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A and E Departments

Volume 563: debated on Tuesday 21 May 2013

(Urgent Question): To ask the Secretary of State for Health if he will make a statement on what evidence he has to show how his plans to change GP services will solve the current crisis in accident and emergency departments.

A and E departments are under great pressure, and the whole House will want to pay tribute to the thousands of doctors, nurses and health care assistants who work extraordinary hours in very challenging conditions. They are there for us when we need them, and we owe them a great debt.

More than 1 million more people visit A and E every year compared with just three years ago—those are additional numbers—and the simple fact is that if growth continues at that rate it will be unsustainable. It also means that when there are short-term pressures on the system, such as a very cold winter, teething problems with NHS 111 or bank holidays, the system cannot cope as well as it needs to and the quality of care is affected.

Let us be clear: A and Es are currently hitting the 95% target. The latest figures show that 96.3% of patients are seen within four hours, and people are waiting on average 55 minutes for treatment. However, if A and E services are to be sustainable, we need both short-term and long-term measures to address the underlying causes of the pressure they are under.

Last week, NHS England announced that it would change the basis on which tariff money for certain A and E cases is spent. For the first time, hospitals will have a say in how money is spent to alleviate demand when that money is withheld for numbers exceeding the 2009 baseline. We also need to address more fundamental issues, which is why I announced to the House on 13 May that the Government will publish in the autumn a vulnerable older people’s plan that will tackle those long-term underlying causes of pressure in our A and Es, particularly for the frail elderly who are the heart of many of the issues we face in both quality of care and service performance.

The changes the Labour Government made to the GP contract took responsibility for out-of-hours care away from GPs. [[Interruption.] Labour Members may not like to hear the facts about the consequences of those changes, but let us go through them—they asked the question. Since those changes, 90% of GPs have opted out of providing out-of-hours care, and they got a pay rise in addition. As a result of those disastrous changes to the GP contract, we have seen a significant rise in attendances at A and E—4 million more people are using A and E every year than when the contract was changed. As researchers from the university of Nottingham found, to give just one example, a reduction in out-of-hours services provided by patients’ usual family doctors is a direct cause of increased A and E attendance by children.

There are other issues too, including the lack of integration with social care, and vulnerable patients being discharged from hospital with no one co-ordinating proper health and social care to support them in their own homes. That lack of integration was something else that the previous Government failed to address over 13 long years.

Then there are the problems inside A and E departments caused by the disastrous failure of Labour’s IT contract. When people are admitted to A and E departments, the departments are unable to see their medical records, which could have an enormous impact—[Interruption.]

Order. First of all, the Secretary of State should not have to shout to be heard. Secondly, the more heckling there is, the slower progress tends to be. I want to accommodate colleagues, but as a matter both of courtesy and of practicality the Secretary of State should be heard in silence.

We will address those problems inside A and Es and the system-wide issues. It is not all about the GP contract, but that is a significant part of it, because confidence in primary care alternatives is a key driver in decisions on whether to go to A and E. We will take responsibility for sorting out those problems, but the Labour party must take responsibility for creating a number of them.

The Secretary of State could brief the newspapers last night, but he could not give a straight answer to my question today. He has not outlined his plans to change GP services.

The facts are that A and Es are under severe pressure and people are waiting hours on trolleys in corridors or in the back of queuing ambulances to be seen. Last week, a third of major A and Es missed the Government’s lowered targets—some were seriously adrift. At University Hospitals of Leicester, 78% of patients were seen within four hours. Seventy-nine per cent. of patients were seen within four hours in Portsmouth. Things have taken a more serious turn today, with news that 20 senior A and E doctors say they are unable to guarantee patient safety.

For weeks, the Opposition have warned the Secretary of State to get a grip. His only substantive response was to tour the TV studios to blame the 2004 GP contract. We today read that his answer is yet another costly NHS reorganisation, this time of GP services. Where is the evidence to support his contention that that will solve the A and E crisis? Why did he not outline his plans to the House—he has already given the news to newspapers?

