I beg to move,
That this House is concerned about the growing pressure on Accident and Emergency (A&E) departments across the country over recent months; notes this week’s report from the King’s Fund which concludes that waiting times in A&E recently hit a nine-year high; further notes that in the Labour Government’s last year in office 98 per cent of patients were seen within four hours; believes that a combination of factors lies behind the extra pressure on hospitals but that severe cuts to social care budgets are one of the most significant causes; is further concerned that one in three hospitals in England say they do not have sufficient staffing levels to deal safely with demand on services; further notes that over 4,000 nursing posts have been lost from the NHS since May 2010 and that a recent survey by the Health Service Journal revealed that a further round of front-line clinical job losses are planned for the coming year; further believes that the Government has failed to show sufficient urgency in dealing with these problems; and calls on the Government to bring forward an urgent plan to ease pressure on hospitals by, amongst other things, re-allocating £1.2 billion of the 2012-13 Department of Health underspend to support social care in 2013-14 and 2014-15, and ensuring adequate staffing levels at every hospital in England.
Since the turn of the year, the Opposition have been warning the Government about building pressure in A and E departments, and yesterday there was confirmation of just how bad things have got. This year, waiting times in A and E hit a nine-year high, according to the King’s Fund. The pressure is not confined to A and E, however, and wherever we look we can see warning signs: hospitals operating with close to 100% bed occupancy, way beyond safe recommended levels; a treatment tent in a car park; long queues of ambulances outside A and E, double the number waiting longer than 30 minutes; a huge spike in the number of A and E diverts, where ambulances are turned away from units that cannot accept any more patients; reports of some hospitals issuing more black alerts in the past year than in the previous 10 years combined; more cancelled operations than for a decade; and a 30% increase in bed days lost to delayed discharges because care plans cannot be put in place, leaving older patients stranded on the ward and A and E unable to admit them.
The evidence is clear: this health and care system is showing serious signs of distress. In truth, A and E is the barometer of the system, and problems or blockages anywhere will soon show up in A and E as the pressure backs up. The situation requires decisive action and a comprehensive plan, both of which have been distinctly lacking in the Government’s response so far.
Today the Prime Minister complacently implied that the problems had been fixed, but for 34 of the 38 weeks this Secretary of State has been in post, major A and Es have missed the Government’s lowered A and E target. Today, six in 10 trusts are warning that next winter will be even worse. The Government’s response to date has been totally inadequate for the scale and urgency of the problems. First, they came to the House and denied there was a problem. On 15 January, the Under-Secretary of State for Health, the hon. Member for Central Suffolk and North Ipswich (Dr Poulter) stated that
“patients are being treated in a much more timely manner than under the previous Government.”—[Official Report, 15 January 2013; Vol. 556, c. 720.]
An inaccurate statement without any basis in fact.
As the pressure built, it was clear that that line would not hold, so the Secretary of State’s spin operation began. He said that the root cause of the pressure was the 2004 GP contract and changes to out-of-hours care. One must ask how the Secretary of State pushed that line with such confidence, given that a freedom of information request from his Department revealed that the first time he went to an A and E as Secretary of State was on 3 April—a full six months after he was appointed. Even then, it was the A and E within walking distance of this building. Did he just repeat back on camera what the first person he met said to him?
Throughout the early months of 2013 the NHS was going through the worst winter for a decade, yet the Secretary of State did not bother to visit any A and E department to see for himself the ambulance queues, the patients held on trolleys, or the staff stretched to breaking point. Just weeks before his first visit to A and E, he told us that hospitals were “coasting”. What an unbelievable statement. Would he have dared to say that if he had actually visited an A and E beforehand?
Does my right hon. Friend agree that one of the pressures on A and E comes from this Government’s cuts to adult social care? We all know that if old people are not given care in their own homes they are more likely to end up in hospital, yet the Government have cut more than £2.6 billion from adult social care, and more than 230,000 people are now not getting help, compared with four years ago.
My hon. Friend is absolutely right. Two-thirds of NHS finance directors have identified social care and its collapse as the single biggest driver of the pressure on A and E. The Government do not like to talk about that because of the record my hon. Friend just outlined, and I will come to that later in my remarks.
The Secretary of State visited his first A and E in April, and NHS England requested action plans only on 9 May, when hospitals had already been battling with the problem for months. It is simply not good enough. The NHS needs leadership and he has not provided it; instead, he has stuck to the spin. He continued to blame the GP contract, even when experts queued up to tell him it was not the cause of the problem. The NHS Confederation, the Royal College of General Practitioners, the King’s Fund and the Foundation Trust Network all told him that the causes lay elsewhere, but he was not listening because it did not suit his argument. When the NHS needed a Secretary of State, it was left with a spin doctor-in-chief.
That brings us to the crux of this debate and the charge that I lay directly at the Secretary of State’s door. By persisting with spin and by diverting attention elsewhere, the real causes of this crisis have been left neglected.
If the right hon. Gentleman looks at the graph of A and E attendances, he will see that the figure was pretty constant at 14 million until 2003-04, when it rose steadily to 21 million. Why does he think that there was that big rise in A and E attendances at the time of the change to the GP contract?
The spin continues, doesn’t it, Mr Deputy Speaker? Let me explain why that happened. [Interruption.] I will explain if the hon. Gentleman will listen. Perhaps he should look at the subject in more detail before he comes to this place and makes a comment like that. In 2003-04 the statistics changed, and visits to walk-in centres and minor injuries units were added to the figures. If he read the King’s Fund analysis of trends in A and E over the past decade, he would see that it says that very clearly. Perhaps the next time he comes to a debate like this he might do his homework.
In the vacuum that the Government have left, it has been left to Labour to show the leadership that the NHS desperately needs. Last week, Labour convened an A and E summit here in Parliament to refocus minds on the real underlying causes of this pressure. We wanted to give front-line staff from all over England the chance to tell us in their own words about the reality on the ground right now and to suggest practical ways in which the pressure might be relieved. Now, today, we bring this urgent debate to the House to shock the Government out of their complacency and to force them to act on what was said at the summit. There were two overriding messages that all politicians would do well to hear: first, the pressure in A and E is an issue for the whole health and care system; and secondly, there is no one simplistic, single cause but a range of complex underlying factors.
That is a laudable aim. I do not think it is going to solve the A and E crisis right here, right now, but I do not disagree with it as an aim.
Drawing on what was said at the summit, I have developed an A and E rescue plan with five practical proposals. [Interruption.] Government Members do not want to hear it. Okay, later on they can give me their plan. I am putting forward a plan and calling this debate. They are not calling this debate. Why are they not doing something to take a grip on the situation? It is no good just sitting back and saying, “Oh”—[Interruption.]
Before my right hon. Friend gets on to his plan, may I ask him a question? Given the chaos that he has described throughout the whole country—in London, ambulance queues have doubled in the past couple of years—why does he think that the Secretary of State believes it is sensible to downgrade the A and E service at Lewisham and divert tens of thousands of people to other hospitals where the ambulances are queuing all down the road?
In the preceding debate, the Government tabled an amendment of great worth answering all the points with regard to badgers, but there is no amendment for this debate. They have no answer and are not prepared to put anything on paper about how to get over this current crisis in A and E. Does that not speak volumes?
I absolutely agree with the right hon. Gentleman that there are no simple answers. Does he agree that one of the pressures that is adding to the problems in A and E is that £3 billion has been taken out of the NHS to fund a reorganisation under the Health and Social Care Act 2012 that nobody needs and nobody wants?
I agree entirely. That decision was catastrophic for the NHS. Not only did it siphon £3 billion out of the front line to pay for back-office restructuring; it took people’s eyes of the ball. When they should have been focusing on the front line and patient care, they were worrying about their jobs and which organisations they would work in. The Government were warned about this reorganisation and I will come on to that. I have new evidence, which I will put before the House today, that says that this Government were explicitly warned about the risks to A and E of proceeding with their reorganisation at a time of financial stress. It is pretty damning and I will come on to it later.
What I want to do today is achieve something for NHS staff watching this debate. Let us try to reach some agreement about the causes and the practical steps that now should be taken. First, on social care, which my hon. Friend the Member for Warrington North (Helen Jones) has mentioned, the survey of NHS financial directors says that this is the single biggest cause of the pressure. More than £1 billion has already been taken out of budgets already by this Government, and the Association of Directors of Adult Social Services says that councils are planning further spending and services cuts this year. This is simply not sustainable. It is a false economy. Social care is the preventative part of the care system. If the Government continue to hammer councils, the problem will simply end up on the doorstep of the NHS and it will get bigger and bigger. The human cost will be huge.
We heard at last week’s summit that more and more people with dementia are presenting at A and E. That is intensely sad and it is the wrong place for them to be.
Does my right hon. Friend agree that the most upsetting comment made at the summit was by the nurse at Kingston who told us of a lady with dementia who, when she is hungry or lonely, phones 999 for an ambulance and says that she has heart pain?
The room went quiet when the nurse spoke at the summit. I pay tribute to my hon. Friend for being at the summit during the parliamentary recess to hear that nurse. It was a valuable event. My hon. Friend is absolutely right: the loss of simple support in the home for people such as that woman means that they are left with no alternative but to go to A and E or the hospital as the last resort. That is the false economy that I am talking about. By ransacking council budgets to pay for their NHS spending plans, the Government have left this system with major problems that they urgently need to address. The worst thing of all is that they have left older people with no option but to end up in hospital.
I am grateful to my right hon. Friend for giving way; he is being very generous with his time. He is absolutely right: areas such as Stoke-on-Trent have had their budgets slashed and destroyed year on year under this Government. In Stoke-on-Trent, which is the third hardest hit area, the local authority is expected to spread the money it does have even more thinly across a population that is not only deprived, but ageing. The sniping and comments from those of the Government Front Bench are totally inappropriate. Does my right hon. Friend know when the Government got the NHS to write to accident and emergency departments to ask for their plans?
That is part of my point. NHS England wrote to clinical commissioning groups on 9 May. What is going on here? They were all in the chaos of reorganisation until then—no one could have received a letter, because CCGs were not in place. In the crucial period between January and March, when the NHS was under intense pressure, primary care trusts were on the way out and CCGs were not in place. As a result, the NHS was in limbo; at the precise moment that it needed grip and leadership, it was drifting. That is absolutely shocking.
As I have said repeatedly, the Government must act to shore up social care in England, which is collapsing. Our solution is for the Secretary of State to use about half of last year’s underspend in the NHS, £1.2 billion, to provide emergency support to councils over the next two years to maintain integrated, home-based support. As he knows, the Budget revealed a £2.2 billion underspend in last year’s Department of Health budget. No use was made of the budget exchange scheme. In other words, he handed that money back to the Treasury. I call on him to reconsider his decision, reopen negotiations with the Treasury and act to prevent a social care emergency.
Between 2005 and 2010, the population of over-65s grew by 730,000 and the population of over-80s—the very elderly—grew by 27%. Why did the previous Government increase the budget for adult social care by less than 1% a year to cope with that additional demand?
Oh dear, Mr Deputy Speaker. It is hard for this Government, who have decimated social care, to lecture us about it. Between 2005 and 2010, A and E waits fell. That was after the GP contract was signed. Let us have some facts. We did much to support social care and to deliver an NHS with the lowest ever waiting lists and the highest ever patient satisfaction.
The second point in our A and E rescue plan concerns safe staffing levels—another aspect that we have raised repeatedly with the Secretary of State.
I will give way to the right hon. Gentleman in a moment.
All over the country, NHS staff are saying that there are not enough people on the ward to deal safely with the pressure that they are under. The College of Emergency Medicine has warned of a “workforce crisis” in A and E and of
“a lack of sufficient numbers of middle grade doctors and Consultants in Emergency Medicine to deliver consistent quality care.”
More than 4,000 nursing posts have been lost since May 2010 and the Care Quality Commission says that one in 10 hospitals in England is understaffed. It emerged last week that the problem is set to get worse. A survey of NHS HR directors by the Health Service Journal found that 27% of trusts were planning to cut nursing jobs in the coming year, that 20% were planning to cut doctors and that one in three was not confident that they had enough staff to meet demand.
As I have said before, all parties in this House, including my own, need to learn the lessons of the failures in care at Mid Staffs and of the Francis report. The primary cause of those failures was dangerous cuts to front-line staffing. There is a clear risk that the NHS is repeating that mistake. I therefore call on the Secretary of State to intervene in the further round of job cuts and to ensure that all hospitals in England have safe staffing levels.
