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A&E Departments: Winter Pressure

Volume 616: debated on Thursday 3 November 2016


Select Committee statement

We now come to the Select Committee statement. Dr Sarah Wollaston, the Chair of the Health Committee, will speak on the subject for up to 10 minutes, during which—I remind colleagues of this relatively new procedure—no interventions may be taken. At the conclusion of the statement, the Chair will call Members to put questions on the subject of it and call Dr Wollaston to respond to them in turn. Members can expect to be called only once each. Interventions should be questions and should be brief. Those on the Front Bench may take part in questioning.

The Health Committee held an inquiry into winter pressures in accident and emergency departments. What we found, however, was that those pressures are now year-round, and that they worsen in the winter.

I would like to start by thanking all those who work in our national health service and our ambulances services, and all those who submitted written evidence and presented oral evidence to our inquiry. I also want to thank all fellow members of the Committee and the Committee team, especially Huw Yardley and Stephen Aldhouse, for their contribution to the report.

The root of the problem is unprecedented demand. It is not just about the sheer number of people arriving in our accident and emergency departments—on average, around 40,000 people attended a major accident and emergency department per day in 2015-16, which was 6,000 more per day than five years previously—it is also about the complexity of the conditions with which they are presenting. The worsening performance that we are seeing, which is of great concern to the Committee, is also a reflection of system-wide pressures across the whole NHS.

We noted that only approximately 88% of patients arriving at major accident and emergency departments are being admitted, transferred or discharged within four hours. That is concerning, because it falls considerably short of the target performance standard of 95%. We should not think of this as just an arbitrary target or a tick in a box; it matters for patient safety and for patients’ experience of the care they receive.

Our report identifies a number of factors. We are also concerned about the level of variation in performance of accident and emergency departments. Often that performance cannot be attributed only to local pressures or demographics. We acknowledge that there are many things that hospital trusts can do to learn from the best performing departments to help improve the flow from the front door to the point of discharge, and to prevent people from getting caught in that revolving door by being readmitted. I pay tribute to the efforts of NHS England and of all those working locally and regionally to try to make sure that the NHS starts to learn from best practice, and I particularly commend Pauline Philip and her team for what they are doing.

One thing, however, comes across very clearly from our report: the impact that the deficiencies in social care are having on accident and emergency. If we cannot discharge patients at the end of their journey because no social care packages are available, it has a domino effect throughout the whole system. Not only that, but people arrive in accident and emergency departments who could have stayed at home if they had had the right social care package. The Committee therefore repeats its request to the Chancellor to look at social care in his autumn statement and to prioritise it.

We also recognised that many accident and emergency departments are under particular pressure because of their working infrastructure—the premises may be completely inadequate to cope with the increase in demand and complexity—so we repeat our call to the Chancellor to look in his autumn statement at the capital budgets in the NHS and to make sure that the funds are available to allow the transformative changes that can bring struggling A&Es up to the same performance level as those that are functioning the best.

There are also, of course, issues with the workforce. We are concerned about the impact of workforce shortfalls in the NHS, and we ask Health Education England to redouble its efforts to look at them.

When we visited East of England ambulance trust we found that it was concerned, as were others who submitted evidence, about the impact of delayed transfers at the front door of accident and emergency departments. Again, there is great variation, and it is not all about infrastructure. If ambulances are all gummed up in one accident and emergency department it has a serious knock-on effect within an ambulance trust area, so we call on those who are not putting in place the correct procedures to look carefully at the impact that that is having and to make changes this winter.

The Government also need to look at issues around alcohol policy. Anybody who has attended an accident and emergency department on a Friday or a Saturday night will know of the pressures that problem drinking creates. We ask the Government to consider making health an objective for licensing and to look at doing all they can to reduce the impact of alcohol. That impact is felt not just on waiting times, of course, but on the morale and wellbeing of staff working in our emergency services.

I thank all those who have contributed to this inquiry, and I look forward to hearing the Government’s response.

I echo the words of the Chair of the Select Committee in thanking all the staff who work so hard in the health service. I also thank those who produced and contributed to the Select Committee’s report, which is important and concerning in equal measure.

The report is clear that years of underfunding in social care are now having a dramatic effect on A&E presentation. Does the Chair of the Select Committee agree that, ahead of the autumn statement, if there is to be the necessary injection of cash into the social care sector the Chancellor will have to come up with a better solution than one that relies on hard-pressed local councils raising the necessary funds locally?