This morning, the chief executive of the NHS Confederation told the Select Committee on Health that there is no link between today’s pressures on A and E and the 2004 contract, echoing expert analysis from the King’s Fund. If the GP contract is the root cause, as the Secretary of State claims, will he explain why 98% of people were seen within four hours in 2009, five years after the contract was signed? That figure has deteriorated sharply under his Government, and mainly on his watch. Major A and Es have missed the target in 33 of the 35 weeks when he has been Health Secretary. His complacency is dangerous. Is it not time he stopped blaming GPs to divert attention from a mess of the Government’s own making and addressed the real causes?

Two weeks ago, NHS England told the Secretary of State what those causes were. He needs to provide convincing answers on each. What steps is he taking to prevent the collapse of adult social care in England? What is he doing to ensure that all A and Es in England have enough doctors and nurses to provide safe care? Will he update the House on the status of his plans to cobble together a £400 million A and E crisis fund, news of which was leaked a fortnight ago? Will he halt the closure of NHS walk-in centres and personally review all planned A and E closures? What is he doing to sort out the failing 111 service? Did he not speed up implementation against official advice?

The truth is that this is a mess of the Government’s own making. It will not be solved by the Secretary of State’s spin or by blaming GPs. He has been found playing politics when he should be dealing with the real causes of today’s chaos. Faced with a real crisis, he has been found wanting. He needs to cut the spin and get a grip.

What the right hon. Gentleman says would have some credibility if he looked at the facts. Fact: under this Government, we hit the A and E target for last year. Fact: Wales, where Labour is in control, has not hit the A and E target since 2009.

The right hon. Gentleman says, “Forget Wales,” but why has he never once been prepared to condemn the appalling failures in A and E in Wales, caused by the Welsh Labour Government’s decision to cut NHS spending by 8%? What he says would have some credibility were he at least prepared to condemn what has happened in Wales, but he never does.

The right hon. Gentleman asks for the evidence, and I will tell him. Patrick Cadigan of the Royal College of Physicians says that the pressures on A and E are caused because many people assume that, after 5 pm, the lights in the NHS go out everywhere except A and E departments—a direct consequence of those disastrous 2004 changes to the contract. Nottingham university conducted an independent study, and last year’s GP patient survey found that only 58% of patients know how to contact their local out-of-hours service, 20% find it difficult to contact their out-of-hours service, and 37% feel that the service is too slow—problems that we are trying to address. Perhaps he should visit some A and E departments and talk to consultants, doctors and nurses, because they will tell him that the changes to the GP contract, which he says have nothing to do with the pressures on A and E, have had a huge and devastating impact.

He talks about taking responsibility for these problems. Let us see if he is prepared to take responsibility. Is he prepared to take responsibility for the target-at-any-cost culture in some parts of the NHS under Labour, which led to the disaster of Mid-Staffs? Is he prepared to take responsibility for the IT failures that mean that A and E departments cannot access GP records? Will he nod his head if he is prepared to take responsibility? [Interruption.] He is not prepared. Is he prepared to take responsibility—

Order. Let us get this back on track. There are two very simple points: first, those on the Opposition Front Bench should not be yelling at the Secretary of State; secondly, for the avoidance of doubt, the responsibility of the Secretary of State is to answer questions, not ask them.

Order. I have told the Secretary of State what the position is. It is not for argument or debate. His responsibility is to get on with answering in the way the House of Commons expects.

And I would always seek to do so, Mr Speaker.

Finally, the right hon. Gentleman constantly seeks to run down the performance of the NHS. Where is the recognition of the outstanding performance of the NHS under this Government: the fact that under this Government 400,000 more operations are happening every year than under Labour; the fact that the number of people waiting for more than a year for an operation has gone down from 18,000 under Labour to fewer than 1,000 under this Government; the fact that MSRA rates have been halved; and the fact that mixed-sex wards have nearly been eliminated? We will stick up for the great achievements of our NHS and we will not allow people to run it down. However, we will also tackle problems honestly and ensure that we address crises, many of which were caused by the previous Government.

Does my right hon. Friend agree that patients seeking urgent care will go to that part of the health service where the lights are on, and that the failure of the Opposition, over 13 years, to create genuinely integrated emergency care is the fruit we are now harvesting?