May I bring the right hon. Gentleman back to the interface between social care and health care? He knows that I have a lot of sympathy for the points that he made about the importance of making that interface work more smoothly than it has done for a long time. Is the House to interpret his remark that an additional £1.2 billion ought to be made available for social care as a spending commitment that has the consent of the shadow Chancellor, on the day when the Labour party has said that it will not make good the child benefit changes that it opposed earlier in the Parliament?
It is important for me to answer the Chairman of the Health Committee. Those of us who are in the club of former Secretaries of State understand that the health and social care systems are interconnected and must be seen as one system, because the failure of social care lands on the doorstep of the NHS.
To answer the right hon. Gentleman’s point directly, the money that I was talking about would come from the underspend. It is part of the allocated budget that his Government gave to the Department of Health for 2012-13. The Department did not spend the whole budget so there was a £2.2 billion underspend. As he knows, the practice has been that Departments can take forward that resource to meet new pressures in later years. I am asking the Secretary of State please to ask for access to that money to relieve the pressure on social care. Simply handing it back to the Treasury when there is an A and E crisis and social care is collapsing is not good enough.
The third point I want to address is out-of-hours advice and the introduction of the 111 service. Last week’s summit heard worrying evidence that the problems of 111 are not just teething problems, as the Secretary of State has claimed. We were told that the problems were more structural and were a result of how 111 has been set up—a feature of the cost-driven contracts that have replaced the successful and trusted NHS Direct. Contracts have gone to the lowest bidder, and they are saving money by having inexperienced call handlers working to a computer algorithm that too often results in the advice “Go to A and E”. There has also been a huge reduction in nurse-led call back, which was the norm with NHS Direct.
Does my right hon. Friend know that we had a useful debate on this subject in Westminster Hall this morning, when I made the point that the dropping back from clinician-led triage has caused a problem that the chief executive of my local hospital told me about—that falling back on computer and non-clinician advice has led to patients being brought into the emergency departments when they were actually on end-of-life pathways and should have community input?
That shows the human cost of the failure that we have seen in recent weeks; my hon. Friend has identified yet another aspect of it.
There has been a huge reduction in nurse-led call back, so inexpert advice is being to people who should probably have other options put to them. An internal graph produced by NHS Direct shows that under the old 0845 NHS Direct service, about 60% of calls received a nurse call back; under 111, that has now dropped to between 17% and 19%. What is happening to these people? They are getting poor advice, so they are frightened and are going to A and E. What is this Secretary of State doing about it? Absolutely nothing.
The Public Accounts Committee recently heard evidence about out-of-hours services in Cornwall. The bad experiences there showed that a lot of cost shunting was going on. If there was even a risk of taking somebody on through the GPs on call, it was cheaper and easier for that service to shunt the costs to the NHS through for ambulance services. Does my right hon. Friend agree that that is a complete waste of money and that it underlines the shambles that he has just described?
I agree that there is a false economy here. The picture is repeated. The Government go for these privatised contracts, such as with 111, at the lowest cost, resulting in a drop in standards and less clinical support. What happens? People then turn up at A and E. What happens when social care is cut? People turn up at A and E. What happens when NHS walk-in centres are closed? People end up at A and E. This has serious implications. Across England, 22 serious incidents, including three deaths, are being investigated in connection with NHS 111, and we know that one in five calls is abandoned. This service is failing; it needs urgent action to tackle these problems.
With the Serco contract for out-of-hours GP services in Cornwall having been referred to the Care Quality Commission, the manipulation of the data, falsely representing the outcomes of the service, has been identified. It is worth reminding the right hon. Gentleman that this was set up under a contract that resulted from decisions made when he was in government.
I remember debating that with the hon. Gentleman when I was the Secretary of State. Those problems rightly needed to be addressed, and the particular issue he raises today should be investigated. I hope, however, that he will also understand the problem that I am describing to the House. If we go down the path of fragmenting services—if we take a successful national service such as NHS Direct, for example, which was trusted by the public, and then break it up into a patchwork of fragmented, some privatised, services—this sort of chaos will be the result.
A report has emerged this afternoon, showing that the viability of NHS Direct is in serious question. The headline states, “Leaked report casts doubt over NHS Direct’s ‘overall viability’ in the wake of NHS 111 failings”. This is a warning that NHS Direct may well go down altogether. What an indictment that would be of this Government’s mismanagement.
I entirely agree, and I shall say more about that issue shortly.
Let me return to the subject of the 111 service. Will the Secretary of State review the contracts with the aim of negotiating changes so that more calls can be handled by nurses? The use of the computer algorithm should be reviewed as a matter of urgency, and the full roll-out of 111 should be delayed until the problems have been solved.
There are more general questions to be asked about the scale and pace of NHS privatisation. NHS Direct offers an illustration of what happens when services are broken up. Those who attended last week’s summit heard that in some areas there had been a huge increase in the provision of 999 ambulances by private companies. It was said that on a single day in Yorkshire, 50% of 999 calls had been responded to by private operators. I think that the public would be surprised to know that. It shows that there is no part of our NHS that cannot be put up for sale by this Government.
Is the Secretary of State satisfied that those private crews are appropriately trained and have the right equipment? Is there not a danger that because contractors are operating in isolation from the rest of the system, they will all too often simply transport people to A and E? Does the Secretary of State envisage any limits to private 999 services? Given that the issue raises fundamental questions about emergency services, should there not be a debate about it before this goes any further?
Fourthly—I come now to the point raised by my hon. Friend the Member for Harrow West (Mr Thomas)—there is good evidence to show that NHS walk-in centres have diverted pressure from A and E units. In 2010-11, there were about 2.5 million visits to such centres from people who might otherwise have gone to A and E. Analysis by the House of Commons Library shows that 26 of them closed in the last year alone, and that the number is down by a quarter. The Government have let that happen, but at least Monitor has intervened and set up a review of the loss of walk-in centres. Will the Secretary of State halt all further closures while the review is taking place?
That brings me to my fifth and final point, which concerns A and E closures and downgrades. At least 25 A and E units—one in 10—are under threat or have recently closed. The trouble with these plans is that they were drawn up in a different context, when A and E was not under the pressure that it is under today. Let me say this to the Secretary of State: if a clinical case can be made in support of closures—if there is evidence that lives can be saved—the Opposition will not oppose the plans. However, we cannot accept the pushing through of proposals that have not taken enough account of the latest evidence, and cannot show that extra pressure can be safely absorbed by neighbouring units. That is important, because the public will rightly ask this simple question: how can it make sense to close A and Es in the middle of an A and E crisis? To reassure people, will the Secretary of State personally review all the ongoing A and E closure or downgrade proposals on a case-by-case basis, in the light of the very latest evidence of pressure in the local health economy?
What my right hon. Friend has been saying will be music to the ears of people in west London, where four A and E units are slated for closure. All of them are coping with dreadful circumstances. Will my right hon. Friend—and perhaps also the hon. Member for Enfield North (Nick de Bois), who seems to share his view—have a word with my local Conservatives, who are supporting all those closures?
I think that everyone needs to consider their position in the light of the evidence that is emerging about pressure on A and E, particularly in London. I pay tribute to the excellent and determined campaign run by my hon. Friend, and I noted what was said yesterday by the hon. Member for Enfield North. Perhaps one of the consequences of today’s debate will be agreement across the Floor of the House to delay any closures pending a personal review of the evidence by the Secretary of State.
As my right hon. Friend will know, my local A and E unit at Trafford general hospital is one of the 30-odd units that are scheduled for downgrading. Meanwhile, it is more than 30 weeks since the two nearest A and E units, at Central and South Manchester hospitals, failed to meet the 95% performance target last September. Does my right hon. Friend agree that the Secretary of State should also publish advice that he has received from the Independent Reconfiguration Panel which will inform his decisions, so that we can determine whether the latest pressures have been taken into account?
I think that full openness about these decisions is essential in the current context. I know that the panel’s report is with the Secretary of State, and I think he owes it to local Members of Parliament to be open about its conclusions and the evidence on which they were based. That is why I ask him to review every proposed A and E closure personally, and to give a guarantee to communities such as that represented by my hon. Friend that no changes will be made unless he is personally satisfied that it is safe to make them.
In conclusion, this is a crisis that could have been avoided. For the last three years the NHS has been struggling with the toxic medicine of budget cuts and top-down reorganisation. All the focus should have been on the front line, but instead the Government siphoned £3 billion out of it to pay for a back-office reorganisation that no one wanted and no one voted for—a reorganisation that has placed the NHS on a fast track to fragmentation and privatisation.
But it is worse than that. The Government’s own risk registers, which they refused to publish during the passage of the Health and Social Care Act 2012, warned them of the consequences of pushing ahead with a reorganisation when the NHS was facing great financial stress:
“The consequences could be compromised clinical care and patient safety, the failure of the 95% operational standard for A&E wait and a concomitant impact on other trust services”.
So they knew the risks they were taking when they reorganised the NHS at a time of financial stress; they were warned about this A and E crisis, but ploughed on regardless. It is the height of irresponsibility. No wonder they wanted to keep the risk registers secret. But with the looming cuts to jobs and social care, the problems in A and E will get worse, not better, if no action is taken on the points I have outlined today.
We have given the Secretary of State a practical plan, and he either needs to accept it or put one forward of his own. Right now, his complacency is one of the biggest dangers facing the NHS. He has failed to act on warnings about the collapse of social care. He has sat on his hands while front-line jobs are cut in their thousands. He has presided over the disastrous 111 service. He has closed NHS walk-in centres and downgraded A and Es without a convincing clinical case. It is no good his standing up today and blaming everyone else: this is a mess of his making—his first real test as Secretary of State and he has been found badly wanting. People want answers and action, and he needs to start providing them right now.
What we have heard today will rank as one of the poorest speeches ever given by an Opposition on the NHS. [Interruption.] I predict—[Interruption.]
Order. [Interruption.] Mr Karl Turner, thank you for your advice, but we can manage without it today. I make this appeal to both sides: I want to hear what the Secretary of State has to say, just as I wanted to hear what the Opposition had to say.
Thank you, Mr Deputy Speaker.
I repeat: it was one of the poorest speeches ever given by an Opposition on the NHS, and I predict that the right hon. Member for Leigh (Andy Burnham) will bitterly regret choosing to make an issue of A and E pressures, because the root causes of the problem have Labour’s fingerprints all over them.
The right hon. Gentleman was right on one thing, however: there is complacency on this issue—not from the Government, who have been gripping it right from the start, but rather from Labour, which still does not understand why things went so badly wrong in the NHS on its watch.
Labour’s narrative has, I am afraid, a single political purpose at its heart: to undermine public confidence in one of our greatest institutions—an institution which, in challenging circumstances, is performing extremely well for the millions of vulnerable people who depend on it day in, day out.
Labour’s story today is a totally irresponsible misrepresentation of reality. One million more people are now going through A and Es every year than in 2010, which creates a lot of pressure, so how are A and E departments actually performing? The latest figures show performance, against the 95% target, of 96.7%. The week before it was 96.5%, then before that 96.3%, 96.6% and 95.6%. Yes, we had a difficult winter and a cold Easter, and I will come to the causes of the problems we had then, but, thanks to the hard work of NHS doctors and nurses, our A and E departments are performing extremely well.
My right hon. Friend should know that my constituents welcome his decision to refer to an independent review the plans to close the four A and Es closest to my constituency. Does he agree that the review will need to look carefully at whether due consideration was given to the impact of those four closures on the neighbouring hospitals and their A and E departments?
I absolutely agree with my hon. Friend that the impact on neighbouring A and Es in all reconfiguration decisions is extremely important, and I will not authorise any changes in service provision unless I am satisfied that they will be consistent with improved patient safety.
I will make some progress and then give way. I want to ask why the Opposition have chosen to call this debate. I am afraid it is nothing less than a smokescreen, because their objective is to try to dress up the pressures on A and E as a short-term crisis when, as every A and E department in the country will tell us, to deal with the pressures we need to address long-term structural problems that the previous Government either ignored or made worse.
May we talk about one of the pressures on A and E, which is the pressure of social care? I hope that the Secretary of State will accept that significant cuts have been made in social care under this Government and that the role of social care is crucial in keeping people in their homes in the first place and in returning them to their homes after they have been in hospital. As a result of those cuts, it is very difficult for social care to perform that role. Will he examine the suggestion by my right hon. Friend the Member for Leigh (Andy Burnham) to use the underspend from the Department of Health to support social care to perform its essential role?