I thank the shadow Minister. The Committee agrees that there needs to be more funding for social care. We were concerned that the evidence we heard in this inquiry and previous inquiries is that the money raised from the social care precept has been swallowed up by the cost of the living wage. We absolutely welcome an increase in pay for hard-pressed care workers, but we feel that the increase in funding is completely inadequate to deal with the scale of the increase in demand.

I would like to add my welcome for the work of the Health Committee in this report and to say how pleased I was to have the opportunity to appear before my hon. Friend’s Committee for the first time since taking up this post.

We all recognise that the system is facing a challenging winter, but we are determined to ensure that the NHS and the social care sector are focused on trying to deliver for patients and that the national organisations, where possible, are in a position to support them effectively this winter.

This year, the NHS is better prepared for winter than ever before, with NHS staff working incredibly hard throughout the year and more ready for what will be the busiest time for the NHS. Despite increased demand, the NHS is performing well, with nine out of 10 people seen in A&E within four hours.

We have ensured that there are robust plans in place. That includes providing for the availability of key services, such as primary and social care, during the Christmas and new year bank holiday periods in advance, which has not happened before. For the first time, there is also a national A&E improvement plan to improve flow through hospitals from the front door to final discharge, with the implementation of five initiatives, and there is a specific intervention on discharge.

The Select Committee’s report highlights continuing pressures on emergency departments, so does my hon. Friend share my welcome for the 25% increase in doctors—almost 1,200 more doctors—working in emergency medicine since 2010?

Of course I welcome the increase in staff in our accident and emergency departments. As the Minister will recognise, there is further to go in this regard.

Does the hon. Lady agree that the four-hour A&E target is absolutely vital, because it, more than any other target, shows the overall performance of a hospital, and that the figures are extremely worrying? Does she also share my concern that last winter was very mild, and we were relatively lucky, with the absence of a big winter flu outbreak? If this winter is as cold as this Chamber, the NHS could face a very serious crisis indeed.

Certainly, the evidence we heard in our inquiry was that there is grave concern about the level of existing pressure. As the right hon. Gentleman says, if we see a very cold winter, and the flu vaccine does not work as well as it did last winter, we are in serious difficulties. But I stress again that the Committee was very clear that we want to see the four-hour waiting time standard continued, because it is a good measure of whole-system pressure, and if people are facing very long waits that leads to a deterioration in patient safety. So it is a quality issue, as well as an issue about patient experience.

I note what the Chair of the Health Committee says about social care and delayed transfers of care. Would she commend an initiative taken in hospitals in Fife, where the most senior consultants were put into accident and emergency, which led to a 30% reduction in admissions to the hospital? Does she not agree that more junior staff are sometimes perhaps slightly more risk-averse because they do not have the experience? Does she not think that, where Fife has led, other hospitals around the UK could usefully follow?

I thank my hon. Friend, and I welcome him to the Health Committee. Yes, he is absolutely right that one of the initiatives that has been put forward is to look at streaming at the front door, but what we heard is that this is quite nuanced. If very senior staff are tied up seeing every single person at the front door, that can be a waste of resources. However, if the patients who are most at risk of needing admission—the sickest individuals —are identified early on and seen by the most senior doctors available, then yes, absolutely, that makes a difference.

I had a little smile to myself at the Minister’s response. When I was a commissioner, we often said to each other, “It’s another A&E plan—it must be winter again.” On Monday, I asked the Secretary of State about the £2.4 billion protection for general practice, and I am afraid that there was not a satisfactory answer and the money will not plug the hospital deficits. There are very severe general practice problems in south Bristol and very worrying reports about sustainability. I am looking forward to the report, but will the hon. Lady say something about the role of general practice in the winter pressures issue?

We have to think of A&E winter pressures as a marker for the whole system. The hon. Lady is absolutely right and I welcome her reference to primary care, because if people cannot get an appointment in primary care, they are more likely to end up in A&E. Luton and Dunstable is now co-locating primary care so that people arriving at the front door who are more appropriately seen there can be seen directly in that setting. There is, however, another viewpoint: co-locating can sometimes end up creating demand, meaning that more people go there directly, so our report calls for better evaluation of the different models. One of the things that Luton and Dunstable does particularly well is apply evaluation at every stage to the changes it makes. The answer is complex, in that co-location may be absolutely the right thing for some systems, but not necessarily the right thing across the board. I absolutely agree with the hon. Lady that people need to have decent, timely access to primary care.