and the politicians say.

The situation is a mess. I am sure that Burnley, Pendle and Rossendale are not on their own. We have already heard that Hartlepool and Southport have the same problem. I am sure that it is the same all over the country. Torbay obviously has one hospital too many. The hon. Member for Newton Abbot (Anne Marie Morris) should keep her eye on it because it may well be closed. It is critical that we solve this problem because millions of people depend on their A and E unit and children’s ward. They need the confidence to turn up to such facilities if something happens. Deciding what urgent care does is important, but we should also be more linked to the idea of smaller, proper A and E units if we do not want full-blown A and E units across the country.

It is a delight to serve under your chairwomanship, Ms Clark. I congratulate the hon. Member for Southport (Dr Pugh) on securing this important debate. I know that he has particular interests in health concerns not only in his constituency but around the country. He set the scene very clearly at the outset and described why we need good A and E facilities in this country. However, I was concerned when he talked about hitting himself on the head with an iron bar. I hope that had nothing to do with his frustrations with some of the health policies of the coalition Government.

Let me refer to the three points that were pertinent to this debate.

First, the hon. Member for Southport spoke about a patchwork system that reflected the haphazard way in which emergency services are provided. The White Paper “Equity and excellence: Liberating the NHS” says it plans to develop

“a coherent 24/7 urgent care service in every area of England that makes sense to patients when they have to make choices about their care.”

My hon. Friend the Member for Hartlepool (Mr Wright) raised the issue of local communities understanding where they can best access care. The hon. Member for Newton Abbot (Anne Marie Morris) mentioned the standardisation of services around the country. I will come back to that point later, because I have great concerns about the rest of the White Paper, which is much more about localism and ways to provide service. Such a thrust might be a problem for the particular aim that the White Paper sets out around emergency care.

Secondly, the hon. Member for Southport mentioned the need for baseline standards around waiting times, access and so on. I am again concerned with the thrust of the White Paper and that we may not have that baseline standard around the country. We have already seen the reduction in the waiting-time target in A and E from 98% to 95%, and I understand that it will be removed completely in the future.

Thirdly, the hon. Member for Southport raised the issue of democratic accountability. I have to say that I raised an eyebrow at that point because it was clear that the Liberal Democrat party had got one of its manifesto promises in the coalition agreement, which was to have directly elected members of the PCT, but just a few weeks later, the White Paper basically ripped up that section of the coalition agreement. As I understand it, democratic accountability is now to be through the scrutiny function of local authorities. Although I know that local authorities can carry out such scrutiny very well—we heard from my hon. Friend the Member for Hartlepool about the excellent scrutiny that has taken place in Hartlepool—I am concerned about how they will do it now that their budgets are being cut. To scrutinise health services will require further resources, not least because local authority members will need to be trained up. There is a difference between being able to scrutinise effectively the emptying of bins and so on and being able to scrutinise the very difficult, complicated and technical clinical health services.

I am staggered by the shadow Minister. She is a very reasonable person and I understand that she has a job to do because she is now a shadow Minister in opposition. However, I was surprised that she did not mention, let alone give any credit to, the concept of the health and wellbeing committees, because they will play a crucial role. And there is another thing that surprises me. Presumably, she was perfectly happy when local authorities took on a greater role in public health, so why should they not do so under the proposals in the White Paper?

I am a great supporter of local government and served as a local authority councillor for eight years, so I understand clearly the important role that a local authority can play in a community. However, I am saying to the Minister that effective scrutiny and the effective ability to look at what is often quite complicated work would demand a rethink about the resources that we put into local government scrutiny. If we look back over the years during which there have been scrutiny panels in local government, we find that there is a concern about the capacity of local government to scrutinise services effectively that are outside their own remit.

[Mr Charles Walker in the Chair]

I want to move on, because I want to pay tribute to my hon. Friend the Member for Hartlepool, who, as ever, is a strong advocate for health services in his locality. Importantly, he also raised the issue of NHS Direct. Over the summer, there was a lot of confusion because of the unfortunate way that announcements were made about the future of NHS Direct. So it was important that that issue was raised in the debate, because I think there is genuine concern in the community about it.

The hon. Member for Newton Abbot raised the issues of minor injuries units and the need for appropriate networks of care. The hon. Member for Burnley (Gordon Birtwistle) gave a very full history of what had happened in his community. He discussed the problem of trying to define the difference between “urgent care” and “A and E services.” However, I noted that the Secretary of State for Health has made it clear that the naming of facilities is very much an issue for the locality in which a facility is situated, so the local area needs to determine what title best fits the services that a facility provides.