I will come to that suggestion, but I agree with the hon. Gentleman. If we are going to deal with bed blocking, which is one of the root causes of the problems that many A and E departments talk about, we have to have better integration between the health and social care systems—that is essential. I say to him that the problem of the underfunding of social care did not start in 2010; as my hon. Friend the Member for Stourbridge (Margot James) said, it is a problem that goes back many years, and the failure to integrate health and social care was a failure that happened over 13 long Labour years.
I am going to make some progress and then I will give way.
There is something else that the Labour party does not want the public to notice and it is another elephant in the room: the NHS is actually doing better under the coalition than it ever did under Labour. Let no one forget the NHS we had in 2010: no cancer drugs fund for the 26,000 people who now benefit from it; 400,000 fewer operations every year; double the number of MRSA infections; and 18 times more people waiting for more than a year for their operation.
I am going to make some progress. The right hon. Member for Leigh talked about grip. There is one place where grip is badly lacking. Labour does not like to hear about this because it is Labour-run Wales, where, as the Prime Minister said this morning, the A and E target has not been met since 2009. It is where performance—[Interruption.] I know that Labour Members do not want to hear this, but I suggest they listen to it, because performance in Wales—[Interruption.] Let me finish making the point. Performance was worse in Wales than in England for every one of the weeks that we missed our A and E target this winter. If the right hon. Gentleman really cared about patients, he would be condemning what is happening in Wales.
I will make my point and then I will give way. Labour Members need to hear about what is happening in Wales, because Labour runs the NHS in Wales. One patient in Wales had a cardiac arrest—[Interruption.] I know that this is difficult for Labour Members, but they need to hear about what is happening in Labour-run Wales. One patient had a—
I will give way to the shadow Health Secretary in a minute. One patient there had a cardiac arrest in the eye-examination room as there was no room in the resuscitation bay, and 24 to 36-hour waits for beds are now common in Wales. One patient spent a full three days in a Welsh emergency department. So let me give him a chance finally to condemn what is happening in Wales.
People watching this debate will be wondering why the Secretary of State is talking about something that is not his responsibility; nor is it mine. He is not responsible for the NHS in Wales; nor am I. I have put to him today serious questions about the NHS in England right now. He is the Secretary of State for the NHS in England, so will he now address the questions I put to him?
Order. We want a little more calm. Mr David, you are getting far too excited. It is not good for you and it is not good for the Chamber—[Interruption.] Order. I do not want you to repeat your point. I have just explained to you that I need you to be a little calmer. It is up to the Secretary of State whether he wishes to give way and at the moment he is not doing so. It is his choice and shouting will not make any difference whatsoever.
I will give way to the hon. Gentleman, if he will just take his place for a moment while I make my point. I will also give way to my hon. Friend the Member for Enfield North (Nick de Bois)—[Interruption.] I will reflect on whether I want to give way to the hon. Member for Rhondda (Chris Bryant), but I will certainly give way to the hon. Member for Caerphilly (Wayne David).
What is happening in Wales is directly relevant to what is happening in England, because in England the NHS budget has increased in real terms and NHS spending has increased in real terms. If we did not increase them both, that would mean fewer doctors, fewer nurses and longer waits for operations—[Interruption.] The shadow Secretary of State shouts from a sedentary position that the NHS—
On a point of order, Mr Deputy Speaker. The Secretary of State has just said at the Dispatch Box that the budget for the NHS has increased in real terms. In December, I referred the Secretary of State’s comments to the UK Statistics Authority and I received a letter back saying that they were incorrect. Will you ask the Secretary of State to correct the parliamentary record and ensure that when the statistics commissioner makes a ruling it is adhered to by the Secretary of State?
I thought that the shadow Health Secretary might try to do that, so let me give him the figures. I have the figures provided by the Department of Health finance department, based on the latest GDP deflators, as published at the Budget. Spending in the NHS—not the budget—in 2009-10 was £99.7 billion and for 2012-13 it is forecast to be £106.6 billion. That is a cash increase of £6.9 billion and a real-terms increase of £0.6 billion, so there is a real-terms increase in the NHS budget. The shadow Secretary of State does not agree with the real-terms increase of £600 million in the NHS today; there would be a Labour cut in NHS spending and I suggest that he might want to correct the record, as I am afraid he has got this wrong.
My right hon. Friend knows, as his predecessor does and as the Prime Minister does, of my consistent opposition to the downgrading of Chase Farm hospital. Does he agree with me that it is utterly inacceptable for the hon. Member for Hammersmith (Mr Slaughter), who is no longer in his place, to suggest otherwise in this Chamber?
What Labour did in Wales was cut the NHS budget by 8% and that is why that Government have not met their A and E targets since 2009. Those on the Labour Front Bench in England want to cut the NHS budget here. That would not help pressures on A and E; it would make them a great deal worse.
I shall make some progress, because this gets even worse for Labour.
The shadow Secretary of State wrote to me at the weekend, asking me to relieve pressure on A and E by using the health underspend to put extra money into social care. There is a way of releasing resources into social care, but it is not that, because the underspend he talks of sits largely with NHS trusts and clinical commissioning groups, which are allowed to keep their underspends and roll them over to subsequent years. If we took away that money and put it into social care, we would therefore have to take it away from hospitals, where it is needed most to help tackle pressures in A and E and other places.
Let us look at some of the hospitals that would lose money under Labour’s plans. Wigan and Leigh NHS Foundation Trust, in the right hon. Gentleman’s own constituency, had a £4 million underspend in 2012-13. It would be prevented from using that money to reduce A and E pressures, as would the Royal Cornwall, the Royal United hospital Bath, Nottingham University hospitals—
I am going to make some progress. The Royal Wolverhampton, East Lancashire, Royal Liverpool and Broadgreen, North Bristol, Coventry and many other hospitals would also be prevented from using the money. So Labour’s solution to the A and E crisis is to cut funding to hospitals—about as logical as wanting to reduce debt by increasing the deficit.
From a Labour party that wants to be a Government in waiting, this is not good enough. It is against a cut in NHS spending that did not happen, but when there is a real cut in Wales it says nothing. It is against hospital reconfigurations in England, where we are hitting the A and E target, yet says nothing about reconfigurations in Wales, where Labour is missing the A and E target. It says it is against reorganisations and it has just proposed its own huge structural reorganisation to merge the health and social care system. Why is that? It is because in the end it is more interested—we have seen this today—in party politics than the right policies. I think we can expect better from someone who used to be a Health Secretary.
I shall make some progress because I have some important points to make.
A and E pressures are not the only thing that happened to the NHS this winter; we also had the Francis report into Mid Staffs. That tragedy is also relevant to A and E pressures, because at the height of its failures in care, Mid Staffs, unbelievably, was actually hitting its A and E target. In fact, between 2004 and 2009, there were only three quarters in which Mid Staffs failed to see 95% of people within four hours—hitting the target and missing the point. But in Labour’s NHS, hitting the target was all that counted, because Ministers ignored three reports, 50 warning signs and 81 requests for a public inquiry into Mid Staffs and what was going on.
Things have changed in the NHS, and I say this plainly. It is harder now for hospitals to hit their A and E target, because we will not condone cutting corners to get there. Targets matter, but not at any cost, and we are determined to reach them by doing things properly, making sure that we always treat patients with dignity and respect.
I shall make some progress.
Labour’s complacency on that issue is revealed as even more shocking when we look at the root causes of pressures on A and E departments, because nearly all of them involve issues that Labour either failed to tackle in office or made a great deal worse—for example, the IT fiasco, so heavily criticised by the National Audit Office. It is completely unacceptable that A and E departments are not able to access, with their consent, people’s GP records. Last year, there were 30,000 wrong prescriptions in the NHS and 11 deaths—something we know would be significantly improved with e-prescribing in hospitals. The Government have addressed that, with a fund that I announced last month and an ambitious programme to make the NHS paperless by 2018, learning from that procurement debacle for which we are now paying the price.
Let us look at other causes. The working time directive, which Labour signed up to, makes the recruitment of A and E staff very much harder.
I think the hon. Gentleman should listen to this. Professor John Temple described that as having the biggest impact on the emergency and out-of-hours parts of the NHS, which is why the Government are now having to increase recruitment into A and E through the mandate that the Government have set Health Education England. Or there is the total failure—
In one week in April 2012, 75 people in Sherwood Forest trust waited longer than four hours at A and E. In the same week in April this year, 266 people waited longer than four hours at A and E. That is a 255% increase. How does the Secretary of State account for that?
I agree that A and E departments are under huge pressure, and that is why we are taking a lot of measures to deal with them, which is what I am talking about. But I am saying that we have to deal with the root causes, which were things that the shadow Secretary of State’s Government failed to deal with. [Interruption.] Labour Members need to listen. We listened to the shadow Secretary of State’s solutions, which were not really solutions; now I am telling them what we think needs to happen.
We welcome the fact that the Labour party has now seen the light and recognises the need for integration, but Labour Members need to show some humility, because it was the Labour Government who put in place many of the barriers—in particular payment by results mechanisms—that make that so hard to achieve. We are now trying to make integration a reality through the 10 pilots on removing barriers to integration announced by the Minister of State, Department of Health, my hon. Friend the Member for North Norfolk (Norman Lamb), as part of the vulnerable older people’s plan announced to the House last month. Without integration, we will not solve the problem of bed blocking, which is at the heart of the pressures on A and E.
The Secretary of State is right to say that many of the present failures started in the Labour years, particularly the problems with integration. Does he share the concern that I and many of my constituents feel about the 50,000 beds that were lost under Labour Government? We lost the beds, but the intermediate care services and step up, step down facilities were never created to deal with the consequences. That is what is behind a lot of the A and E referrals today.
That is part of the problem with Labour’s approach to the NHS—a top-down approach of closing or downgrading A and E units and making the NHS sort out the problems. We are not doing that.
It is time that Labour took responsibility for the disastrous changes to the GP contract, which contributed to making it so much harder to get a GP appointment and piled further pressure on A and E departments—[Interruption.] No, they need to listen; this is important. The changes in 2004 handed responsibility for providing out-of-hours services to administrators in primary care trusts, at a stroke removing the 24/7 responsibility for patients that until then had always been a core part of being a family doctor. As we heard earlier today, even a former Labour Health Minister regretted those changes, saying before the last election:
“In many ways, GPs got the best deal they ever had from that 2004 contract and since then we have, in a sense, been recovering.”
It is important that Labour Members hear the list of independent voices all saying that we need fundamental change in primary care if we are to deal with pressures on A and E: the College of Emergency Medicine, the Royal College of Physicians, the NHS Alliance, the Family Doctor Association, the head of the Royal College of General Practitioners, who—surprisingly—said something in support of the Government in The Guardian this morning, the Foundation Trust Network and so on. All those voices were ignored by Labour as it put its head in the sand about that disastrous change to the GP contract.
Does the Secretary of State share my horror that the out-of-hours contracts awarded by the previous Government to companies such as Serco give them a financial incentive to call an ambulance rather than deal with cases through GPs or in the community?
Today’s debate is about the increase in waiting times at accident and emergency departments. In 2010, when Labour left office, 98% of people were seen within four hours; three years later, after three years of Conservative Government, the number of people who have to wait more than four hours has trebled. What is the Secretary of State going to do about that?
Let me say very directly to the hon. Lady that since 2010 two things have happened that have contributed—[Interruption.] I am answering the question. First, 1 million more people are now going through A and E; secondly, the target has been reduced from 98% to 95% on the advice of the College of Emergency Medicine and the Royal College of Nursing. Labour has decided to do the same thing in Wales. Obviously, in that situation, the result is an increase in the absolute numbers; however, year on year since 2010, this Government have hit our A and E targets and we intend to continue to do so.
Mention has been made of an additional 1 million people going to accident and emergency. The derision I received earlier was an attack on organisations such as St John Ambulance, which trains first aiders, because the simple fact is, as I said when speaking to my ten-minute rule Bill 10 years ago, that first aiders will
“reduce visits to overstretched accident and emergency departments by people whose injuries did not warrant hospital attention”—[Official Report, 19 November 2003; Vol. 413, c. 809.]
We should be getting more first aiders out there. If the last Labour Government had listened to that, we would have 1 million more first aiders.