As ever, my right hon. Friend speaks with great wisdom. When it comes to the frail elderly, the key is to have a system that heads off problems before they arrive so that people do not find that they end up having to be rushed into A and E in the middle of the night. That can often be the very worst place for someone with advanced dementia or any condition that makes them extremely fragile and vulnerable. We need to integrate systems properly, and that did not happen under the previous Government. One of the key work streams of the vulnerable older people’s plan will be to look at barriers to integration, particularly the barriers to joint commissioning of social care and health. We intend to make good progress on that front.

Does the Secretary of State accept that when NHS Direct was operating, nurses had the professional competence to decide not to refer people to A and E, and to provide reassuring advice? They have been replaced by call handlers who, understandably, opt to send people to A and E because they have neither the professional competence nor the professional confidence to do anything else?

I agree that there have been teething problems with 111 and we are addressing those problems. [Hon. Members: “ Teething problems?”] There is laughter on the Opposition Benches. We are hitting our A and E targets at the moment, and 111 is available in more than 90% of the country. We are dealing with those teething issues, but I take on board the right hon. Gentleman’s point. The 111 service needs to be quicker at getting advice to people from a GP or a nurse. The fundamental issue with 111 is that giving the public an easy number to remember has highlighted how inaccessible GP out-of-hours services have become. We have to address that if we are to restore public confidence in 111.

If someone cannot get an appointment with their family doctor, they are undoubtedly more likely to end up in A and E, but does the Secretary of State agree that we will not increase capacity in primary care unless we address the work force shortage in general practice and broaden the skill mix of those who can see people in primary care?

I agree with my hon. Friend. Under this Government, we have 6,000 more doctors than we had under Labour, but we need more people going into general practice as well. [Interruption.] Yes, the training might have started under the Labour Government, but the funding happened under this Government, and it would not be possible if we cut the budget, which is what the Labour party still wants to do. She is right to point out those issues, however. One way of making general practice more attractive is to restore the personal link between GPs and the people on their list and a sense of personal responsibility and accountability. We need to find the right way of doing that, given the pressures on general practice at the moment, and I hope to work with her and many others to do that.

May I tell this complacent Secretary of State that in 28 out of the last 30 weeks Southampton general hospital has missed the waiting time A and E target? In the week beginning 7 April, only six out of 10 patients were seen within four hours. It is clear that this is a crisis of the whole health system. Given that in the last six months his own specialist advisers have praised the Southampton health economy for the role that primary care has played in reducing pressures on A and E, will he think again before simply blaming one group of doctors for a problem that runs right through the health system and into social care?

I am not blaming any doctors; I am blaming the Labour party for making disastrous decisions in office. We are addressing the issues that his party failed to address. If Southampton is not meeting its A and E targets, that is unacceptable. We are talking to all the hospitals struggling to meet those targets, but they all say—I am sure that people in Southampton would say this as well—that we need to look at the fundamental issues, which are barriers between the health and social care systems, poor primary care alternatives and problems inside hospitals with how A and E is handled. We are addressing all those issues.

Better co-ordination of ambulance trusts and A and E departments is essential, but it will not happen by accident. Are we not now missing the strategic health authorities, given that ambulances are being sent to units already working at full capacity?

By getting rid of the layers of bureaucracy we had with strategic health authorities and primary care trusts—a brave and important decision made by my predecessor—we have been able to invest in more front-line staff. The NHS is doing much more, in terms of the number of operations, out-patient appointments and people being seen by A and E, because we are investing in the front line, but it is the responsibility of the new clinical commissioning groups to ensure proper co-ordination, and I would expect them to do that.

The Secretary of State attributes the current crisis in A and E in part to a contract that doctors signed back in 2004 and the fact that large parts of the NHS turn off the lights at 5 pm or 6 pm, which they have done for 60 years. Is there anything for which this Government have been responsible in the NHS since 2010?

Yes, we have been responsible for a huge increase in performance, many more people being operated on, the virtual elimination of mixed-sex wards, MRSA rates being halved, more operations than ever before, more outpatient operations than ever before and more GP appointments than ever before.

