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NHS: Accident and Emergency Services

Volume 758: debated on Wednesday 7 January 2015


My Lords, I shall now repeat as a Statement the Answer to an Urgent Question given in another place by my right honourable friend the Secretary of State for Health on major incidents and A&E performance in hospitals. The Statement is as follows.

“Mr Speaker, I welcome this opportunity to come to the House and make a Statement on accident and emergency services.

First, we must recognise the context. The NHS always faces significant pressures during the winter months, but with an ageing population we now have 350,000 more over-75s than four years ago. As a result, we are seeing more people turning up at our A&Es, with 279,000 more attendances in quarter 3 of this year compared to last and a greater level of sickness among those who arrive, leading to an increase in emergency admissions of nearly 6% on last year. This picture is reflected across the home nations, with A&Es in Wales, Scotland and Northern Ireland all missing key performance standards as a result.

A number of hospitals have declared major incidents over the past few days in what is traditionally a particularly busy time in A&E. A major incident is part of the established escalation process for the NHS and has been since 2005. This enables trusts to deal with significant demands, putting in place a command and control structure to allow them to bring in additional staff and increase capacity. It is a temporary measure taken to ensure that the most urgent and serious cases get the safe, high-quality care they need.

The decision to declare a major incident is taken locally, and there is no national definition. We must trust the managers and clinicians in our local NHS to make these decisions and support them in doing so by making sure that there is sufficient financial support available to help deal with additional pressures. I chaired my first meeting to discuss that support on 17 March last year. On 13 June, we gave the NHS an additional £400 million for winter pressures, topped up in the autumn by £300 million to a record total of £700 million, ensuring that local services had the certainty of additional money and time to plan how it should best be used. The NHS started this winter with 1,900 more doctors and 4,800 more hospital nurses than a year ago. This planning and funding has been widely welcomed by experts in the system, including NHS England, NHS providers, the College of Emergency Medicine and the NHS Confederation.

The funding that the Government have put in, which is on top of the year-on-year real-terms increases in funding, is made possible by a strong economy and will pay for the equivalent of 1,000 more doctors, 2,000 more nurses and 2,000 other NHS and care staff, including physiotherapists and social workers. It will fund up to 2,500 additional beds in both the acute and community sectors and provide £50 million to support ambulance services.

However, the NHS also needs longer term solutions to these pressures. We are providing £150 million through the Prime Minister’s Challenge Fund to make evening and weekend GP appointments available for 10 million people, with over 4 million already benefiting from this. Our better care programme integrates, for the first time ever, health and social care services in 151 local authority areas, with plans starting in April to reduce emergency admissions to hospitals on average by 3%. We have funded the NHS’s own plan to deal with these pressures, the five-year forward view, with an additional £1.7 billion for the NHS in 2015-16 and £1 billion of capital over the next four years to improve primary care facilities.

Let me finish by thanking hard-working NHS staff across the country for the outstanding care that they continue to deliver under a great deal of operational pressure”.

That concludes the Statement.

My Lords, I join the Minister in paying tribute to the staff of the NHS who are facing such a pressurised situation at the moment. Does he accept that, for all the actions that he has listed today, the fact is that too many vulnerable people are currently being exposed to too much risk in the NHS as a result of the crisis in A&E? How many hospitals have declared major incidents in the past two weeks? Does he agree that the crisis has been caused principally by the savage cuts in social care and the chaos caused by NHS reorganisation? Why have the Government overseen the closure of dozens of NHS walk-in centres? Why did the Government oversee the replacement of qualified NHS nurses in NHS Direct by unqualified call-centre staff in NHS 111, who have computers programmed to encourage people to go to A&E? When will the Government get a grip?

My Lords, the noble Lord will understand that I am under instructions to keep my answers brief, in the nature of Urgent Questions. To cover his main points, though, we have made social care a priority at the same time as protecting the NHS budget and reducing the deficit. Since 2010 we have allocated additional funding from the NHS each year to support social care worth £1.1 billion in the current year and £2 billion next year. With regard to walk-in centres, there is no evidence that the closure of those centres, where that has occurred, has resulted in additional A&E attendances. A Monitor report in 2013 found that closures were often part of reconfigurations to replace walk-in centres with urgent care centres co-located with A&Es. On NHS reorganisation, I simply point out to the noble Lord that the pressures that we are seeing in the English health service are replicated just as strongly in the NHS in Wales, Scotland and Northern Ireland. Our A&E departments are in fact coping even better than those in the devolved Administrations.

My Lords, I wonder whether my noble friend will give consideration to helping those people who could not get appointments to see their general practitioners, some of whose surgeries were closed for five days over Christmas, by allowing or encouraging hospitals to set up general practices alongside their A&E departments, which would be open seven days a week, 24 hours a day, for people who registered at the hospital general practice. That would mean more funds for the hospital and less funds for the general practices that chose to close up in that manner.

