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Urgent and Emergency Care Review

Volume 570: debated on Tuesday 12 November 2013

(Urgent Question): To ask the Secretary of State for Health if he will update the House on Professor Sir Bruce Keogh’s urgent and emergency care review following this morning’s briefing to the media.

In January this year, the board of NHS England launched a review of urgent and emergency care in England. Urgent and emergency care covers a range of areas, including accident and emergency departments, NHS 111 centres and other emergency telephone services, ambulances, minor injury units, and urgent care centres. The review is being led by Professor Sir Bruce Keogh, NHS England’s medical director. A report on phase 1 of the review is being published tomorrow, and it is embargoed until then. [Interruption.] This is an NHS England report, and NHS England is an independent body, accountable to me through the mandate. The report that will be published tomorrow is a preliminary one, setting out initial thinking. [Interruption.]

Order. There are highly charged feelings on this matter, but the Secretary of State has been asked a question, and his reply must be heard.

I should underline the fact that this morning’s briefing was under embargo, an embargo which, to my knowledge, has been respected. The final version will be published in the new year.

Sir Bruce has said that he will outline initial proposals and recommendations for the future of urgent and emergency care services in England, which have been informed by an engagement exercise that took place between June and August this year. There will be further consultation on the proposals through a number of channels, including commissioning guidance and demonstrator sites. Another progress report will be produced in the spring of 2014.

Decisions on changing services are made at a local level by commissioners and providers, in consultation with all interested parties. That is exactly as it should be, as only then can the system be responsive to local needs. It is vital to ensure that both urgent and emergency care and the wider health and care system remain sustainable and readily understandable to patients. A and E performance levels have largely been maintained, thanks to the expertise and dedication of NHS staff. A and E departments see 95% of patients within four hours, and the figure has not dropped below the 95% target since the end of April. However, urgent and emergency care is falling behind the public’s needs and expectations.

The number of people going to A and E departments has risen historically, not least because of an ageing population. A million more people are coming through the doors than in 2010. Winter inevitably challenges the system further, which is why we are supporting the most under-pressure A and Es with an additional £250 million. Planning has started earlier than ever this year, and the NHS has been extremely focused on preparing for additional pressure.

We will look at Sir Bruce’s report extremely carefully. Reform of the urgent and emergency care system may take years to complete, but that does not mean that it is not achievable. We are exceptionally fortunate in this country to have in the NHS one of the world’s great institutions. NHS staff are working tirelessly to ensure that the care that people need will continue to be available to them, wherever and whenever they need it.

Rarely has this House been treated to a more disrespectful and complacent reply. There are new reports today of 12,000 patients spending 12 hours or more on trolleys in A and E. A and E is in crisis according to the College of Emergency Medicine, and this is before the winter has even started. People are increasingly asking, “Where are the Government and what are they doing about it?” So far all they have heard is, “Crisis? What crisis?” But behind the scenes it is a different story. Such is the panic in Whitehall, the Prime Minister has apparently taken personal charge and this morning the media were given a private briefing on a major review of emergency care. What is going on and why is the Secretary of State running scared, blaming NHS England and trying to keep this House in the dark? It should not be for us to drag the Secretary of State here to give Members information already passed to journalists.

Let me remind the House what the Secretary of State said at Health questions in July. He said that Bruce Keogh’s review

“will report this autumn, precisely so that we can make sure we learn any lessons we need to learn for this winter”.—[Official Report, 13 July 2013; Vol. 566, c. 902.]

To hear him now, it was all about the long term. Let me ask him: what are those lessons, and what immediate action is he now taking ahead of winter?

Weekend briefings suggested Sir Bruce emphasises alternatives to A and E, such as walk-in centres and 111, but Monitor reported yesterday that one in four walk-in centres have been closed and others are today under threat of closure. We need a clear answer. Will the Secretary of State stop further closures of walk-in centres? Does he now accept that his 111 helpline is flawed, and will he put nurses back on the end of the phone, rather than call handlers? And what of the recruitment crisis in A and E? There is a shortage of senior A and E doctors and, according to the Royal College of Nursing, 20,000 too few nurses. Will the Secretary of State give a clear commitment to bring all A and Es back up to safe staffing levels?