I am struck by the fact that no mention has yet been made of the drivers of the reported chaos in A and E and the pressures on primary care out of hours. What of ageing? What of obesity? What of the changes in behaviour, the absence of stoicism, the increase in medical technology costs? Whatever the system that either the Government or the Opposition talk about, it will come under pressure. When will we have some reality in this Chamber about the causes of this problem, because the sooner we have, the better we will all be?

I recognise my hon. Friend’s clinical background. When I talk to clinicians in A and E wards, they tell me that the long-term drivers of the pressures they are under are an increase in the number of older people and an increase in the acuteness of the conditions of people coming through the doors. That is why at the heart of our long-term solution is a vulnerable older people’s plan that ensures we look after them with the dignity, compassion and respect they deserve.

Why does the Secretary of State not increase access to primary care during normal working hours by reintroducing the requirement on primary care services to see patients within 48 hours, as happened under the Labour Government?

That target led to many problems, as the hon. Lady well knows. She might remember, from the 2005 general election campaign, the issues of people being denied appointments for three, four or five days because GP surgeries were being paid to meet specific 48-hour appointments. That is one issue. Too often, if people call GPs for an appointment, they are told that the earliest they can have one is in two, three or four weeks, which makes them think, “What are my alternatives?” and leads them into A and E. We must think about how we can change that and alter the incentives in GP contracts so that they can give the kind of service to their lists they would like to.

Do I need to remind my right hon. Friend that the outgoing Labour Government in 2010 left a note on the desk of the Chief Secretary to the Treasury saying, “There’s no money left”? Is not the challenge the need to make the NHS work on more or less flat funding—though we are doing our best to increase it—while dealing with huge increases in demand? Is not the only answer to do more in the general practice setting, where it can be done more responsibly, more local to patients’ needs and more cheaply, in order to take the pressure off A and E services?

My hon. Friend speaks extremely wisely. We must do just that, particularly for the frail elderly, people with long-term complex conditions, because they are the people for whom an A and E department can be a bewildering place, especially if it knows nothing about them and cannot access their medical records. Prevention is far better than cure, and I agree that that is one way of doing it.

The Secretary of State advises us to visit A and E departments. Were he to visit the one in the excellent Ealing hospital in the constituency of my hon. Friend the Member for Ealing, Southall (Mr Sharma), he would see the grotesque, confusing and expensive sight of a spatchcocked urgent care centre next to an A and E department, one acting as a gateway for the other. It is confusing, divisive and expensive. Is he entirely comfortable with this concept?

The hon. Gentleman makes an important point. We have failed as an NHS to give the public confidence in there being anything between an A and E department and a GP surgery. Whether they are urgent care centres or other centres, the public do not have that confidence and do not understand their role. We need other things, besides those two extremes, and to do a better job of informing the public about how they work. That is part of the reason for reforming primary care.

May I invite my right hon. Friend to visit Frimley Park hospital, which serves his constituents and mine? I went there on Friday and saw the magnificent new A and E facilities in which it has invested. Yes, it has been under pressure in the past year or so, but it has managed and the out-of-hours service is being provided by GPs. I encourage him to come and see what a magnificent service is provided. Its excellent chief executive, Andrew Morris, raised with me the question of the tariff. Will my right hon. Friend explain a bit more his proposals to recompense hospitals such as Frimley Park, which are doing a fantastic job in A and E, for the additional burden they have had to assume?

I agree with my hon. Friend: Frimley Park is a terrific hospital and Andrew Morris a first-class chief executive. In fact, I am visiting Frimley Park in the next month and I will certainly have that discussion with him. My hon. Friend is right that one issue that A and E departments frequently raise is the tariff and the fact that they get paid only 30% of it for any A and E admissions over the 2009 baseline. That was why NHS England announced an important change a few weeks ago. Previously, hospitals had no say over how the money that is withheld from them is spent—it is meant to be used to reduce demand. We are now setting up urgent care boards, and hospitals will have a seat round the table to ensure that the money is spent in a way that reduces pressures on their A and E departments.

Can the Secretary of State say how the numbers attending A and E in south-west London will be reduced by the closure of St Helier hospital’s A and E department, which saw 80,000 people last year?