No, I will make my concluding remarks. We will address these fundamental issues in our vulnerable older people’s plan, which is being published later this year. I have asked Sir Bruce Keogh, NHS England’s medical director, to lead an urgent review of demands on our emergency care and how services should respond in future. In the short term, we have changed the tariff arrangements for A and E payment to give hospitals a say in the use of funds earmarked to prevent avoidable admissions. The result is that A and E targets are now being met, not missed; long-term challenges are being confronted, not avoided; and the NHS, with its extraordinary professionals, is facing up to the great challenges of an ageing population with resilience and determination, treating more people more quickly and more safely than ever before in its history, and rather than deriding that performance for party political purposes the House should be celebrating its success.
That is the most extraordinary speech I have heard from a Secretary of State for Health in all my years in this House. As a former Secretary of State, I know that Secretaries of State cannot be responsible for everything, but this is the first speech in which a Secretary of State has claimed he is not responsible for anything. He quoted the Francis report. One of its most significant features was that it said that we should impose a statutory duty of candour on people working in the national health service; if anything goes wrong, they are supposed to come clean and admit responsibility. I hope that there will be a clause in a Bill introducing the duty that says that this Secretary of State should have a duty of candour and admit the things that have gone wrong.
What have Ministers been doing for the past three years? The main thing they have been doing is dismantling the national health service. Staff have been distracted from their jobs, and money—£3 billion—has been diverted into that reorganisation. Some of that has been spent on redundancy for nurses who work in accident and emergency. The Government have been proudly saying, “We have hit our new target.” Well, they reduced it and made it easier to hit. The 111 line has referred more cases to A and E than NHS Direct did. There have been cuts in social care, which have two effects on A and E. First, it means that more elderly people go to A and E for treatment because they are not getting the attention that they were from social services. Secondly, it means that there will be delays in patients going home, both from A and E and from ordinary hospital beds, and that causes delay, too. Walk-in centres have closed, and the Government have given the surplus money back to the Treasury, yet they deny that any single one of their policies has had any effect on A and E services. They have had three years in power, and they are still blaming other people.
The Government claim that the increase resulted from the change to the GP contract. They know full well that that is not true; they know that it was because walk-in centres and minor injuries units were counted in the figures for the first time. If the Secretary of State expects people in the national health service to respect him and take any notice of him, not just regard him as the Catherine wheel of spin, he has to come clean. He is telling people that if they get things wrong in the health service they must come clean and be honest with the public. If he does not apply that to himself he will be a bit like the dad who has told people not to give their kids a leg up, but who turns out to have employed both his daughters: he did not apply to himself what he said everybody else should do. My right hon. Friend the Member for Leigh (Andy Burnham) was right: there was spare money, but under the new set-up can the Secretary of State get it into the hands of the health service, or did his predecessor throw away that power?
I welcome the fact that we are debating increased evidence of service pressures in the national health service. Having attended health debates in the House of Commons for quite a few years, I can say that there is a depressingly familiar tone to this debate. May I tell the right hon. Member for Leigh (Andy Burnham) that if we want to develop party points in the House and convince the electorate that there is something in it, it is not a bad idea to begin by establishing where the real differences exist between the Government and the Opposition? If we look at the evidence for why we have experienced increased service difficulty in the health service, we see that it is not the differences between the Government and the Opposition that are striking but the fact that there is a shared analysis. However, there is an apparent unwillingness to apply that analysis and work it through in the necessary large-scale service change that we require.
As for the roots of increased service pressures in the health service, I agree with quite of lot of what my right hon. Friend the Secretary of State said about the GP contract, but that is not why those pressures exist. Their true roots go back to the time in which the right hon. Member for Leigh was Secretary of State. In 2009, David Nicholson said that demand would go on rising in the health service, and that given the state of public finances we had to find ways of meeting that demand without continuing to make calls on the taxpayer on the scale that we had grown used to over the first 60 years in the history of the health service.
In Wycombe, ever since our A and E was closed under the previous Government, people have wanted nothing more than to get it back. It is clear that medicine has changed and that they will not do so, but does my right hon. Friend agree that there has been a long-standing failure to explain those pressures to the public?
I absolutely agree with my hon. Friend. We cannot blame people in the country for not understanding the need for change in the health service if politicians never explain why that need has arisen. I quite often quote Enoch Powell—not someone who wins a consensus across the House—who as Health Minister went to the equivalent of the NHS Confederation conference, which is now under way in Liverpool, to explain the need for the change in the service model in mental health. He said in his speech that
“Hospitals are not like pyramids, built to impress some remote posterity”.
That is the case that we need to begin to explain.
I am grateful for the right hon. Gentleman’s generosity. One of the ironies is that Enoch Powell recruited a lot of doctors overseas. He would have had absolutely nothing to do with the argument advanced yesterday by one of the right hon. Gentleman’s colleagues that all the problems in A and E are to do with the arrival of migrants. If anything, we need to change immigration policy in this country, so that more doctors can come here.
I have four minutes, or with two interventions, six minutes, so if the hon. Gentleman will forgive me, I shall not go off into a discussion about immigration policy.
I want to focus on the changing needs that the health service has to meet. I sometimes wonder whether people talking about rising demand on the health service and rising demand for emergency care have ever sat in a GP’s surgery. Have they noticed around them in a GP’s surgery the kind of people who present in a surgery and the conditions that bring them there—dementia, diabetes and drug and alcohol abuse? How can we expect a service that was designed to meet the needs of patients, inasmuch as it was designed at all, in the 1950s, 1960s and 1970s to meet the needs of today’s increasingly elderly and dependent patients, without rethinking the way care is delivered?
This is—I come back to my core point—a shared analysis. It is not a subject of party political debate. It is a shared analysis between the two Front Benches, and what is even more surprising is that not only is the analysis shared, but the conclusions about the right policy response are shared.
Forgive me. I have a minute and a half and I want to develop what I think is an important point.
When I make the case for greater urgency about integration between the different parts of the health and care system, I am often told that I am supporting Andy Burnham’s plan. I am quite happy to support Andy Burnham’s plan. Actually, I gently claim credit for the fact that the Health Committee on a cross-party basis has been advancing this analysis from the beginning of this Parliament, and with due deference to the right hon. Gentleman and to my colleagues on the Select Committee I will also point out that part of the answer that the right hon. Gentleman is—rightly, I think—advancing builds on health and wellbeing boards, which are the creation not of me or of him, but of my right hon. Friend the Member for South Cambridgeshire (Mr Lansley), the former Secretary of State for Health and now the Leader of the House of Commons.
The right hon. Member for Holborn and St Pancras (Frank Dobson) talked about a duty of candour. Could we not have a duty of candour about agreement in the House of Commons—agreement that what needs to happen is not to find artificial divisions, but to build on the need for urgent change to meet the needs of today’s patients?
It is a pleasure to follow the Chairman of the Select Committee, the right hon. Member for Charnwood (Mr Dorrell).
The speech that we heard from the Health Secretary was pathetic. He spent 25 minutes making up excuses for not taking action but not telling us anything about what this Government plan to do.
When I stood for election three years ago, A and E services were not an issue on the doorsteps of Lewisham East but now, as a result of this Government’s determination to decimate services at Lewisham hospital, it is the most frequently cited concern. My constituents are at a loss to understand why, when there is such pressure upon A and E, this Government want to get rid of the full A and E service at their local hospital. This situation is not limited to Lewisham. It is happening all over the country.
My hon. Friend will know that on every occasion when she and I have had exchanges with the Secretary of State—it is a great pity that he has left the Chamber—he has justified the downgrade of Lewisham hospital on the basis that 100 lives across the south-east of London could be saved. We can find no evidence for that. Both my hon. Friend and I have written to Sir Bruce Keogh—I did so on 14 May—who the Secretary of State always says is the man who made this recommendation. The Secretary of State takes no responsibility.
I agree that the evidence on which that assertion was based is deeply spurious and a meeting with Sir Bruce Keogh, which I requested, would be very helpful to the three Lewisham Members.
The situation, as I said, is repeated all over the country. There are more people stuck on ambulances waiting to get into A and E, more people waiting longer for treatment when they get there, and this Government’s answer is to close the A and E, ask people to travel further, and tell them to go to a bigger hospital, where the queue will probably be longer. If this is not the politics of the lunatic asylum, I do not know what is.
My constituents in Lewisham have been told that their full A and E service has to close in order to bail out the hospitals down the road. The whole decision-making process has been opaque and, in my view, deceitful. It is now rightly being challenged in the courts by Lewisham council and the save Lewisham hospital campaign. But for now, my constituents still face the prospect of seriously downgraded services at their local hospital. Not only are my constituents being told that they will have to travel further in future to get to an A and E, but to add injury to insult, they are being told to go to departments where performance is generally below that at Lewisham. In 29 of the 35 weeks between the end of September last year and the end of May this year, people were seen more quickly at the A and E in Lewisham than they were at the hospitals within the South London Healthcare NHS Trust where they are now being told to go.
In the first four months of this year, ambulances were placed on divert 25 times to Lewisham hospital. They were diverted away from the very hospitals where my constituents are now being told to go. It does not take a brain surgeon to work out why 25,000 people chose to march against these proposals in January. Under no circumstances should any changes at Lewisham hospital be made unless ambulance diverts have stopped and waiting time targets in neighbouring hospitals have been met. I do not want the changes to happen at all, but surely this is the least that the Government should commit to.
The Government seem intent on blaming everyone but themselves for the crisis in A and E. They seem oblivious to the fact that the things they are doing now, such as destabilising reorganisations and the devastating cuts to adult social care, are making the situation worse. They are shutting their eyes to the problem and ploughing on regardless with a programme of A and E closures. I accept that in some places reconfiguration of hospital services will be necessary, but this process must be driven by what is in the best interests of patients. That is not what is happening in Lewisham.
The Government want to blame everyone but themselves for the crisis in the NHS. The sooner we ditch the blame game and have a grown-up debate with thought-out solutions, the better our NHS will be for it.
This is an enormously complex issue and we must not look at A and E in isolation. We also have to be very careful about the way we use data. I recommend that all Members look at the King’s Fund blog on this to see how the way in which the codings were changed and the data recorded to include walk-in centres and minor injuries units between 2003-04 gives a different perspective to the debate.
Given that complexity, we need to look at the solutions, which need to come by ensuring that people can see the right professional at the right time in the right place. That is key to this. But as my right hon. Friend the Member for Charnwood (Mr Dorrell) said, we must also recognise that the key driver for demand in this is our ageing population. If we look at the impact within general practice, we see a 75% increase in the number of consultations during a 13-year period. This is not just within general practice. The patients who are arriving are much sicker and have much greater complexity, and that is the root of the problem. It is a cause for celebration that we are all living longer, but dealing with that needs detailed planning.
I am grateful to the hon. Lady for giving way, given her expertise in these areas. Does she recognise the work of Sir George Alberti a few years ago and the establishment of emergency care collaboratives that were very engaged with social care and local councils, and that the further cuts expected in local authorities will make this worse for elderly communities throughout the country?
The reality that we face is that there is a limited amount of public funding. We can spend that pot of public money only once, so we must spend it in the right place, and that often means that we need to spend more of it within social care. That is why I welcome the fact that some of the health budget has been shifted to social care, and that is very important. I also commend Torbay. My constituency covers Brixham and Paignton, and Torbay has been nationally and internationally recognised for its work on integrating health and social care. It is no coincidence that it does so well on A and E waiting times, and we should be looking at what it has achieved.
But how will we keep people out of our A and E centres? In the Health Committee, we heard evidence about the effect that paramedic crews have. If the paramedic crew in an ambulance are highly skilled, the person they treat is less likely to need to go to casualty in the first place because the expertise is there to keep them at home. There needs to be better access to records. We need to consider how we can improve IT so that the patient owns their record and every part of the system can safely access their drug and medical history—with their consent, of course.
I am short of time, I am afraid.
I go back to how we get people directed to the right place. We need NHS 111 to do the job it is intended to do—direct and signpost people to the right place. Some 42% of people do not know how to access their out-of-hours service; they will go to where the lights are on. We need to make sure that there is good-quality information about how to see the right professional in the right place at the right time and about communication in all parts of the system.
We also need to consider how commissioners can be supported to keep people at home, which is the right place for frail elderly people, by using community resources. There are some wonderful organisations in my area—Brixham Does Care, Totnes Caring, Saltstone Caring and Dartmouth Caring. Having the flexibility to commission small local units is vital, rather than there being a push to commission larger units that do not have that local focus. The issue is about local focus helping to have local solutions. What works in Lewisham will not work in rural Devon, so let us get the solutions right and have flexibility.