The hon. Member for Burnley also raised a number of points that I wish to discuss briefly regarding the confusion that exists at the moment about reconfiguration and the current Government’s position on that issue.

I think there is genuine agreement that all changes in health services should be clinically driven and, of course, locally led. My right hon. Friend the Member for Leigh (Andy Burnham) made it clear when he was Secretary of State for Health that tough decisions would have to be made about moving services out of hospitals and into communities, where they would be closer to people’s homes, and about centralising specialist care where it made sense in terms of protecting patients’ safety. The hon. Member for Southport referred to the great deal of research on patient safety that is available and he and my hon. Friend the Member for Hartlepool said that more consideration needs to be given to the transport links that are so vital if communities are to be able to access health care facilities.

I do not wish to take very long to make my comments, because I want the Minister to respond to the particular constituency issues that have been raised today. I just want to raise more general issues regarding the concerns that exist about the Secretary of State’s announcements on reconfiguration.

Before the election, the Secretary of State made great play of touring the country and promising that A and E services would not be closed; he said that such closures would not happen under his watch. Two weeks after the election, he made an announcement at Chase Farm hospital that there would be a moratorium on service changes. The revision to the NHS operating framework 2010-11 was published on 21 June and it states:

“A moratorium is in place for future and ongoing reconfiguration proposals.”

However, several local areas have pressed ahead and made decisions to downgrade A and E services and other facilities, including the downgrading of a maternity unit in Kent, which local GPs are opposed to, and the downgrading of a maternity unit at Chase Farm hospital, where before the election the Secretary of State had said that the plans for the north central London review would be scrapped. Now it appears that those plans are being brought forward again.

Ministers in the coalition Government have made it clear that it is not their approach to intervene in health care services and reconfigurations. Curiously, however, despite the Government’s saying that strategic health authorities should not take decisions relating to service changes, on 29 July David Nicholson, the chief executive of the NHS, wrote to strategic health authorities, asking them to

“undertake an assessment of which proposals have successfully demonstrated the test and should proceed, which require further work and which, if any, should be halted. This initial assessment should have been completed by 31 October 2010.”

I just want to refer to the “test” mentioned in that letter. As I understand it from what the Secretary of State has said, it involves commissioners—the commissioners being GPs—having to reconsider whether or not they support the proposal that is being put forward. It also includes strengthening arrangements for public and patient engagement with local authorities; that is particularly referred to in the “test”. There must also be greater clarity in the clinical evidence for any reconfiguration and the need to develop and support patient choice must also be taken into account. As I understand it, that is the “test” that the coalition Government are putting forward, which has to be gone through, step by step, for any reconfiguration.

However, when we refer back to the statement on the moratorium, that is all rather confusing and contradictory.

May I help the shadow Minister by reading to her what the Secretary of State announced in May would be the guiding principles for new and current reconfigurations? He said that

“reconfigurations must have the support of GP commissioners; demonstrate strong public and patient engagement; be based on sound clinical evidence, and consider patient choice.”

I hope that helps to clear up her confusion, although I expect it will not.

I am grateful to the Minister for going through that list of criteria again. However, I think that the hon. Member for Burnley will remain confused, because in his contribution to the debate he made it very clear that local GPs overwhelmingly opposed the proposal that was being put forward in Burnley but that the primary care trust was pushing ahead with the proposal. That does not quite fit with the “test” that the coalition Government have put forward.

The actual movement of the A and E unit to Blackburn was carried out under the hon. Lady’s Government and the decision to move the children’s ward was made under her Government. I am hoping that the coalition Government will reverse the decisions that were taken under her Government to move the children’s ward, in order to fit in with what the Minister has just mentioned.

With the greatest of respect, I do wish to be political, although I do not want in any way to rewrite history. I understand very well the events that the hon. Gentleman has just set out, which happened under the last Labour Government. However, what concerns me now is that we have a coalition Government who have made contradictory statements about their plans for reconfiguration of services. The hon. Gentleman is faced with a particular issue in his constituency. At the moment, there seems to be confusion. Overwhelmingly, GPs in Burnley do not want the transfer of services to go ahead, but their feelings are being completely ignored by the PCT. I do not wish to intrude on private grief, because obviously this is a matter for the hon. Gentleman’s Government to deal with, but I just want to point out that that is an example of the contradiction that exists at the moment and the confusion that exists around the country.