I have not seen any plans for the closure of St Helier. I know that NHS London is looking at possibilities to improve services in those areas, but, as the hon. Lady will know and should take comfort from, if a major reconfiguration is proposed and then referred to the Secretary of State by the local overview and scrutiny committee, I will not approve the change unless I am convinced that it will improve patient care.

Does my right hon. Friend agree that we could make better use of the ambulance service and that if we had more fully trained ambulance men who could assess whether a patient needed to go to hospital, we could reduce A and E admissions that way?

My hon. Friend rightly draws attention to the importance of the ambulance service, which is also feeling the pressure on A and E departments. We need to help the ambulance service to do its job better too. One thing that it always strikes me would make a huge difference to ambulance services is if staff could access the GP records of someone they were picking up on a 999 call, so that they would know that the patient was a diabetic with mild dementia and a heart condition, for instance. That kind of information can be incredibly helpful. I hope that by sorting out the IT issues with which the last Government struggled, we can help ambulance services to do that.

The Select Committee on Health heard evidence today from the College of Emergency Medicine about a 50% shortfall in trainee doctors and consultants. On average, trusts—I was going to say PCTs—spend £500,000 on locums. What does the Secretary of State intend to do about that?

We certainly intend to address A and E departments’ recruitment issues, which I recognise are one of the causes of the pressure. Over-reliance on locum doctors is not a long-term solution to improving the performance of A and E departments either, so those are both areas that we will be looking at.

The Government—Governments generally—cannot legislate to predict or control accidents or genuine emergencies, but they can direct resources. Hospital bed numbers have been cut by about 30% in the last 10 years. Does my right hon. Friend agree that it is difficult for A and E departments to function effectively if they do not have adequate bed capacity behind them?

I do agree, but what hospitals say is that the issue is not the number of beds, but the people in them who are not being properly discharged into the social care system. I was at King’s College hospital last week, where I was told that the hospital had probably two wards full of people who could be discharged into the social care system but had not been. Breaking down those barriers—something that I am afraid the last Government did not get round to doing in 13 years—will be an important priority.

The A and E department at Wolverhampton’s New Cross hospital recently saw a record 365 patients in one day. Those pressures will increase with the downgrading of Mid Staffordshire hospital. Does the Secretary of State agree that it will be deeply unfair to patients in both Wolverhampton and Staffordshire if the added burden on Wolverhampton’s New Cross A and E department is not met with increased resources from him, in terms of size and staff, to cope with the increased pressures?

We have not had the final recommendation from the special administrator appointed by Monitor for what will happen at Mid Staffordshire hospital, but we will make absolutely sure that any changes made improve patient safety and care.

Does the Secretary of State agree that the new role that GPs will play in commissioning will greatly assist the production of better community services and more integration with social care, all of which has been championed so frequently by the King’s Fund?

I completely agree with that. I pay tribute to my right hon. Friend the Member for South Cambridgeshire (Mr Lansley) for piloting those important reforms through the health service. I just hope that the Labour party, which claimed to support practice-based, clinically led commissioning, will see the error of its ways and understand that proper clinical commissioning holds the key to solving many of these problems.

One of the concerns raised with me is about the lack of commissioning of community services to help patients to be discharged from hospital, which has a knock-on effect on A and E and queuing ambulances. Is not the reality that, as health professionals tell me, the lack of community services, which is what causes the problem in A and E, is a direct result of this Government’s reorganisation?

Quite the opposite: the changes introduced by my predecessor make it possible to have truly joint commissioning between clinical commissioning groups and local authorities, which are responsible for social care. I hope that will deal precisely with the problems the hon. Gentleman talks about. That is what we have to encourage and facilitate in every way we can.

One million more patients a year are going through A and E departments and an increasing number of family doctors are progressively opting out of out-of-hours care. Why does the Secretary of State think that the King’s Fund can see the correlation but the Labour party cannot?

Because, I am afraid, the Labour party is completely failing to take responsibility for some catastrophically bad decisions that it made when it was in power. Labour Members might want to talk not only to people such as the King’s Fund, but to their own constituents, who say that traditional family doctoring is something they would like to see return.