Let us make sure that we address the delays within casualty departments and the pressures that cause that. Very often the issue is to do with diagnostics. Let us look at the groups of people who constantly re-attend. I do not want to bore the House too much with my views on minimum pricing, but anybody who wants to spend a Friday or Saturday night in an inner-city casualty department will see what the delays are due to. I hope to win my bet eventually with the right hon. Member for Exeter (Mr Bradshaw).
Let us have a sensible policy that considers mental health, for example. A huge number of readmissions in casualty departments involve people with mental illness. In the west midlands, liaison psychiatry is being used to help reduce readmissions among those with mental illness—again, it is about getting people the right support at the right time in the right place. Some 5.6% of bed days in the NHS are taken up by people who have been readmitted within a week of discharge. That is simply not acceptable.
There is also the issue of designing the tariffs. I was pleased to hear the Secretary of State refer to tariff reform. If the financial drivers are in the wrong place, we will not solve the problem. Let us try to take the party politics out of this debate and focus entirely on how we can support NHS England and our clinical commissioning groups to get the right care in the right place at the right time.
I associate myself absolutely with the remarks made by the hon. Member for Totnes (Dr Wollaston) about tariff reform, but given the time constraints, I will restrict my remarks to one particular issue that is putting pressure on the A and E crisis. I am talking about access to GPs.
I want to share testimony that I have recently received from people in Exeter. The first comes from a young teacher:
“Again and again, whenever I want to see a doctor there are no appointments available for as long as a week away, in addition to appointments not being made available at accessible times. Being a teacher, I am unable to easily pop out for a doctor’s appointment.”
Another constituent wrote to me last month about the A and E crisis:
“I believe one of the main reasons for this is that it has become very difficult to see your own GP unless you are prepared to wait three weeks for an appointment. I have personal experience of this, as do many of my friends and colleagues, and this is making people with minor ailments attend A and E in order to be seen.”
You will remember, Madam Deputy Speaker, that when Labour was in government, we introduced a requirement on GPs to grant appointments to their patients within 48 hours. We also introduced incentives in the GP contract for GPs to open at weekends and in the evenings, and we established GP walk-in centres in every primary care trust in England—in some areas, we established more than that. It worked. By the end of our Government, complaints from the public about GP access had declined significantly, as had pressure on A and Es that resulted from people not being able to see a GP.
By May 2010 more than 75% of GP practices in England were opening in the evenings and at weekends. Under this Government, however, 500 of those practices have reduced their opening times again. By May 2010, there were walk-in centres in every area offering quick, easy access to a GP, seven days a week and 12 hours a day. Since 2011, 25% of those centres have closed, and scrapping the requirement for GPs to offer an appointment within 48 hours has led to a return of the bad old days of people waiting days or weeks to see a GP, and therefore going to A and E instead.
I regret I will not do so because I have so little time.
When I wrote to the Health Secretary with the cases from Exeter that I referred to earlier, his colleague, Earl Howe, replied:
“It is our view that 48-hour access did not focus on outcomes, and specifying a particular model to deliver better services for patients misses the point about local needs, local services and local accountability.”
That, I am afraid, is gobbledegook. My hard-working constituents, who pay for the NHS, want to be able to see a GP when they need to and at a time convenient for them. Earl Howe’s letter went on to say that as this was a local issue, I should raise my concerns with the clinical commissioning group, which I promptly did. It replied stating:
“As this relates to GP services, the letter should be sent to NHS England.”
I await its response with interest.
Will the Minister help the House by making clear in her response who is responsible for ensuring that the public can see a GP quickly and conveniently? I was encouraged to hear the Under-Secretary of State for Health, the hon. Member for Central Suffolk and North Ipswich (Dr Poulter) tell the “World at One” yesterday that he wanted to improved GP access, including opening times, in response to the A and E crisis. Hallelujah! May I suggest, however, that he and he colleagues start by stopping the closure of walk-in centres, and reintroduce Labour’s requirements and incentives for GPs to give appointments within 48 hours and to open their surgeries at weekends and in the evenings? Without such measures, I am afraid that current pressures on A and Es will simply get worse.
The last time I was in A and E I had hit myself on the head with a 300 lb iron bar—don’t ask why. I had a lump the size of an egg, but no lasting damage, apparently. The time before I was involved in an accident on the M1. I was not driving the car, but I ended up in North Hampshire A and E. My latest visit was with my mother-in-law who had had a suspected heart attack. I use those cases to illustrate that although nobody wants to go to A and E, people end up there for a whole range of reasons. Either they have a genuine accident and emergency, or they fear that they have had an accident or emergency and need informed triage, or they have a problem and simply do not have anywhere else to go. I suspect that we are looking not at increased pressure because of a huge number of accidents and emergencies—although there are many elderly people, which will increase the number—but at a big increase in cases to triage and in the number of people with nowhere else to go.
I note that the situation is not inferior to that before 2004, but in relative terms I am prepared to admit that it is a crisis. So far the debate has been about whose fault that crisis is. We cannot say that the situation is entirely due to the GP contract and the extraction from out-of-hours service, but we could say that that will not help. We cannot say it is down to the strange decision to replace midstream NHS Direct with the 111 service, but that will not help. We cannot say it is all down to a massive reorganisation of the NHS and the siphoning off of millions into redundancy payments, but clearly that will not help. We cannot say it is due to the closure of walk-in centres. They were often paid for by the PCTs of the past and are not necessarily popular with GPs, but their closure will certainly not help. We cannot say that the situation is due to the absence of strategic health authorities, although in the past those authorities often forced ambulance trusts and hospitals to work seamlessly together, not just gaming their own targets and looking at performance indicators. They helped to stamp out trolley waits, parking up and needless diverts, but the absence of a strategic oversight is clearly not going to help. We cannot say that the failure of our system to deal with chronic alcohol abuse is the sole reason, but as the hon. Member for Totnes (Dr Wollaston) pointed out, it is not helping. The fact that we do not link treatment to successful rehab certainly does not help.
What would help, as we all agree, is rapid progress towards the integration of health and social care, proper community budgeting, stopping unnecessary admissions, increasing co-operation and resource efficiency, and making better use of hard-pressed social services budgets. This was the big-ticket item in the in-tray in 2010—the holy grail. There was also the instability of the acute sector. It is a genuine pity that well-intentioned people in this place spent the first two years of the Parliament wrangling about a largely pointless, if not positively unhelpful, reorganisation. Never mind missing A and E targets because of the stupid, adversarial, arrogant and hubristic culture of this place, where each successive Government feel obliged to do everything in a new way: it is not just A and E that missed the target; we missed the target.
As colleagues will know, over the past few months I have read from the direct experiences of the 2,500 people who have written to me about their treatment in the health service. This time, I am going to speak about my husband, who died in October last year. That is because I have had the 117-page report from the hospital, which I asked a GP friend to have a look at because a lot of it is gobbledegook to any ordinary person.
My husband died from hospital-acquired pneumonia. One of the concerns that I have talked about is upheld by University Hospital of Wales in Cardiff. The report says:
“A delay in review by medical staff did occur in AU. Mr Y”—
it is anonymised, ridiculously—
“remained in EU for 6 hours longer than the target timescale of 4 hours. Mr Y then remained in EU for approximately 21 hours, significantly longer than the target time of 8 hours for this type of area.
Mr Y should not have been nursed in the EU/AU for the length of time he remained there. The length of time Mr Y spent in EU and AU fell significantly below the standard expected, and this is unacceptable.
The distress this poor experience caused is acknowledged and the Health Board apologises that the standard experienced by Mr and Mrs Y was below that expected.
This concern is upheld.”
There are many other things I would have liked to talk about, but there is not enough time. I asked my GP friend to look at the hospital’s record, and she said:
“I don’t think that the notes you were given are supposed to be a complete record that Owen was properly investigated or treated.”
She goes on to say:
“Of course Owen spent too long in Casualty. The analogy with a ‘battery hen’ is apt: cooped up on a too small trolley for 27 hours, pressed against the bars…no record of adequate food or water and unclothed.”
She goes on to ask:
“Why ever not? In 27 hours Owen is recorded as drinking 150 ml and eating one ice-cream—and he was dehydrated when he came in.”
There was apparently a “Do not resuscitate” notice. She goes on:
“The DNR notice and records are lamentable, and reinforce my impression that because Owen’s care plan on 11 October could not be fulfilled, there was no other clear care plan in place for him…But I am not surprised you did not fully comprehend what they were not going to do. The enquiry papers state UHW does not follow the Liverpool Care Pathway; this is a pity as they wrote Owen up for the LCP recommended medication after antibiotics were stopped yet failed to attend to the spiritual needs of the patient in this critical juncture.”
No, I am sorry, I cannot.
Finally, my GP friend said:
“These matters and the ways you expressed your concerns are so similar to the events described in the many many letters you have received from others who have described similar misgivings. It must be very difficult to have to ‘use’ your own very personal experience as a prompt to drive the response and search for answers that so many want from you. But that is your job as Member of Parliament, to identify what, if anything—”
This debate has improved as the Back-Bench contributions have gone on. It started off fairly gracelessly, with an attempt to lay all the blame for the pressures in A and E on this Government. That was pretty shameful. I like and respect the shadow Secretary of State, the right hon. Member for Leigh (Andy Burnham), but it was graceless of him to suggest that this is entirely of this Government’s making.
As a number of hon. Members have said, there is a broad range of issues behind the pressures on A and E services. Long before I was elected, I campaigned against some of the changes that made a difference in my own constituency and increased pressure on the NHS. We have heard about bed reductions and the lack of joined-up social and health services. I think there is an issue with GPs and I respect the view of the Health Committee Chairman on that. A lot of residents were confused—this was touched on by the right hon. Member for Exeter (Mr Bradshaw)—about where GPs’ services were and how they could access them after the change in 2004 in particular. I think that that has contributed to people choosing to access other services. I confess that I have absolutely no idea how the out-of-hours service in my area works. I am lucky that I have never had to use it, but a lot of people were incredibly confused by their out-of-hours service after 2004. The right hon. Gentleman also mentioned walk-in centres, but my area did not get one. If we are expected to use the one in Scunthorpe, that is not a sufficient local alternative.
We have also heard about a demographic shift, which is clearly a huge issue, as is population growth. After the failure of health services and all Governments to deal properly with palliative care and end-of-life plans, one of my hospitals in Goole experienced massive reductions in services, largely on the previous Government’s watch. Our mental health ward went and all the town’s mental health beds disappeared, as did medical beds in general. Service after service disappeared. When those mental health services were lost and replaced by apparently intensive home support, we ended up with people in crisis and, as my hon. Friend the Member for Totnes (Dr Wollaston) has said, presenting to A and E and other services.
The failure of social care is a problem, but I remember one of my local authorities—East Riding of Yorkshire—changing the criteria for access to its services many years ago as a result of funding pressures from the previous Government. I wish that Labour councillors at my other council, North Lincolnshire council, had listened to the Secretary of State before they tabled their budget for this year, which proposed removing social care from thousands of my constituents and changing the required criterion from “moderate” to “substantial”. If it had not been for Conservative councillors voting down the Labour budget and instead voting to protect social care, there would have been massive social care cuts in my area. I hope that the right hon. Member for Leigh will relay that to his colleagues in my area.
The failure to have proper intermediate care services has also been mentioned. My local authority is trying to address this through a £3.2 million scheme in my constituency to create a 30-bed unit. Bed blocking has been a massive problem in recent years and we all know about it. Plenty of people come in, but not enough go out the other side. The Labour party has to take some responsibility for that problem, because it has not appeared overnight. The issue has been affected by population growth and a demographic shift.
In the brief time remaining, I concur with the Health Committee Chairman that it would be much better to take the politics out of this debate.
I think that most people who have heard this debate would agree that we have generated more heat than light. That is a shame, because when one hears the words of my right hon. Friend the Member for Cynon Valley (Ann Clwyd), one realises that this is way beyond a party political issue. This is not about game playing or seeking political advantage for one side of the Chamber or the other. I have sufficient respect for the Secretary of State and the shadow Secretary of State to know that neither of them wishes to go down that road. This matter is simply far too serious.
We have heard tonight that A and E services are often the indicator or signifier—like the canary in the coal mine—that warns about the condition of the rest of the national health service. We have heard about a number of factors. One accusation is that there is a lack of knowledge about A and E.