The shadow Minister does not want to “intrude on private grief” and I appreciate that. I want to help her to stop digging. If she waits until I make my response to the debate and address the point made by the hon. Member for Burnley, my response might help to clarify her mind.

As always, I am very interested to hear what the Minister has to say. However, there are three specific points that I would like him to address. First, is there currently a moratorium on reconfiguration proposals, and if there is, why are local areas able to take decisions to downgrade A and E Departments?

I am very happy to let the Minister respond in full in a few moments. I am reaching the end of my comments.

Secondly, does the assessment of proposals that SHAs have been asked to carry out apply to existing schemes? Thirdly, if it is not for Ministers to intervene in service changes, why did they promise to halt closures of A and E departments and maternity departments before the general election?

I also want to say, Mr Walker, that I am delighted to serve under your chairmanship today. I am not sure if this is your first opportunity to be in the Chair in a Westminster Hall debate, but it is certainly a pleasure to see you in the Chair today.

What an unexpected pleasure it is to serve under your chairmanship, Mr Walker. It is a first for me, and I hope that there will be many such occasions in future. I congratulate the hon. Member for Southport (Dr Pugh) on securing this important debate. I will start by dealing with some general aspects, and will then discuss some of the specific issues raised by hon. Members and the Minister.

Obviously they were not happy for the country, or the hon. Lady would not be a shadow Minister now. But there we are; that is life. I pay tribute to the many members of NHS staff in the constituency of the hon. Member for Southport for all the hard work that they do to provide dedicated, committed health care to his constituents and those of other hon. Members in the neighbourhood who are served by the facilities there.

This Government were elected on a platform of reform of the national health service. Our White Paper, to which the shadow Minister alluded, sets out our plans. More than any other Government in the history of the NHS, we will devolve real power to patients, GP commissioners and all clinicians working on the front line. As the NHS becomes increasingly locally led, it will become locally accountable to local authorities and health watch groups. As the White Paper unfolds and reforms are implemented, subject to current consultations, I hope that that commitment will give some reassurance to all those hon. Members who mentioned democratic accountability. Local authorities and health and well-being committees will have a significant role, in terms of democratic accountability, in a way that primary care trusts and strategic health authorities did not.

I would be interested to know what the Government’s rationale was for removing the section in the coalition agreement that said that PCT boards would be elected. Why was that in the coalition agreement if it was to be ripped up five weeks later, and if the White Paper was to get rid of PCT boards?

As the hon. Lady will be aware, this is a coalition Government. That means merging the best practice that each party to the coalition has to offer. That is why we have adopted from the Liberal Democrat manifesto the policy of abolishing SHAs. When we unveiled our proposed reforms, which concentrate commissioning with GP commissioners and GP consortiums, because GPs are at the forefront and are closest to patients, it became clear that if we were to have proper democratic accountability with local authority involvement, the role of PCTs would be diminished to the point where it would have been a waste of resources to keep them, as their functions would be performed by other groups, such as GP consortiums and local authorities. It is a question of merging best practice to get the best solutions and provide the best health care for all our constituents.

I will, but I am relatively short of time if I am to deal with all hon. Members’ questions.

It should be said that the previous Government shied away from every chance to give a decisive voice on the construction of health services to anybody who held elected office. I promoted a private Member’s Bill that endeavoured to introduce a different form of democratic accountability, but the test of the White Paper will be whether people with a democratic mandate have a voice in deciding health services.

I am grateful for that intervention. The hon. Gentleman makes a valid point.

As we do away with politically motivated, top-down-process targets, we will focus all the NHS’s resources on what doctors and patients most want: improving health outcomes. Accident and emergency and urgent care services will be reshaped to reflect those changes in the coming years. I will outline some of our plans.

For many years, accident and emergency services have been operating under the rigid law of the four-hour wait target. How long someone waits in A and E before receiving treatment is important, of course. Not only does it affect the patient’s overall experience of care, but timely treatment generally means better and more effective treatment. However, the problem with the four-hour wait target, an incredibly blunt instrument by itself, was that it became the be-all and end-all of performance management. Such a narrow focus led to the distortion of clinical priorities. I am sure that we are all familiar with tales of hospitals admitting patients unnecessarily, solely in order to meet the target. There have even been persistent allegations that some hospitals have failed to record figures properly, undermining confidence in the whole system. I am sure that hon. Members will agree that that will not do.