Last week, a complacent Prime Minister stood there, told us everything was fine, and even claimed that the average waiting time in A and E had gone down to 50 minutes, but that is not true. I have here a written reply from the public health Minister telling us it has gone up to over two and half hours. When are the Government going to show this House and the country some respect, cut the spin, and give us the real picture about a crisis that is happening right now?

Mr Speaker, I will tell the right hon. Gentleman what complacency is: it is refusing to have a public inquiry into Mid Staffs, where staff in A and E departments were bullied and harassed when they tried to speak out. He did not think it was worth having a public inquiry into the poor care that his Government swept under the carpet and which we are doing something about. There is one figure that he refused to mention: the A and E performance figures published last week of 96.4%—hitting the target, higher than the previous week, higher than this time last year. That sums it up: in a good week he wants to run down the performance of hard-working staff whereas this Government are backing them.

Why are we having an A and E review? It is to clear up the mess and confusion caused by 13 years of Labour mismanagement of our emergency services. The right hon. Gentleman talks about walk-in centres. Why were they introduced? Because of the disastrous mistake over the GP contract. The brave thing for his Government to have done would have been to admit they got that wrong and reverse it, but they did not. They introduced a whole new raft of services, which confused the public: A and E, walk-in centres, GP surgeries, telephone helplines. Tomorrow we will sort out those problems. Yes there are difficult decisions, but they are decisions his Government ducked and left the public exposed as a result.

Before the right hon. Gentleman runs down our A and E services, let me just gently remind him that he talked about a recruitment crisis, but we have 300 more A and E consultants than when he was Health Secretary, we have nearly 2,000 more people—[Interruption.] I am sorry that this is difficult for those on the Opposition Front Bench to listen to. We have nearly 2,000 more people being seen within four hours every single day than when the right hon. Gentleman was Health Secretary —that is some 700,000 more people every year. We have more hospital doctors, more hospital nurses, more treatments and fewer long waits than when he was Health Secretary, and he should celebrate that improvement in our NHS’s performance, instead of trying to run down the people on the front line.

I will tell the right hon. Gentleman something else we are doing. We are tackling the long-term causes of pressure in A and E that his Government absolutely failed to do: not just the GP contract but also the integration of the health and social care system, the lack of which means that hospitals are not able to discharge people from their beds on time, causing huge pressure. Today, the shadow Health Secretary has shown his true colours. The man whose Government made so many wrong decisions about A and E is exposed as trying to make political capital while this Government sort out his mess.

How many extra lives does my right hon. Friend expect to save through consolidating the A and E facilities in London, by having a smaller number of hospitals with more doctors? Does he expect to replicate that across England?

My hon. Friend is absolutely right. The changes we announced in north-west London will save hundreds of lives, by using principles that we will hear more of from Sir Bruce tomorrow. In particular, we are putting 800 extra people into out-of-hospital care, which will help the frail elderly, many of whom should never go to A and E—it is the most confusing place that someone with advanced dementia can go. If we can treat them at home, it is better for them and for our hard-working A and E departments.

May I assure the Secretary of State that the people of Exeter are not confused about their walk-in centres, but appreciate them and have been using them in ever-increasing numbers? These centres are now under threat, so will he at least admit that closing NHS walk-in centres and scrapping Labour’s GP access targets has been a dreadful mistake?

Perhaps the right hon. Gentleman might like to hear what the British Medical Association said yesterday about walk-in centres. The BMA is not known for its support of Government policies, but it said that urgent care centres

“were often opened in places with little patient demand…The result has been a lot of money being spent on these facilities with some now closing because commissioners have found there is not sufficient demand”.

That is the problem we are sorting out.