My noble friend has made an extremely important point. I have visited hospitals where that very model has been in place, for example, in Luton, where I went not so long ago. More and more hospitals are adopting this suggestion so that when people turn up at A&E they can be triaged immediately into urgent and less urgent cases, often to be channelled through to the GP service.

I endorse the sentiments just expressed by the noble Lord, Lord Tebbit, unusual though that may be. I ask the Minister to commend those hospitals and health authorities that have introduced GP services as part of their A&E emergency response. I also draw his attention, if he has not seen them already, to the statements of the Royal College of Nursing and the College of Emergency Medicine. Both said emphatically that a substantial part of the reason for the present pressures is the effect of the reduction of local authority funding which means, in the words of one of the college leaders, that there is no community care. That has meant that people have to be accommodated in hospitals who would otherwise be in either their own homes or local authority homes. Is it not the case that the savage cuts imposed on local authorities, which have had a direct impact on commitment to care for the elderly especially, are to blame for a substantial part of this crisis? Will the Government consider, in addition to NHS funding, reversing at least some of those cuts?

My Lords, I thank the noble Lord for his endorsement of the model which my noble friend proposed for GP presence in or alongside A&E departments. I fully agree with him on that. It works well. As regards local authority funding, social care expenditure, in particular, has decreased over the past three years. Obviously that has had an effect on the NHS. It would be idle to pretend that it has not. However he will know the very constrained funding environment in which we stand, and I understand that the party opposite has not undertaken to reverse the reductions in funding to local authorities for understandable reasons. That means that we have got to think clever, and one of the initiatives that we are launching next year is the better care fund which will bring together the NHS and social services in a meaningful way. By far the lion’s share of the funding in the better care fund will go to social services.

Since 2010 there has been an average decrease in social care funding in local government of 26%. Are the Government tracking the coincidence of reductions in budgets for things such as continuing care beds and increased attendance at A&E?

The impact of reductions in social care expenditure is not, I am afraid, entirely clear. I wish it were, because more people are now outside the formal care system. However, outcomes for service users within the formal care system have held up over the period.

Can the Government confirm that they are working with the College of Emergency Medicine—and I declare an interest as a fellow of that college—to manage their STEP programme? It requires sustainable staffing levels within emergency medicine departments, renegotiation of the tariff to make sure that they are adequately funded and dealing urgently with exit block. The college has calculated it would free 20,000 bed days if delayed discharges from the rest of the system were able to happen on time. The “P” of course is for primary care co-location which has already been addressed. Does the Minister recognise that these departments are working incredibly hard? Although people are waiting longer, by and large they are managing to protect outcomes for individuals who are severely ill and who are seen.

I am grateful to the noble Baroness. It is worth observing that while the standard is that 95% of people arriving at A&E should be seen and treated within four hours, that standard has not been met in recent weeks. Nevertheless, on average, hospitals are seeing and treating around 90% of patients. The department is working closely with the College of Emergency Medicine. Indeed, I have the college’s paper in front of me. I am well aware of the issues that it has identified, but it is worth noting that the college says that the latest figures show that in England hospitals and their staff have coped extraordinarily well.

My Lords, can the Minister confirm that staffing, particularly of emergency medicine doctors, is acute in the sense that probably enough are being recruited but not enough are being retained in emergency medicine and that there is a significant loss of those qualified practitioners overseas? What is being done to address that?

I recognise that issue. Having said that, we currently have a record number of A&E doctors in the NHS, which is good, and across the system we have 1,800 more doctors and 4,700 more hospital nurses than we had a year ago. However, being an A&E doctor is a stressful occupation, and doctors are sometimes tempted to go overseas. We are concerned about the loss of any A&E doctor, and that is being looked at in conjunction with the royal colleges and the BMA.

My Lords, there can be no doubt that the figures which we have been given by the Minister need to be looked at very carefully. It would be a miracle if this enormous demand could be faced with no financial troubles at all. However, does he recognise that there is quite a bone of contention, and that the argument is building up that those who bear the heat and the burden of the day working in A&E departments seem to get a fairly small salary compared to the enormous sums that are paid out to managers within the health service? I do not know whether it would be possible to rein that back a little, but if that is the case, it seems very unfair.

I am grateful to my noble friend. Of course, rates of pay are a sensitive matter, and it is true that the constraints on pay rises over recent years have had an effect on the attractiveness of particular careers in the health service. We can do little about that in the short term, but there are ways and means of improving the work-life balance and working lives of those who work in the health service, even if we cannot increase their pay at the current time.