From next April, we will introduce a range of more meaningful performance indicators balancing timeliness of treatment with other measures of quality, including clinical outcomes and patient experience. I trust that the shadow Minister will reflect on that. She is looking a little puzzled, because that is at variance with the shock-horror statement about targets and A and E that she made in her contribution.

Just so that we are all clear, is the Minister saying that there will still be a waiting time target for patients in A and E?

No, that is not what I said. I am sure that you were listening carefully, Mr Walker, but for the benefit of the shadow Minister, I will repeat what I said, so that there can be no misunderstanding whatever. From next April, we will introduce a range of more meaningful performance indicators balancing timeliness of treatment with other measures of quality, including clinical outcomes and patient experience. Those performance indicators are currently being drawn up by the profession and will enable doctors and nurses on the ground to deploy their greatest asset: their own professional judgment. Based on clinical advice, the Secretary of State has already reduced the threshold for meeting the four-hour target from 98% to 95%, as the shadow Minister said. The move has been widely welcomed within the medical profession.

The shadow Minister will understand that the issue is about locally led, clinically led services. The same goes for the configuration of those services. It is vital that the NHS continues to modernise and improve for patients’ benefit, but it is also vital that when that means reconfiguring local services, reconfiguration is based on sound clinical evidence, has the support of GPs, clinicians and the local community and considers patient choice. The days are over when a select group of people could meet behind closed doors to decide the future of local health services. In future, change will be led from the ground up, not from the top down.

Where local NHS organisations have already started to consider changing services, we have asked them to go back and ensure that the proposals meet the new criteria and, if they do not, to take steps to ensure that they do so before they proceed. We have asked commissioners to complete any such reviews by 31 October. However, we do not intend to ask the NHS to reopen previously concluded processes or to halt work that has passed the point of no return—that is, projects where contracts have been signed or building work has started.

The hon. Member for Southport discussed the lack of clear definitions for various services. When somebody walks through the doors of an A and E department, a walk-in centre or an emergency care centre, what exactly should they expect? What ailments or injuries are most appropriate for each setting? It is not only an issue of general confusion; it is also a matter of safety. If someone presents at a place describing itself as an accident and emergency department, but it does not have the same facilities as most A and Es, that patient could face delay and unnecessary risk.

As part of the quality, innovation, productivity and prevention programme, work on standardising urgent and emergency care is under way. Its aim is to clarify what services can be expected in various facilities. By using criteria based on clinical evidence, it should be possible to standardise those terms across the country. That is currently being done in three pilot areas: east Lancashire, Manchester and Salisbury. The conclusions should be published by the end of the year, alongside the operating framework. However, it will not state which types of service should be provided in particular areas. That decision will be made locally.

The hon. Member for Southport specifically raised the issue of children’s services in his constituency. I understand that services were reconfigured across Southport and Ormskirk hospitals in 2005. As a result of that reorganisation, emergency surgeries, including adult accident and emergency, were centralised in Southport. All children’s services, including A and E, were concentrated in Ormskirk, as the hon. Gentleman said.

I know that the hon. Gentleman has been vigorously campaigning for the development of a children’s walk-in centre for Southport for some time. Sefton primary care trust commissioned two national experts in paediatric emergency medicine to conduct an independent clinical review of that proposal. On 8 September this year, I understand that the hon. Gentleman met Mike Farrar, the chief executive of the North West strategic health authority, to raise some serious issues about the content of the report that he was shown in advance—issues such as his belief that the report mixes up issues of clinical safety with those of affordability.

The SHA has suggested that the PCT receive that report as a preliminary report, and that further work should be conducted to address the hon. Gentleman’s concerns. The final report should be completed by December. I understand that my right hon. Friend the Secretary of State fully endorsed such an approach when he met the hon. Gentleman yesterday. Although that will add a further three months to an already drawn-out process, I hope that it will provide a far stronger platform for moving forward. Such an approach will also underline the Government’s determination that decisions about local services should be taken locally and include the views of GPs and the wider community.

On the question of children’s A and E services, one important aspect of high-quality care is ensuring that a particular institution receives a sufficient volume of cases to be safe. Patients are best seen by professionals who have access to the right equipment and support services, the right specialist skills and frequent opportunities to exercise those skills. Mercifully, serious illnesses and injuries are relatively rare but, when they occur, it may be better for a patient to travel slightly further to a specialist centre where the appropriate skills are concentrated. That is why regional trauma and stroke centres have been set up and are proving such a success. Similarly, children are best seen by specialist paediatricians in a child-friendly environment. Of course, that is and remains a matter for local decision making, based on local demand for urgent care for children.