One long-term cause of pressures in our A and E departments is the lack of parity of esteem between physical and mental health. Does the Secretary of State agree that it is unacceptable that two thirds of people experiencing a mental health crisis do not get access within four hours to a psychiatric assessment? Was it not a failure of the previous Government not to set access standards for people with mental health problems? Is it not time, as the mandate does today, to deliver just that?

My right hon. Friend is absolutely right about that. We do need parity of esteem between mental and physical health. The situation puts particular pressure on A and E departments, including the one closest to this House, at St Thomas’s hospital, where people said that the biggest single worry they have and the biggest single thing that makes it difficult for them to meet their targets is the lack of quick access to psychiatric services. We are looking at this matter and he is right to highlight it.

The Minister said that changes taking place in urgent and emergency care are done locally for local need. What does he think of the following statement made by Sir David Nicholson last week before the Select Committee on Health? He said:

“We are bogged down in a morass of competition law…we have competition lawyers all over the place telling us what to do, which is causing enormous difficulty.”

Does the Secretary of State not agree that the Government were warned about that when they brought in the Health and Social Care Act 2012? They were told that competition law was going to create chaos in the NHS, and it is doing exactly that.

I think the right hon. Gentleman will find that some of the competition law powers that are being used and are causing Sir David worry were actually from the Enterprise Act 2002, which we are now looking at to see whether we can sort it out.

Is the Secretary of State aware that hospitals in Norfolk have recently made it clear to MPs that one of the key drivers of a big increase in people going to A and E is the fact that many people are not going to their doctor? Does he agree that it is essential that the GP contract of 2004 is rewritten so that doctors provide that 24/7 cover? When will he be able to sit down with the BMA and make real progress to right a serious mistake that the Opposition made?

My hon. Friend speaks wisely. The most senior A and E doctor in the country, Professor Keith Willett, said that he thought that between 15% and 30% of the people attending A and E could be looked after in the community. This is a root cause of pressure. I am afraid that the Labour party needs to show some humility before it starts whipping up public concern about problems that it had a very big part in making. I am in the process of discussions with the BMA, and I hope my hon. Friend will not have to wait too long for some good news.

Will the Keogh review genuinely examine the lack of parity in respect of those who are physically ill and those who are mentally ill? We are already suffering from a crisis in emergency mental health beds in London and we are seeing an increasing use of A and E departments for those who are mentally ill. Surely we should be looking at an increase in walk-in centres for the mentally ill, which have proven to be remarkably effective in helping those on the brink of a serious fall.

The hon. Lady is absolutely right that the urgent emergency care we offer to people with mental health problems is not up to scratch and needs to be a great deal better. Different solutions will be appropriate in different parts of the country, but often going to a normal A and E is not the right approach. We need to consider whether, when people have such conditions, there can be better access to people who know them, their medical history and their condition and who are in a position to advise them in a way that means they do not end up doing what I have seen happening time and again in A and Es, where people end up as frequent fliers, going again and again to an A and E just because there is nowhere else to go. That is one thing that we are trying to sort out tomorrow.

We have heard a lot today about NHS A and E services in England. Will my right hon. Friend tell the House whether there are any lessons to be learned from A and E services in Labour-run Wales?

Wales has not met its A and E target since 2009 because the Welsh Government followed the advice of the shadow Health Secretary and cut the NHS budget by 8%.

This Government have been in power for three and a half years. They could have chosen to remedy some of the continuing problems in the health service, but what did they do? They decided to reorganise it from top to bottom. Is there any wonder there is a crisis this winter? Instead of closing A and Es and walk-in centres, why does the Secretary of State not walk away? It would give him more time to count his money.

Let me tell the hon. Gentleman that thanks to the reorganisation that he is so bitterly against, we have 5,500 more doctors on the front line and 8,000 fewer managers. We would not be managing to hit our A and E target today if we had not taken the difficult decisions that the Leader of the House took when he was doing my job.