I spent 10 years working in the A and E department of the Middlesex hospital and University College hospital. I must say that I worked in an ancillary capacity, rather than as a qualified medic, although I did wear a white jacket and would occasionally bluff. There is a huge difference between A and E then and now. Like a lot of MPs, I mystery shop in my local A and E once a month, just to sit and listen to what is being said. The difference between then and now is that virtually everybody who came into the Middlesex was brought in by ambulance and there were very few walk-in patients. I am not saying that it was not in a residential area, because it was. We had an excellent Member of Parliament in my right hon. Friend the Member for Holborn and St Pancras (Frank Dobson). Plenty of people did the right thing and voted for him. There is a difference of attitude now. That is exemplified by what we saw last week, when a mother took her daughter to a north London A and E department to ask that a doctor remove canine faeces from her daughter’s shoe in the safest possible way. There is no question but that there is a problem. People’s expectations have changed.
There have been some suggestions today. The prescription of the hon. Member for Colchester (Sir Bob Russell) was risible. The idea that we should lie back with a scalpel in one hand, biting on a bullet and perform our own abdominal surgery was fairly ludicrous. At least, that is how I heard his proposal.
I agree that we should make more use of community pharmacists, but above all we must recognise that we are now in a different world. People do not come to A and E in the middle of the night because they want to; they come to A and E because there is not a walk-in centre they can access during the day and there is no out-of-hours GP service because most of the GPs in London are elderly, single-handed GPs. People go to A and E out of sheer desperation. Yes, there is always a fool who comes in with a headache or something, but if Members go to their local A and E, as many of us do, they will see people who are on the edge of absolute seriousness.
We have to address the totality of the issue. The hon. Member for Southport (John Pugh), in one of the best argued speeches that I have ever heard, pulled the whole thing together. He did not refer to a mosaic of misery, but to all the competing factors. That is what we have to consider.
I do not see the Secretary of State as some Gargantua or Godzilla, crashing through Nye Bevan’s glorious creation and seeking to destroy it at every opportunity; I see him as a man who might be overwhelmed by the scale of the problem facing him. Let us step back from party political advantage and think about the people out there—the exhausted staff in the A and E departments and the patients in pain and agony.
It is a pleasure to follow the hon. Member for Ealing North (Stephen Pound). I agreed with some of the points that he made, but I did not agree with all his conclusions and he may not agree with mine.
It is striking that nobody has mentioned the report that was published today by the NHS Confederation and the Academy of Medical Royal Colleges. That report calls for the closure of hospitals and indicates that the funding model for health care in this country is not sustainable in the medium to long term. It is significant that so many organisations that should be respected by this Chamber have come to such difficult and politically unpalatable conclusions.
I have been encouraged by some of the contributions from the Back Benches in the past hour or so. There has been mention of the drivers of demand in this country and across western society, such as ageing, obesity and increased drug and technology costs. As was mentioned by the hon. Member for Ealing North, there has also been a significant change in attitude, which is difficult politically. Essentially, the population is becoming a bit softer. The generation that survived the war, a more stoic generation, would not think or dream of calling their GP in the middle of the night unless their arms were dropping off, but they are passing away and are being replaced by people who think it appropriate to call their GP at midnight because they have had a sore throat for a couple of hours. Clearly, that is not sustainable.
The challenge of the A and E crisis, which is the reason for this debate, is I suspect a first manifestation of evidence that the system is not fit for purpose. It is not fit for purpose before the baby boomer generation hit their 70s, and we should mull on that. We should also recognise the fact that change is inevitable and that hospital closures and reconfigurations will have to take place. My conclusion on how to deal with that is not party political.
An ideological legacy is in play here. We have a system that was designed for a stoic post-war generation—taxpayer funded and copied only by Cuba. We need to recognise that it is not fit for purpose and we need to have some tough debates with the public about how to fund it going forward. A financial legacy is also relevant. A recent one is the PFI scandal of the last few years, but let us be realistic: this country has significant debts and liabilities five times the size of our economy, so it means we need to be realistic about what we can afford in the future.
In conclusion, I agree with Members who said that we should take the party politics out of this debate. I would like to see a plan of where hospitals should be in the future. We need a hub-and-spoke model for acute hospitals; there has to be a national plan, so that we do not see some hospitals unfairly closed and others retained for various legacy reasons. The plan needs to be cross party; otherwise it will not pass. We need to reflect, too, on GP out-of-hours provision. I think GP surgeries should be open for longer and more appointments should be available for about 12 hours a day. I am not so sure that the current out-of-hours service is sustainable or, indeed, advisable in the longer term. Above all, we need a proper informed and rational debate with the British public about what is affordable, what is do-able and what is in all our best interests.
I am grateful for the opportunity to follow the hon. Member for Bracknell (Dr Lee). Given the views he articulated, I hope he will come and canvass for my opponent at the next general election; we would be very happy to have him there. I say that in the context of the situation in the North West London Hospitals NHS Trust, which in 2010-11 was well within the waiting times targets for A and E. Just 2.9% of patients waited more than four hours, but by 2011-12, that figure had risen to some 10.8% at the end of the year, while for the whole of the last financial year the figure is 12.2%—the second worst set of statistics in London, surpassed only by the Barking, Havering and Redbridge University Hospitals NHS Trust, where almost 16% of patients had to wait over four hours.
I am grateful to my hon. Friend and neighbour for giving way. In view of what he has just said, does he think that the best possible prescription is that currently recommended by the Government whereby the existing A and E departments at Ealing, Park Royal, Hammersmith and Charing Cross all close? Does he think that will improve waiting times in A and E departments?
My hon. Friend, as ever, is ahead of me. He makes the perfectly reasonable point that if the Northwick Park and Central Middlesex A and E departments are not achieving the 95% target now, how can our constituents have any more confidence about reaching that target should the Central Middlesex and Ealing hospitals close?
As my hon. Friend knows, Northwick Park is just in my constituency and we share that border. Does he agree that whatever the future configuration of hospitals in north-west London, it is absolutely essential that the A and E unit at Northwick Park is expanded to cope and that that should happen before any reconfiguration?
Order. I remind the House that there are nine speakers still to be called, and that the winding-up speeches will begin at 6.40 pm. That means that some Members who have been sitting in the Chamber will not be able to contribute. I therefore ask Members to be sparing with interventions, and to make them only when they are absolutely crucial. I also remind them that interventions must be short, and must relate to the point that the speaker was making at the time rather than be an extra debating point.
I share the view of my neighbour and hon. Friend the Member for Brent North (Barry Gardiner). We need that expansion to go ahead, and to go ahead soon.
In an intervention during the speech of my right hon. Friend the Member for Leigh (Andy Burnham), I raised the plight of many of my constituents who formerly used Alexandra Avenue polyclinic, an extremely popular walk-in centre which used to be open from 8 am until 8 pm, 365 days a year, to people who were genuinely concerned about their health and did not feel that they could wait to see their GPs. It was opened by Ara Darzi some five years ago. Amazingly, its opening was opposed by my political opponents in Harrow, but it quickly came to be greatly appreciated by, in particular, people living in the south Harrow and Rayners Lane area. Those people have noted with considerable regret that, after the last general election, the primary care trust decided to restrict the opening hours of their walk-in centre, but not those of the walk-in centre in Pinner, in the constituency of my other neighbour, the hon. Member for Ruislip, Northwood and Pinner (Mr Hurd).
As a result of the cuts that the primary care trust decided to make, the walk-in service now operates only between 9 am and 3pm on Saturdays and Sundays. The fact that it remains open at all is entirely due to the scale and strength of feeling about the loss of what was an excellent service, and the campaign that we were able to run in order to save it. Perhaps some of the £3 billion that the Prime Minister spent on what was—as others have already pointed out—a completely unnecessary reorganisation of the NHS could have been invested in keeping Alexandra Avenue polyclinic open, and some of the pressure that my constituents are imposing on Northwick Park hospital’s accident and emergency unit could have been alleviated.
Staff at the excellent Pinner ambulance station in Rayners Lane do an extremely good job, generally spending all their shifts out on the road. It is clear that they, like the rest of the staff of the London Ambulance Service, are under extremely heavy pressure. On occasion, ambulances have been used as temporary reception or holding areas at Northwick Park when patients cannot be admitted to A and E as they arrive because of the pressure on that department.
There is also concern about the district nursing service in Harrow. My personal experience of that service has been mixed. An elderly relative and, more important, that person’s carer have found it difficult to gain access to it by telephone when problems have developed. It has been slow to respond, and has demonstrated poor co-ordination with other parts of the local health care system. Again, funding was cut by the primary care trust.
The new clinical commissioning group has given notice to the local trust which runs the service that it may outsource the contract, but I am not convinced that that is the answer. Investment in staff—trained staff—and, crucially, investment in management time by the local trust seems to be the immediate requirement if the problems in the service are to be sorted out. Meanwhile, to those who are aware—as many of my constituents are—that the district nursing service is far from brilliant, it is hardly surprising that family members should want to delay the discharge of elderly patients from Northwick Park.
It is telling that the number of cancelled operations is rising fast at Northwick Park. So far, it has risen by some 13%. That is a further symptom of the crisis in the national health service, as evidenced by others—
I have only a brief amount of time, so I will not repeat what other Members have said about demographics. I would also have liked to have talked about the NHS funding formula and the fact that Lancaster and Fleetwood is a rural area and there is no accounting for geography or the numbers of old people.
I agree with the hon. Member for Southport (John Pugh) and others who said we need a non-political debate. I shall focus on the question of staffing in A and E. People talk about crisis and chaos, but the majority of my electorate get a very good service from highly qualified professionals, who are working extremely hard. There is a staffing issue, however: we need to ensure there are enough properly qualified emergency specialist consultants working in A and Es both now and in the future and that they are not stretched to breaking point.
All this information comes from the doctors working in my A and E at the Royal Lancaster. This issue was also flagged up in a College of Emergency Medicine report, “The drive for quality”. The problem, which has been building over many years, is that ever fewer doctors want to move into the A and E specialty. That is largely because of the pressures of the work and the long and unsociable hours, including high-pressure weekend shifts that do not arise in other specialties. In turn, that leads to even more pressure on the few qualified consultants that remain, who have to work longer shifts and take on ever more responsibilities, and many of whom therefore eventually choose to go into other specialties as well. As a result, there is always a shortage of specialists.
To see how bad the problem was, I submitted a series of freedom of information requests last year, asking hospitals how many consultant emergency physician vacancies they had and how many people had applied for posts when they were last advertised. There seemed to be some regional variations—and my area, the north-west, seemed to be having particular difficulties—but there were some worrying general trends. Without naming individual hospitals, here are some examples: one hospital advertised for a senior clinical fellow on three separate occasions over the course of nine months, but there were no suitable applicants; another hospital advertised for three consultant emergency physicians, but no one applied; elsewhere, seven consultant vacancies were reported in one hospital, representing some 33% of its planned consultant staffing rate.
Even when there are applicants, competition is fierce. One hospital advertised for six vacancies and received four applications, but three of them withdrew prior to interview, presumably because they had been poached by employers elsewhere. Worryingly, sometimes the quality of applicants is not up to standard, as in the case of the hospital which advertised for five consultant emergency physician vacancies, only to conclude that none of the applicants was appropriately qualified.
I again stress that, according to the College of Emergency Medicine, this issue has been worsening over many years. We need to work constructively to ensure that emergency physician status is better recognised and rewarded within the NHS, so it can recruit and retain the required quality staff. This might not all be about money, by the way, but we definitely need to do more to tackle the issue and to give due credit and due status to the physicians who maintain the existing A and E service—which, as I have said, for the majority of my constituents is a good service.
I will be very brief, as I want all Members who wish to contribute to the debate to be able to do so.
It feels as though we are telling the public that somehow they are being irrational by attending A and E. They are being entirely rational, however, if they live in urban London. They are being rational because they cannot get access to their GP services. Their GPs have contracted-in times and their walk-in clinics have been closed, so their only alternative is A and E. The 111 service is also, in effect, A and E, because it is so risk-averse. Our current system is not based on what is best for the patient; it is based on what is going to cause the least legal damage to the NHS if things go wrong.
My local hospital, St Helier, is up for closure despite the fact that its A and E is the only one in south-west London that meets the targets. Its maternity unit is also to close, even though it is the most clinically safe unit in the country. It is very difficult to explain that that is a rational decision to any member of the public, including me.