How does the decision to close the A and E unit at King George hospital in Ilford, which was taken by the Secretary of State’s predecessor, who is sitting next to him, and confirmed by him recently, help to take the pressure off Queen’s hospital in Romford?

As the hon. Gentleman knows, the decision has been taken, but the A and E department has not been closed and will not be closed until it is clinically safe to do so.

The last Labour Government closed accident and emergency at Crawley hospital, but in the last few years the urgent treatment centre has been able to see more and more patients. Does my right hon. Friend agree that upskilling urgent treatment centres is part of the answer to the problem?

I do, and my hon. Friend is right to point out that the last Labour Government closed or downgraded 12 A and E departments. The Opposition have criticised us in the press—indeed, the shadow Minister, the hon. Member for Copeland (Mr Reed), who is sitting on the Front Bench, has criticised me for not getting on and closing more A and E departments, which is what he seems to want to happen. Every time there has been a controversial reconfiguration, Labour has opposed it all the way. I think we could expect a bit more consistency from a shadow Secretary of State who was once a Health Secretary.

About eight weeks ago, the Secretary of State made a commitment to refer the decision to close four out of nine A and E departments in north-west London. Can he tell the House why he has not kept his word?

It is a very important, complex and difficult decision, so I thought it was right to get independent advice from the Independent Reconfiguration Panel, and that is what I have done.

There is a general acknowledgement and recognition that one of the problems for A and E departments, particularly at night and on weekends and bank holidays, is people going to them who do not need to. Does my right hon. Friend think there is scope for the new clinical commissioning groups to commission primary triage at the entrance of A and E departments, so that those who need only primary care treatment are directed towards to it, and those who need A and E treatment go through to A and E?

My hon. Friend will be pleased to know that that actually happens in many places throughout the country, but we need to go even further. When it comes to the most frail, vulnerable older people, we need to commission services in a way that ensures that someone outside hospital knows what is happening with them the whole time, is accountable for their care and treatment, and can pre-empt the need to seek emergency care in the middle of the night. That will be the key to ensuring that the pressures on A and E are sustainable.

Today, the Health Committee heard that this Government’s cuts to social care were a direct cause of increased A and E attendances: patients cannot be returned home on time, and all the services that used to keep people well have been cut. This Government cut local authority budgets, resulting in £2 billion going out of adult social care. Will the Health Secretary now accept what the experts are telling us on the Health Committee: that that is the direct cause of the increased A and E attendances?

Once again, the Labour party opposes every single cut made by this Government then tries to pretend that it is serious about getting the deficit under control. On this point, I remind the hon. Lady that the NHS is giving £7.2 billion of support to the social care system for health-related needs, precisely in order to ensure that services are not compromised. Where they have been compromised, we are looking into it and we are disappointed about it, but we continue to monitor the situation and to urge local authorities to ensure that they discharge their responsibilities properly.

As my hon. Friend the Member for St Ives (Andrew George) said, we cannot divorce emergency care from the provision of acute beds. The Secretary of State mentioned the fact that an increasing number of patients with acute illnesses are going into hospital. May I urge him to look carefully at any proposals to reduce the number of acute beds anywhere in the country, because I believe that we shall need them all?

My hon. Friend makes an important point. I commend him for the extremely responsible and committed way in which he has been keeping an eye on what is happening in his local hospital. He is absolutely right to suggest that, before implementing any big reconfiguration, we need to be certain that what we are doing will improve patient care and not damage it. I will continue to ensure that that is the case.

I can assure the hon. Gentleman that many more walk-in centres would be shut if we had to cut the NHS budget, which is what the Labour party wants to do.

The issue of out-of-hours care and the additional pressure on A and E has been present in Suffolk since before the election. Just last Friday, I was in Felixstowe to meet the four patient participation groups there, and yet again out-of-hours care was identified as a real problem. I welcome the reforms that might be announced later this week, but can we ensure that patients realise that we are on their side and that we want them to be back with their family doctor?

Absolutely. It is extraordinary that in this debate in Parliament today, Labour Members have their heads in the sand about the low public confidence in out-of-hours GP care, which is a major driver of the problems in A and E departments. We are going to sort out that problem—[Interruption.] If they do not want us to, they are just going to have to watch while we do it.