Geography dictates that my Montgomeryshire constituents depend on A and E services in hospitals in England. Will my right hon. Friend reassure us that devolution will not be allowed to create a health care iron curtain between England and Wales, and will he ensure that decisions on A and E services in Shropshire take account of the interests of my constituents?

We will absolutely ensure that there is no iron curtain, but I must say that the increasing number of people coming from Labour-run Wales to seek treatment in England is an indication that people are voting with their feet because they know where the NHS is being better run.

On repeated occasions in this place, the Health Secretary has claimed to be saving A and Es when his proposals would remove intensive care units in many hospitals and allow blue-light ambulances to go sailing past their doors. Will the Health Secretary tell me what his definition of an A and E is?

That is exactly what tomorrow’s report is designed to clarify. It is not for me—[Interruption.] Let me say very straightforwardly—[Interruption.]

Order. I can scarcely hear the Secretary of State’s answers, and I want to hear them. Let us hear the response.

Thank you, Mr Speaker.

The hon. Member for Lewisham East (Heidi Alexander) will know that her constituents have some of the best stroke survival rates in England because we reduced the number of hospitals in London offering stroke services from 32 to eight. I am not going to stand in the way of those changes if they save lives.

I very much look forward to the review, which is urgent. Given that accident and emergency departments do not operate in isolation, will the Secretary of State assure me that the review will consider the whole system, including support services, critical care units and the availability of specialist consultants—particularly those in paediatrics—who need to be available for an A and E to function effectively?

No one has campaigned more assiduously than my hon. Friend for his local hospital, despite the incredible tragedies and difficulties that it has been through and the pressures that has created for the people of Stafford. He is absolutely right: if we are going to solve the problem, we must consider the system holistically and consider how different A and E departments can specialise services. We need much more of a hub-and-spoke system, rather than one where every A and E has to offer exactly the same menu of services. If we do that, we will save more lives and that has to be the right thing to do.

Following Monitor’s report yesterday on the closure of walk-in centres, is it not the case that at the heart of the Government’s NHS reforms is a massive shift in power from the consumers—the patients—to the producers of services? When the Government’s slogan is, in effect, “All power to the producers”, it is not surprising that services have been reorganised in a way that does not benefit patients. May I suggest that instead of sticking up for the BMA, the Secretary of State starts to stick up for patients?

After what happened at Mid Staffs, we will not take any lessons on sticking up for patients—none whatsoever. We are taking the power out of the hands of the managers in PCTs and SHAs and putting it into the hands of doctors on the front line who are seeing patients every day. That is the best thing we can possibly do.

My constituents tell me that they much prefer to go to their doctor than to any other centre. Will the Secretary of State try to get more doctors involved in out-of-hours care?

That is the tragedy of what happened in 2004, when the personal link between doctor and patient was broken because the previous Government abolished named GPs for every patient. My hon. Friend speaks very wisely, as that is exactly what most members of the public want—they want to be able to get in and see their own GP quickly and easily. That is at the heart of the problem that tomorrow’s review of A and E will seek to address.

Notwithstanding the brilliant local work of nurses and doctors, hospitals like those in the Brighton and Sussex University Hospitals NHS Trust face real challenges, including bed shortages and people having to wait for many hours for tests such as X-rays and so on. Sometimes, people wait in A and E for 12 hours for a bed. Does that not demonstrate how reckless and dangerous it is for the Secretary of State’s Department to impose cuts of £30 million on that hospital trust this year and next year, and will he reconsider?

Let me gently remind the hon. Lady that we have protected the NHS budget—we took a very difficult decision—but how the NHS budget is spent in local areas is a matter for local discretion. It is challenging for all hospitals, because if we are to address the long-term stability of the NHS we need to spend more money out of hospitals, which means finding efficiency savings in hospitals. We do not want to duck those challenges, which is why we are having the review that will be published tomorrow.

My right hon. Friend will be aware that there are concerns about whether blue-light ambulance services will continue to define what an A and E is. Does he agree that for some years now victims of stroke, trauma and other serious problems have not necessarily gone to their local A and E but to specialist hospitals, and that that has been the reason behind the excellent improvement in outcomes?