On issues to do with the NHS and how consultations are carried out, we are told and implored to see things differently. How can we see things differently when consultations do not include the public and when consultations are held over the school summer holidays rather than at a time when people and halls are available, and those of us who rely on voluntary assistance in making our arguments can get people to provide it? Better Services Better Value in my constituency intends to start its consultation at the end of the month and run it over July and August, dismissive of the arguments of the public that they cannot meet that timetable. Better Services Better Value has meetings without announcing where they are or what time they are at, and it does not even use microphones. I have been a publicly elected politician for more than 30 years and some of these NHS meetings I have attended have been the worst I have ever encountered during that time. If we wish to bring the public with us in difficult decisions, we have to be reasonable, fair and straightforward in our proposals. Nobody in my constituency understands why the solution to longer A and E waits is the closure of A and Es that are effective and actually work.
I am proud of the NHS and of the staff who work for it daily in my constituency; they are part of a huge team that saves lives every day.
The issue of A and E waiting times has shot up the political agenda, but I am concerned that many of the staff working in those departments will fear that their deeply held commitment to the job will not be getting the recognition it deserves. Across the country, 22 million people have visited A and E, with 96% being seen within four hours—that is nearly 1 million more people than a year ago, which is positive news.
I have great respect for the shadow Secretary of State, but I do not think the A and E crisis is as acute as the Opposition like to suggest. The reality is that in some areas A and E is going incredibly well. Let me talk about my constituency and the Lister hospital, where our team sees about 135,000 patients a year, about 25% of whom are children, with 21% of the patients seen by our A and E department being admitted to hospital.
I shall read a couple of quick reviews from the past few months. One said:
“I Twice needed help in last 2 months, in each case response on phone was excellent and doc phones back within 20 min. Ambulance was there quickly and I was in A&E within the hour. Excellent treatment there and can’t recommend the service highly enough. Could not have done better anywhere. Everyone involved needs to have a big thank you and how lucky we are to have such a great service. I am 83 and still going strong because of this great care. Again thank you all very much.”
“I was recently admitted to Lister via A&E and can only praise every member of staff who dealt with me from that point until I left.”
A third said:
“My son quickly became very ill with strep A and toxic shock syndrome and from the immediate ambulance response to being put in the Short Stay Unit after A&E, he received the most wonderful care and compassion. All of the staff were lovely and we can’t thank them enough.”
So A and E across the country is not as bad as people like to make out. I visited the A and E in Stevenage, spending two and a half hours sitting in the waiting room and then being dealt with very courteously and professionally. It was a very positive experience. I have also been out with the ambulance service in Stevenage and gone around the constituency. I dealt with a number of 999 calls, one of which involved a nine-year-old boy being rushed to A and E. He was dealt with incredibly efficiently by the teams there, who were waiting for him upon his arrival and helped to save his life. They had to put him into an induced coma because of the severity of the condition he was admitted with.
I know that there are issues to address in some parts of the country, but in Stevenage we are benefiting from a £150 million redevelopment of our hospital, which will make it one of the most modern and advanced facilities in the UK. As part of that, a new £20 million A and E unit is being built at the moment. It will be fully open in autumn 2014. I visited the building about a month ago and I can tell hon. Members that it is almost twice the size of the current one. It will have a range of fantastic facilities and services; we have doubled the equipment and doubled the number of people. The staff have been involved every step of the way in designing the new facility with the builders, even pushing the carts around the building to understand the best way in which they can achieve what they want. It will also have a dedicated adult section and a dedicated child section. The Lister hospital and its A and E are doing a great job in my constituency for people every day. A legion of doctors, nurses and clinical staff are doing this fantastic job, and I am proud of them and I am proud of the A and E in my constituency.
I was beginning to think that the debate was about A and E services in London, so I am pleased to be able to say a few words from these Back Benches. The views of people from the north on the London-centric debates we have in this country have been pretty consistent—so let me move on very quickly.
I have been active in health in Parliament over the many years I have been a Member, particularly during the previous Parliament when I chaired the Select Committee on Health. Until a few weeks ago, I had never heard anyone put the case that any problems we had in primary care, or even in secondary care, were to do with the 2004 contract agreed with GPs by the then Government.
On 21 May, I came in to hear the urgent question and listened to the Secretary of State talk about the concept that as
“a result of those disastrous changes to the GP contract, we have seen a significant rise in attendances at A and E”
“direct consequence of those disastrous 2004 changes to the contract”
even though my right hon. Friend the Member for Leigh (Andy Burnham) had said that on that very day
“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”.—[Official Report, 21 May 2013; Vol. 563, c. 1055-57.]
Yet today we have heard that argument again. I never heard it when I was on the Health Committee; I never heard it until this year, and I do not believe it. That is my fundamental position.
I am pleased to see that the Secretary of State has come back into the Chamber. On 21 May, my hon. Friend the Member for Middlesbrough South and East Cleveland (Tom Blenkinsop) asked the Secretary of State how many walk-in centres had been shut since May 2010. The right hon. Gentleman said:
“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.”—[Official Report, 21 May 2013; Vol. 563, c. 1065.]
My hon. Friend the Member for Liverpool, Wavertree (Luciana Berger) asked the Secretary of State
“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?”
“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.”—[Official Report, 21 May 2013; Vol. 563, c. 1069.]
The walk-in centre in Rotherham stops people going to the A and E. It is open 12 hours a day, seven days a week, unlike doctors’ surgeries. During that urgent question, we heard talk about lights going out at 5 pm. When did GPs’ lights not go out at 6 pm at any point in my lifetime? They would start at 4 and go on to 6 pm. The lights were never on in primary care and it is such centres that are really helping.
Today, we have eventually found out that 25% of walk-in centres—that is, 26 of them—have closed. When the one in Rotherham opened, there was opposition from one of the doctors in my constituency who publicly campaigned against it, but that was all about the money that went into his private individual business. That is wrong. The Secretary of State should get off the political fence and start making decisions about what is happening to health care and our people, rather than about what will happen in 2015 at the next general election.
I am grateful to previous speakers, particularly the hon. Members for Lancaster and Fleetwood (Eric Ollerenshaw) and for Mitcham and Morden (Siobhain McDonagh), who made some of the comments I would have made and therefore saved me a good minute.
The crisis in emergency departments is multifaceted and we are facing a downgrade of the emergency department in Cheltenham general hospital. The rationale has not been funding pressures or extra admissions but, as the hon. Member for Lancaster and Fleetwood said, the shortage of emergency doctors. The College of Emergency Medicine recommends that we should have 20 emergency medical posts over the two A and Es in Cheltenham and Gloucester. The trust has only just managed to fill the 12th, so we are at not much better than half strength. That has obvious safety implications and has driven the trust’s recommendations for downgrading A and E at Cheltenham.
The staff shortages have their root in work force planning issues that date back many years. They must date back to the Secretary of State’s predecessor’s time and, clearly, to that of the previous Government, too. The hon. Member for Ealing North (Stephen Pound) was quite right, however, and we should not be playing a party political blame game. We should simply admit that we have a really serious problem and work out what to do about it.
The College of Emergency Medicine suggests that the initial recruitment to the discipline is quite respectable and that retention is the problem. Emergency medicine involves long hours, with a 24-hour cycle of shifts, and is an intense and stressful form of medical practice. I hate to accuse anyone of mercenary motivation, but of course those who work in emergency medicine cannot moonlight in private practice, either, which makes it less attractive from that point of view. So we do need a rethink nationally. I welcome the urgency with which the Government are now addressing that. It should have been done years ago.
In the meantime, changes inevitably are being proposed by local hospital trusts. I do not think we can blame them for that, but, as the hon. Member for Mitcham and Morden said, the process must be open, accountable and transparent. That was, after all, the idea of the new structures that the right hon. Member for South Cambridgeshire (Mr Lansley), the previous Secretary of State, foisted on us in the new system.
The consultation in Gloucestershire has raised real questions. Why has not the trust even tried to pay more for emergency medical posts, as it has the freedom to do so as a foundation trust? Could it have looked more seriously at overseas recruitment? Why has it not been prepared to wait for the Keogh review, or the Secretary of State’s urgent review of recruitment, before making the changes permanent? Why was it not prepared to trial changes just for a year, as Liberal Democrat members of the health overview and scrutiny committee requested yesterday? I deeply regret the fact that Conservative councillors on that committee from all over Gloucestershire voted down that very modest compromise proposal and backed the downgrading of A and E in Cheltenham.
In my detailed evidence I raised issues of increased mortality, and of possible increases in health inequalities resulting from these changes, but I have no evidence that my submission, or the thousands of petition signatures that we gathered locally, have been properly considered at all. The primary care trust consultation website actually disappeared halfway through the consultation process because, of course, the primary care trust ceased to exist and handed over to the new clinical commissioning group. The obvious suspicion locally is that this was a foregone conclusion, and that it is only a matter of time before the trust proposes the outright closure of the A and E at Cheltenham.
That suspicion was strongly reinforced yesterday. Within hours of the health overview and scrutiny committee meeting, the trust issued a joint statement with the new clinical commissioning group, instantly announcing that the changes would now be going ahead on a permanent basis, despite the fact that the trust has not actually considered the outcome of the consultation exercise at either its board or the CCG’s board. That is not open, accountable and transparent, and it must be in future.
We have a crisis in A and E; that is clear from this afternoon’s debate. The King’s Fund report this week detailed the worst performance in nine years, with 5.9% of patients waiting more than four hours. It has been suggested that patients are just going where the lights are on. Is that the case?
I got information on A and E from the chief executive of Salford Royal NHS Trust, comparing the third and fourth quarters of 2011-12 with those in 2012-13. He found that there are 10% more ambulance arrivals every day. We actually have sicker patients, with more arriving by ambulance. There has been a 13% increase in admissions of people staying longer than 72 hours, and fewer are staying for shorter periods. There are 25% more triages into the hospital’s resuscitation area, and there has been a significant increase in risk and co-morbidity among patients and increased admissions into critical care. There is something going on there.
We know that the rising demand for A and E is particularly concentrated in those aged over 85, and cuts in social care budgets are now widely acknowledged as contributing factors. My local authority of Salford must make £24 million of cuts this year. It is the third year of cuts, and now the authority, having held on to services meeting a moderate level of eligibility, is moving to meeting only substantial levels of eligibility, taking £3.5 million out of adult social care this year and £3.5 million next year. Our former Salford primary care trust had already cut the two walk-in centres that we had, and axed the pilot of active case management for people with long-term conditions.
How is that affecting people? What do carers say? Carers UK has carried out a survey of 3,500 carers, 55% of whom are caring for a person who has been admitted to emergency hospital services in the past three years. A significant percentage of those carers referred to areas where additional support could have prevented those emergency admissions. What types of care were needed? Six per cent. said that they, the carer, needed replacement care because they were ill themselves; 21% per cent. needed a higher quality of care and support for the cared-for person; 10% needed adaptations in the home, and 7% would have been helped by telecare and telehealth. Those findings tie in with some of my casework in recent weeks, when I have heard some very similar cases.
The King’s Fund report tells us that the prospects for adult social care are bleak. Councils are planning to reduce their budgets by another £800 million a year. That is a cumulative cut since 2010 of 20% in adult social care. My local hospital tells me that patients are coming in sicker, they are admitted for longer stays, they require more time and attention and they are now heavy resource-users. It is time that Ministers stopped making excuses and started dealing with this crisis.
I am most grateful, Madam Deputy Speaker.
A report in the Evening Standard last Thursday revealed that a spot inspection of Charing Cross hospital in my constituency showed that it was
“so overcrowded that operating theatres were turned into makeshift wards”.
“used the theatres when it ran out of critical care beds—with doctors caring for seriously ill patients because there were no nurses available.”
Charing Cross is one of the four hospitals that are to lose their A and E department—indeed, in the case of Charing Cross hospital, it is to be demolished, with 97% slated to go. I plead with the Secretary of State to accept the point made by my right hon. Friend the Member for Leigh (Andy Burnham) and to review all these closures. The services are in crisis. Please, do not go ahead with any closures of vital A and E services, particularly in north-west London, until a proper review has been carried out and the crisis has been seen for what it is.