I shall turn briefly to the points raised by the hon. Member for Hartlepool (Mr Wright), who mentioned a number of issues concerning the provision of health care in the Hartlepool area. As he rightly said, we have had a number of debates on health care, and I am starting to feel extremely familiar with his constituency’s issues, although sadly I have not yet visited it. First, on the issue of NHS 111—which was, of course, inevitably picked up by the hon. Member for Kingston upon Hull North (Diana R. Johnson)—as I am sure the hon. Member for Hartlepool knows, NHS 111 is being piloted in four areas this year. We will evaluate the experiences and knowledge we gain from those pilots and roll out nationally the 111 number to replace the NHS Direct number. He will appreciate that a 111 number is more easily identifiable in everyone’s mind than the far longer 0845 number that NHS Direct uses. We will wait and see what happens on that matter.

The situation that the hon. Member for Kingston upon Hull North outlined was not quite accurate. There has been no confusion. Ironically, what my right hon. Friend the Secretary of State is doing in piloting a 111 number is simply reflecting and implementing a manifesto commitment made by the hon. Lady’s party at the last election. There are times when political parties share views and think that an idea should be experimented with. I am running out of time for my speech, but I reassure her that there is no confusion.

The hon. Member for Hartlepool also mentioned the issue of A and E and ambulance services. As he will be aware, ambulance calls are put into the category of A, B or C. Any cover from Hartlepool would be imaged under that system, and who should use what type of ambulance or transport would depend on the category that their condition, illness or injury falls into. At this stage, I believe—I shall choose my words fairly carefully, so that the hon. Gentleman does not immediately intervene and contradict me—that the A and E at Hartlepool has not yet closed. If he will allow me, I shall look into the matter a little further, because I would like to know for my own education and knowledge exactly what is going on there. If he thinks it would be helpful, I will write to him after I have looked into the matter. I hasten to add that I do so simply for my own education and knowledge, because decisions must be taken locally.

My hon. Friend the Member for Newton Abbot (Anne Marie Morris) raised some extremely important issues, not least those relating to mental health. She also mentioned a crucial matter that not only causes problems in the health sector, but gives rise to antisocial behaviour and law and order considerations: that of alcohol and alcohol-related admissions to A and E or minor injury units. I reassure her that considerable work on that is being done across Government, including in the Department of Health, because we are as concerned as she is to come up with solutions to alleviate and reduce that pressing problem, which affects all our towns and villages, particularly on a Friday and Saturday night. On the question that my hon. Friend raised about opening hours and the availability of some minor injury units at Newton Abbott, Teignmouth and Dawlish, I will make sure that her comments are drawn to the attention of the South West SHA, so that it is aware of her concerns.

The hon. Member for Burnley (Gordon Birtwistle) was courteous enough to give me advance warning of the issues that were of particular concern to him. I understand and appreciate the points he raised. I know that he has written to me and if a response has not yet been received, one will shortly be sent to him from the Under-Secretary of State for Health, my hon. Friend the Member for Guildford (Anne Milton). I must emphasise that it is not for me to reconsider the application of the new criteria with regard to the proposed reconfigurations in the hon. Gentleman’s area. That is for local people to consider. It is for GPs, the public, local authorities and local PCTs to reassess what they consider to be a viable and successful future for the services provided in Burnley and Blackburn.

The Department of Health has asked the local NHS to look at how ongoing schemes meet the new criteria, as laid down by my right hon. Friend the Secretary of State, including meeting patients’ needs. NHS North West has advised us that that work will be concluded in October 2010, and that it will be able to advise on the process and the progress of that review then.

As the hon. Member for Burnley outlined, he has done considerable work. I encourage him to share his and his constituents’ concerns again and again with NHS North West or the PCT, as is appropriate. He needs to ensure that the strong body of public feeling and opinion within his community and constituency is brought home to the relevant authorities that are considering the matter and recommending decisions on what should happen, so that they can fulfil the criteria that my right hon. Friend the Secretary of State has set out.

In conclusion, this has been an extremely helpful and useful debate. A number of very important issues have been raised by hon. Members across the divide, and by the shadow Minister, the hon. Member for Kingston upon Hull North. I know that there are a number of things that she will never accept, not least in the vision unveiled in the White Paper. However, as with all other areas of health care, on A and E—urgent care—I reassure her that the overriding principle of this coalition Government is to judge patients’ quality of care by raised outcomes, rather than through process targets. That will ensure that we can give the finest health care to all our patients.