My hon. Friend speaks extremely wisely. We have talked about stroke, so let me give another example, which is trauma. We have cut mortality rates by 20% as the result of a strategy to specialise trauma care. Those are the difficult decisions that the Government believe that we should not duck and that we need to face up to. If I may say so, when the Opposition were in power, they took a slightly wiser approach to the issue than the party political posturing we are getting today.

The Secretary of State earlier quoted the suggestion that GP walk-in centres were in the wrong places, where there was little demand. Last year, 33,000 people used the under-threat Accrington Victoria hospital walk-in centre, and now there is deep anger with the Conservative party. Will he explain how 36,000 people going to overstretched Royal Blackburn hospital A and E will help the situation there?

The hon. Gentleman makes my point for me extremely eloquently. Under the previous Government, we had a top-down, ham-fisted policy of opening walk-in centres everywhere as a sticking plaster solution to the disasters with their GP contract. Sometimes they were valuable services, sometimes they were not. We are clearing up the mess, but sometimes, when those centres are useful and important for the public, we will keep them.

The origins of the recruitment crisis in A and E obviously predate this Government. Will Sir Bruce Keogh’s review highlight the local trusts, like that in Gloucestershire, which appear to have significantly worse recruitment and retention records than neighbouring trusts and have used it as a rationale for downgrading services—such as, in this case, those at Cheltenham general hospital?

I hope that it will. I hope that it will give clarity about the long-term future for A and E departments, which has been a difficult issue for this Government and for the previous Government. What people want is stability, and they want to know that there is a Government who are prepared to face up to difficult decisions. They want to know that they have a future, and I hope that tomorrow’s review is the first step towards providing that security.

Is the Secretary of State aware that the A and E crisis is creating a huge backlog in specialist procedures, and will Sir Bruce Keogh’s review take that into account?

The number of people waiting more than a year for an operation has gone down from 18,000, when the hon. Gentleman’s Government were in power, to fewer than 1,000 now. We have reduced long waits at a time of great pressure on the NHS, so I do not recognise the hon. Gentleman’s figures at all, I am afraid.

My right hon. Friend will have seen the disastrous reports that have come in about Barking, Havering and Redbridge University Hospitals NHS Trust, with some of the most alarming things including a report of a baby being put in a stationery cupboard. I am sure that, as he said in a recent debate, he will conduct a full review of King George hospital. Can that be done urgently, as we are now in a very serious situation?

I pay tribute to my hon. Friend for raising both publicly and privately his concerns about the hospital provision that his constituents face. We shall of course make sure that there is a proper review before any service changes are made. I hope that he will be reassured by the big change that happened this year with the introduction of an independent chief inspector of hospitals, who is going round the country rooting out poor care, not sweeping it under the carpet, as happened so often under the Labour Government.

The number of hospital nurses has gone up since the election, and as a result of the changes in the Francis report—the hon. Gentleman’s party refused to have a public inquiry many, many times—I hope that the NHS will recruit many more nurses.

The three Members for north Northamptonshire— the hon. Member for Corby (Andy Sawford), my hon. Friend the Member for Wellingborough (Mr Bone) and I—have come together on a cross-party basis, and are working with local clinical commissioning groups and Kettering general hospital to try to attract more investment to our local A and E because of the increase in the local population. May I share with the Secretary of State the fact that all agree that up to a third of attendees at A and E could be better treated closer to home, particularly in excellent urgent care centres such as that in Corby?

My hon. Friend speaks extremely wisely. He invited me to visit Kettering hospital, and I saw for myself that it was a very, very busy hospital. In the end, if we just stick with the current model we will reach bursting point, which is why we need to look at new models. That is why tomorrow’s review is important, and part of that—in fact, the bulk of the work in tomorrow’s review—is about how we transform out-of-hospital care, which is the big strategic change that we need to make in our NHS, and on which I am afraid the previous Government made so little progress.