We have had a full and thorough debate, with some 18—or perhaps 17 and a half—Back-Bench speeches. I pay tribute to my right hon. Friend the Member for Holborn and St Pancras (Frank Dobson), my hon. Friend the Member for Lewisham East (Heidi Alexander), my right hon. Friend the Member for Exeter (Mr Bradshaw) and my right hon. Friend the Member for Cynon Valley (Ann Clwyd), who made a very personal contribution to the debate, as well as my hon. Friends the Members for Ealing North (Stephen Pound), for Harrow West (Mr Thomas) and for Mitcham and Morden (Siobhain McDonagh), my right hon. Friend the Member for Rother Valley (Mr Barron), and my hon. Friends the Members for Worsley and Eccles South (Barbara Keeley) and for Hammersmith (Mr Slaughter). I also pay tribute to the right hon. Member for Charnwood (Mr Dorrell) and the hon. Members for Totnes (Dr Wollaston) and for Southport (John Pugh), and other Members, too many to mention individually, who contributed to the debate.
I start by paying tribute to the thousands of doctors, nurses and health care assistants who provide extraordinary and professional care in our A and E departments. They are there for us when we need them most and we owe them a huge debt of gratitude. It was apparent from the Secretary of State’s speech that he has absolutely no plans to deal with the disastrous situation in A and E that is entirely of this Government’s own creation. We know that, since this Government came to power, there are 4,000 fewer nurses, the disastrous NHS 111 service is in meltdown, walk-in centres are being closed and social care is in crisis. All those factors contribute to the current crisis in our A and E. We have all seen the news reports of ambulances queuing outside hospitals, with unacceptably long waits and some people even having to be treated in tents in car parks. It is time for Ministers to stop blaming others and to get a grip on the crisis in A and E.
Bluntly, what we are seeing today in A and E is the culmination of three full years of mismanagement of the NHS, with a needless top-down reorganisation and the waste of billions of pounds that could and should have been spent on front-line care. The truth is that there is no grip on the NHS in England. No wonder things are going so wrong so quickly.
When Labour left office, A and E was performing well, with 98% of patients seen within the four-hour target time. Since the election, the number of patients waiting more than four hours has nearly trebled and ambulance queues have doubled. Only yesterday, in a report by the King’s Fund, we saw that A and E waits are at their worst for nine years, with more than 313,000 patients waiting more than four hours between January and April this year. Simply put, under this Government more people are waiting longer. The proportion of patients attending A and E who have to wait longer than four hours is at its highest for 10 years. What more proof do Ministers need to understand that A and E departments are under real pressure and that action is needed, and needed now?
Many patients cannot even get through the doors of our hospitals. We have a shameful situation in which growing numbers of patients are waiting in ambulances to get into A and E because those departments are full. Equally shameful is the number of patients experiencing the indignity of waiting for hours on trolleys in A and E before they can be found a bed on the main hospital wards. It is almost as though we are back to the future—back to the bad old Tory days of the 1980s and ’90s.
There are many other factors that have pushed A and E into the danger zone. Indeed, A and E is a bellwether for the overall state of the NHS and social care. The Government’s cuts to local authority budgets have seen £2.6 billion taken out of adult social care since the election alone. As a result, many older and vulnerable people are having services withdrawn that could have helped them to stay healthy and independent in their own homes, and many others face rising charges for the care that they need. That is a major cause of the A and E crisis, as fewer older people get the care that they need at home, and ever more have to be admitted to hospital. It also means that there are delays in ensuring that appropriate support is available at home, or in the community, which delays a patient’s discharge. That has a knock-on effect right through the hospital: with no free beds on the wards, A and E staff cannot admit patients to the hospital wards, and with A and E full, ambulance staff cannot hand over patients.
As we have heard, under-staffing is also causing huge problems in the health service. Since the election, more than 4,000 nursing posts have been lost from the NHS, and the Care Quality Commission has warned that one in 10 hospitals is failing to meet the standard for adequate staffing levels. Hospitals are continuing to make severe cuts to front-line staffing, with many operating below recommended levels. Under this Government, right across England, we are seeing the closure of well-used NHS walk-in centres, meaning that more people are having to go to major A and E departments when they could be helped elsewhere.
Lastly, there is the meltdown of the 111 helpline; NHS England identified the poor roll-out of 111 services as one of the main reasons for the deterioration in A and E department performance. As the 111 service uses staff who do not always have clinical training, they are more likely to play it safe, meaning that more people are being directed towards A and E departments. Over Easter, callers in 30 areas waited for more than an hour for a call back, and in some regions more than 40% of calls were abandoned by patients. One patient waited 11 hours and 29 minutes.
It is no good Ministers arguing that there has been a large increase in the number of people attending A and E, driven by changes to out-of-hours care that were caused by Labour’s renegotiation of the GP contract in 2004; that was nine years ago. The Secretary of State’s spin was blown out of the water by the Chair of the Select Committee on Health, the right hon. Member for Charnwood—and by the chief clinical officer at Stockport clinical commissioning group, who said:
“The focus on the 2004 GP Contract as a main cause is not only a incorrect assumption but also serves to distract the public from the urgent debate that’s needed about the choices the NHS, the public, media and politicians now need to make”—
his words, not mine.
The Government parties should and must do more to protect the NHS from the immediate crisis, so will they now implement our A and E rescue plan? The Secretary of State derided our initiative to use underspends in the NHS budget to put an extra £1.2 billion into social care over the next two years, but that investment would not only relieve pressure on A and E, but help tackle the scandal of care services being withdrawn from older people who need them.
Will the Under-Secretary of State for Health, the hon. Member for Broxtowe (Anna Soubry), review all 111 contracts? Early indications are that the number of cases referred to nurses has fallen from 60% through NHS Direct to just 17% with 111. What will she do about that? Will she also ensure that all hospitals have safe staffing levels, and intervene to prevent further job losses? Will she halt the closure of NHS walk-in centres and await the review that is being conducted by Monitor to see what the impact is on the local community and the NHS? Will she immediately and personally review all planned A and E closures and downgrades, and use the very latest evidence of local pressures to ensure that plans are based on robust clinical evidence?
Instead of accepting responsibility for the mess that they have created, the Government have spent recent weeks casting around for scapegoats. We have seen them blame the winter weather; influenza; bank holidays; immigrants; GPs; and today’s latest from the public health Minister, female doctors, because they get married, have children and work part time. [Interruption.] She protests, and I notice she had to put out a statement this afternoon to
“clarify discussion on female GPs” .
“I fully support women GPs, my comments were not intended to be derogatory.”
The truth is that this Government do not even know who to blame any more. It is just not good enough. While the components of the A and E crisis might be complex, the real cause is simple: you just cannot trust the Tories with the NHS.
Oh dear, what a pity. Until the hon. Member for Denton and Reddish (Andrew Gwynne) rose to speak, it was going rather well. There was almost an outbreak of consensus after a number of thoughtful contributions from Members on both sides of the House. Unfortunately, as ever, the hon. Gentleman had to fall back into the old ways of cheap party political points and cheap partisan comments. I agree with him on one point. [Interruption.] Hon. Members may want to calm down and chill out a little. The hon. Gentleman rightly paid tribute to all the doctors, consultants, nurses, receptionists and everyone who works in our accident and emergency departments.
That sort of cheap comment does the hon. Lady no justice whatsoever or credit. Let me explain to her—I was here for the debate, and she was not—that I did not in any way blame women doctors. As someone who has worked as a woman professional all my life, I really do not want to hear any lessons from Opposition Members. What I did was echo the comments of the president of the Royal College of General Practitioners, and I paid tribute to all our GPs for their hard work and dedication to our NHS, and to their patients.
There are immense pressures on the NHS as a whole, and on A and E in particular. Our A and E departments are dealing with 1 million more people than they did when the previous Government were in power. The causes of that increase in demand are complex: a long, cold winter; an ageing population; and more people with long-term conditions. The system itself, let us be honest, has not helped, from poor integration between health and social care to the lack of public confidence in out-of-hours primary care services. We can have an argument about the 2004 GP contract, but as the hon. Member for Southport (John Pugh) rightly said, it has not helped. Today, we have a situation in which, if people do not know where to go, or they are not sure that they will get a good service, they go to A and E. In a recent hearing by the Select Committee on Health, Dr Patrick Cadigan, a registrar from the Royal College of Physicians, set out the position perfectly:
“Patients will go where the lights are on. In many of these alternatives, the lights are not on after five o’clock in the evening or at weekends.”
That presents a set of challenges that the Government are determined to address. First, it is important that we deal with the current situation, and we are.
Already, emergency departments have recovered from the dip in performance over the winter. [Interruption.] The hon. Member for Denton and Reddish did not give way, and I am adopting his admirable approach in this debate.
For each of the past five weeks, the four-hour waiting time target has been either reached or exceeded. The average wait in A and E is currently 50 minutes. More importantly, we are making the NHS fit for the future: a future where care is designed and delivered around the specific needs of an individual patient; where care is integrated across primary and secondary care and across health and social care; and where local clinicians, not national politicians, decide what is best for their communities. The Government have taken tough decisions that will create a strong and sustainable NHS, now and for generations to come. The Health and Social Care Act 2012 has finally brought local health and social care communities together to design integrated services around the needs of their patients, building in strength for the future. So if more services are needed outside hospitals, local clinicians working with community partners can make those decisions, without having to wait for a Minister to tell them what to do.
We have not stopped there. We have provided £7.2 billion to local authorities for social care. We have given hospitals the ability to carry over underspends—free to pool their budgets locally to improve care for patients. We have new urgent care boards which will use the savings from the marginal rate emergency tariff to reduce pressure on A and E. The NHS Medical Director, Sir Bruce Keogh, is currently reviewing the provision of urgent and emergency care. This autumn the vulnerable older people’s plan will set out how we will improve primary and out-of-hours services for the frail and the elderly and how we can remove barriers to integrated care. At every step of the way we are putting local doctors and nurses in charge and designing care around the patient.
I shall deal briefly with some of the very good speeches that were made on both sides of the House. We heard first from two former Secretaries of State for Health, the right hon. Member for Holborn and St Pancras (Frank Dobson) and my right hon. Friend the Member for Charnwood (Mr Dorrell). Both were eloquent and informed. I have to say that the speech and the comments of my right hon. Friend found more favour with me. The hon. Member for Lewisham East (Heidi Alexander) asked for a grown-up debate, and we had a good contribution from my hon. Friend the Member for Totnes (Dr Wollaston). I have addressed the unfortunate remarks that she made, perhaps not having read Hansard, if I may say so.
I turn to other valuable contributions. The right hon. Member for Cynon Valley (Ann Clwyd) made a contribution, as we would expect. Then we heard from my hon. Friend the Member for Brigg and Goole (Andrew Percy), who spoke briefly about his local experience in his constituency and brought those experiences, rightly, into the debate. He touched on walk-in centres, an issue that was raised by—I nearly said my hon. Friend; I beg his pardon if that is in any way disparaging to him—the right hon. Member for Rother Valley (Mr Barron), who beautifully forgot that any decision about the future of any walk-in centre is a local decision. It is for local people—[Interruption.] I am not knocking anybody; I am explaining the facts. I appreciate that the right hon. Member for Leigh (Andy Burnham) has a problem with the facts, but the facts are that these are local decisions made by local communities and local clinicians.
My hon. Friend the Member for Bracknell (Dr Lee) gave a thoughtful and challenging speech, and I hope that many will take that away and listen to what he said. I shall deal briefly with the comments of my hon. Friends the Members for Lancaster and Fleetwood (Eric Ollerenshaw) and for Stevenage (Stephen McPartland) and the hon. Member for Cheltenham (Martin Horwood), who spoke about some of the difficulties that we have with the recruitment of doctors. Departmental officials have met. We know that it is a problem. We have worked with the College of Emergency Medicine and we know that we need to tackle the problem. We did that in 2011 and those issues will in due course be considered. I hope we will see some changes.
The hon. Member for Mitcham and Morden (Siobhain McDonagh), as ever, championed her local hospital, as I expect her always to do, but she spoke about a lack of public consultation and many of us will take away her wise observations on that. It is important to remind the House of the comments of my hon. Friend the Member for Lancaster and Fleetwood. He, like others in the debate, reported that his constituents get a good service from good staff. All of us should remember that.
To conclude, in challenging circumstances, and with this Government’s support, the people of our NHS are performing admirably. There are over 400,000 more operations now than under Labour. The proportion of cancellations remains unchanged. Fewer than 300 people—276—are waiting more than a year for an operation, compared with 18,000 under the Labour Government. Some 8,500 more clinical staff are working in our NHS, including 5,700 more doctors. MSRA rates have halved. Mixed-sex wards have been practically abolished. We are finally moving towards a paperless NHS by 2018. In addition, in stark contrast to the Labour party’s plans, we now have a protected NHS budget, with real terms—