I ask the Secretary of State to deplore the personal attacks that are being made on Julie Bailey, who was responsible for drawing attention to the many deficiencies in Mid Staffordshire hospital. She has suffered personal attacks in the street and has had faeces pushed through her letterbox. We should all deplore the fact that that is happening to such an important and brave whistleblower.

The right hon. Lady speaks wisely, and I completely concur with her comments. Those attacks are totally reprehensible and I condemn them utterly. Julie Bailey is a remarkable lady, and it is thanks to her that the standard of compassionate care in hospitals across the country is going to improve dramatically. We all owe her a huge debt.

Thanks must go to all the staff at Kettering general hospital’s A and E for doing their best to cope with a 12% year-on-year rise in A and E admissions, which is being driven by one of the fastest household growth rates in the country. My hon. Friend the Member for Wellingborough (Mr Bone), the hon. Member for Corby (Andy Sawford) and I have written to the Minister responsible for A and E services, as part of a cross-party campaign, to request a meeting to discuss the special circumstances that Kettering’s A and E faces. Does the Secretary of State agree that that meeting should take place at the earliest opportunity?

Of course. I have visited Kettering hospital myself and seen just how hard people are working there. They are doing a terrific job. My hon. Friend is right to say that the significant increase in attendance has been driven by changes in the local population.

The basic problem with the 111 service is the national specification of the triage system. The ambulance drivers in my constituency warned of this two years ago when the service was trialled, and last year the north-east local medical committee also told the Department of Health that the system was not working. It is the Secretary of State who has his head in the sand. Why does he not listen to the professionals on the ground?

I am listening. I have said that we have teething problems and that we want to sort them out. I am prepared to look at the whole of the 111 service to see whether it is delivering the service that the public need. However, I would say to the hon. Lady that the issues with 111 have focused public attention on the poor standard of out-of-hours care in many parts of the country. There is a particular issue of enabling people to speak out of hours to a GP who can, with their permission, look at their medical record, which is a pretty basic starting point. Until we sort that out, we will not be able to sort out the wider issue of confidence in 111.

Despite my warnings in the Chamber, this Government closed the Newark accident and emergency department, as a consequence of which there has been a 37% increase in deaths. I know that the Secretary of State is too much of a survivor ever to dare to mess with Bassetlaw A and E, but does he agree that the reconfiguration of services in London has absolutely nothing to do with the reconfiguration of services in north Nottinghamshire?

All decisions on reconfigurations have to be taken on a case-by-case basis. The really important thing is to ensure that, when we reconfigure services, we have a good alternative in place and we are able to give the public the confidence that it is in place. As the hon. Gentleman knows, we follow the four tests before any ministerial approval is given for a reconfiguration to go ahead.

Tomorrow is the 40th anniversary of the opening of the present Charing Cross hospital. The Secretary of State is welcome to come to the party, although he might be unpopular, as the A and E department there is one of the four in west London that he wishes to close. Three months ago, at Health questions, he told me that he would refer those decisions to the IRP, but he now appears to be telling my hon. Friend the Member for Ealing, Southall (Mr Sharma) that he is taking advice on whether to do that. Will he stick to his promise and make that referral for a full review?

In 2009, long after the GP contract was introduced, accident and emergency units were hitting their 98% target. The Secretary of State has reduced that target to 95%, but we are now hearing that units around the country are not even achieving that. How can that possibly be? What steps is he going to take to deal with the situation?

The Secretary of State appears to have managed to make the hon. Member for Hammersmith (Mr Slaughter) smile. The occasion should be noted.

Thank you, Mr Speaker. That is probably the nicest thing you have ever said to me. I shall dine out on it.

The answer to the question from the hon. Member for Edmonton (Mr Love) is that the changes in the 2004 GP contract are not the only cause of pressure on A and Es, but they are a significant cause. They set in train a process of declining public confidence in GP out-of-hours care, which has fuelled the growth in A and E attendances, and that growth has continued so that in the three years since 2009, attendances have gone up by more than 1 million. That is why those changes are having a significant impact on A and E services.