Tomorrow’s review is supposed to deal with issues to do with this winter. Will the Secretary of State give the House an assurance that there will be no crisis of A and E on his watch this winter?

A and E departments are under huge pressure. We are seeing about 1 million more people every year than three years ago, and we have done more this year than has ever been done in NHS history to help to prepare the NHS for winter, including giving £250 million to 53 local health economies where the pressures are greatest. We continue to monitor the situation very, very closely to give more support where we can.

The crisis in nurse vacancies and recruitment highlighted today by the Royal College of Nursing affects the North Tees and Hartlepool NHS Foundation Trust, which tells me that it has been forced to recruit trained nurses from the Philippines, as there are insufficient UK nurses available. What is the Secretary of State doing to address that particular part of his failure?

I have to gently say to the hon. Gentleman that recruiting nurses from the Philippines did not happen for the first time under this Government. One reason why those nurse vacancies have gone up is that the Government decided to conduct a public inquiry into what happened at Mid Staffs. The system reacts to that by wanting to hire more nurses, and I think that he should welcome that, not criticise it.

The report by the Health Select Committee on the A and E crisis found that only 16% of hospitals had the right level of consultant cover in A and E. Yesterday, we learned that half the vacancies for senior A and E doctors are unfilled, as doctors move to work overseas. The issue of staffing in A and E has been understood for the past three and half years, and there have been repeated warnings and reports. What has the Secretary of State done to address it and make sure that A and E wards have sufficient staff cover?

Recruiting 300 more A and E consultants than when the hon. Lady’s Government were in power.

What has the Secretary of State got to say about the fact that in my area, compared with four years ago, it is harder to get a GP appointment. We no longer have NHS Direct, and cuts in adult social care mean that patients are not making room for other patients to go to A and E. The person raising that with me is the chief superintendant of Darlington police, who is fed up with his officers being held up by taking patients to A and E, as those patients would otherwise wait more than an hour for an ambulance?

The hon. Lady makes some important points, and I congratulate her on being the first Opposition Member to raise the fact that it has become harder and harder to get an appointment with a GP. [Interruption.] I know that it is hard to accept, but it is a fundamental problem, and a challenge facing our A and E departments that the Government are determined to sort out.

Before tomorrow’s report on the urgent and emergency care review, may I tell the House that in Northern Ireland, we treat urgent referrals by direction to the doctor on call and linking up with the chemist. Emergency referrals are done through hospitals, showing good practice and delivery. Is the Secretary of State prepared to contact the Northern Ireland Assembly and the Minister responsible to see how best practice works?

I am in regular contact with the Northern Ireland Minister for Health, Social Services and Public Safety about good practice in Northern Ireland, and I am delighted to hear that they are doing some good things in urgent and emergency care. We should be open to all good practice, not just in our country but all over the world.

The Secretary of State may have seen the report in The Sunday Times at the weekend about the dispute between the medical director for London, who said that 20% to 30% of blue-light A and Es should close, and Sir Bruce Keogh, who said that less than that should close. Disgracefully, the Secretary of State has not told us what is in Sir Bruce Keogh’s report, but we know that it is below that figure, so why did he announce to the House two weeks ago that four out of nine—45%—of blue-light A and Es in west London would close, pre-empting the Keogh review?

Because it is going to save the lives of the hon. Gentleman’s constituents; it will mean that 800 more people are employed in out-of-hospital care; it will mean three brand-new hospitals for the benefit of his constituents; it will mean seven-day working; and it will mean seven-day opening of GP surgeries. That is why.

On reflection, does the Secretary of State regret the fact that he described people who felt ill enough to have to go to A and E on a number of occasions as “frequent flyers”? And would he like to apologise?

I am sorry, that is a completely ridiculous thing to say. I was using the phrase to talk about people who have to go back to the NHS time and again. The whole purpose of the reforms is to make sure that we give a better service to people who regularly use the NHS, and he should understand perfectly well what I was talking about.