I recently visited the London ambulance service. When ambulance staff cannot hand over a patient to A and E, the patient is kept waiting in the ambulance. Will the Secretary of State confirm that the number of handover delays lasting more than 30 minutes has doubled to 200,000 in the past three years? Will he also update the House on when he expects that trend to be reversed?

Handover delays are unacceptable, and the short-term and longer-term measures that I am putting in place will, I hope, help to reduce them. The hon. Lady might want to talk to her own Front Benchers about this, however, because they seem to be setting their face against improving primary care as a way of reducing the pressures on A and E departments, even though that goes against the grain of what the public and the NHS want.

I support the request from the hon. Members for Kettering (Mr Hollobone) and for Wellingborough (Mr Bone) for a meeting with the Secretary of State to discuss resources for Kettering general hospital, which is in a fast-growing area. Corby has the highest birth rate in England and is one of the fastest growing towns in Europe. I urge the Secretary of State also to recognise that the issues with the 111 service are rather more than “teething problems”. Twice this year, Kettering general hospital’s A and E has had to close its doors to all patients other than those arriving by ambulance and to notify the public not to come to the unit. That is extremely worrying for my constituents.

As I said, we need to address all the problems with 111. The lack of confidence in GP out-of-hours care is one of the contributing factors to a lack of public confidence. The meeting that the hon. Gentleman mentions will be going ahead.

Eighteen months ago, Nottingham University Hospitals NHS Trust experienced a sustained increase in visits to A and E and hospital admissions, resulting in thousands of cancelled operations. The trust conducted an independent investigation to help it to understand and respond to the crisis, which had multiple causes. Will the Secretary of State confirm that the study did not conclude that poor provision by GPs or the out-of-hours service was to blame?

If I recall correctly, the study said that there were multiple causes, but it was Nottingham university that said that poor out-of-hours GP provision was responsible for an increase in paediatric A and E admissions, so Nottingham university understands this issue.

On Sunday, some of my constituents dialled 999 for an ambulance for an 83-year-old woman who had fallen in the street. They were told to ring 111, but after 15 minutes, with the operator saying he was still assessing needs and the lady still lying in the street, they abandoned the call and rang 999, when an ambulance was dispatched. Is that the norm for this service?

No, it is not the norm; it is totally unacceptable. That is why the changes we are introducing will hopefully eliminate the vast majority of those kinds of issues. No, we are not going to stand by failures such as that when they happen.

The Secretary of State seems to have decided that changing GP out-of-hours services is part of the solution to the A and E crisis. In the Public Accounts Committee a few weeks ago, we heard from clinical commissioning groups that they fear a single tender just to GPs because of the threat of legal action. We have seen that played out in Hackney, where GPs have been knocked back by the clinical commissioning group. When will the right hon. Gentleman get a grip on his Department and let the CCGs have the freedom to commission local GPs rather than fear the legal action that prevents them from doing so?

I want them to have that freedom, but they are operating under the same constraints as primary care trusts, which means having to abide by European procurement law. It is the Labour party that is against any changes in our relationship with the European Union.

Can the Secretary of State confirm how many walk-in centres have closed since May 2010? Will he accept that those closures are linked to the rise in A and E attendance?

We absolutely need better alternatives to A and E, but let me remind the hon. Lady that if we followed her party’s Front-Bench policy of cutting the NHS budget from its current levels, many more urgent and walk-in centres would have to be closed.

In Northern Ireland as in England there have been lots of problems with increasing numbers presenting at A and E. The Northern Ireland Minister of Health, Social Services and Public Safety introduced the triage system, which enabled more effective processing of patients and allowed people to get the level of care and medical attention they needed. Will the Secretary of State agree to discussions with that Northern Ireland Minister to see what can be learned from what has been done in Northern Ireland?

I always welcome discussions with the devolved Administrations to see what we can learn. Better triaging at the point of entry to A and E is certainly one of the things that makes a difference between A and E trusts that are managing to meet their targets despite very high pressures and those that are not.

I am grateful to the Secretary of State, the shadow Secretary of State and the 40 Back Benchers who contributed to the debate on the urgent question.