What discussions has the Secretary of State had with his colleagues across government about the need for urgent additional investment in social care? Surely he appreciates that the savage cuts to local authority social care budgets have only added to the pressure on accident and emergency units.

I find it a little difficult to take a lesson from the right hon. Gentleman, as his Government cut social care funding per head when they were in power and when the economy was in much better shape than it has been since the financial collapse that they caused. If he looks at what we announced this summer, he will know that the Chancellor announced an extra £2 billion of support for the NHS budget going into social care to deal with precisely the problems that he raised.

Order. I apologise to the hon. Gentleman, but there was a lot of noise. I am sure that the House will wish to hear his question—let him start again.

Last week the Secretary of State assured me that A and E at Ealing hospital is safe, but since then we have heard very confusing and contradictory statements in the local area. First, will the Secretary of State reassure us today that the A and E department at Ealing hospital is safe in the future? Secondly, will he meet me and my colleagues from the west London area—I have written to him—to discuss our concerns and so that we can express our feelings?

I am always happy to meet colleagues if they have concerns about what is happening in their constituency, but I absolutely stand by what I said. There will remain an A and E at Ealing. That was the decision that I made because I wanted to give clarity, but I also said that the shape and size of that A and E may change in accordance with the announcement that is being made tomorrow by Sir Bruce Keogh. I hope that will give the hon. Gentleman further clarity and further certainty to reassure his constituents.

The Secretary of State has already acknowledged that keeping people in their own home is one important way to relieve the pressure on A and E. I do not understand why, if he wants to make a real difference, he will not reinvest the NHS underspend to make up for the cuts in local government and put it into social care.

We have put in an additional £2 billion—that makes a total of £3.8 billion being invested to support the social care budget. That is significant because it is recurring expenditure. We have shown our commitment by continuing to support the social care system through this Parliament. The trouble with underspends is that they depend on how many resources we have in any particular year. It is therefore much harder to invest off the back of them.

The Secretary of State has spoken about the importance of continuing care from one’s own GP to limit admissions to A and E, yet in Hackney, when GPs tried to take over and run the out-of-hours service, the commissioners were paralysed by the fear of legal challenge and, rather than putting patients’ interests first, put the rich lawyers’ interests first.

If I may say so, it was the Government whom the hon. Lady supported who removed the responsibility for out-of-hours care from GPs. I welcome and want to help any GPs who want to take it back.

This Secretary of State has been forced to answer more urgent questions in the House than even the Prime Minister about Mrs Bone. When will he stop blaming others about the mess he has made of our NHS, take some responsibility for the top-down reorganisation and get on with the job that he has been over-promoted to do?

Let me tell the hon. Gentleman how well the NHS is doing. If one listens to the rhetoric from the Opposition Benches, one could completely underestimate the hard work of people on the front line. There are 800,000 more operations being carried out every year in the NHS than ever happened under Labour. At the same time, long waits for operations have gone down. I think that is something to be proud of.

The response that the public health Minister gave to my written question showed that ambulance response times have increased over the past two years in 11 out of 12 trusts in England. Why is this happening?

Just as there is more pressure on A and E departments, there is also more pressure on ambulance services. We are treating that as very much part of how we support accident and emergency services over the coming period. There are particular pressures in the London area, the east of England and the east midlands, and we are doing everything we can to put those problems right.

The Secretary of State referred to the Chancellor’s recent announcement about money for social care, yet this is only a tiny fraction of what the Government have already taken out of the social care budget through their 30% cuts to councils. Did he not realise the impact that that would have on A and E, or did he just not care about it?

I am very conscious of the pressure that having to sort out Labour’s deficit is creating on all Government Departments, but the Opposition cannot have it both ways. They cannot say that they are in favour of fiscal responsibility and then complain about every single cut. The difficult decision that this Government took was to protect the NHS budget. That is something that the Opposition did not agree with. They wanted to cut the budget from its current levels.