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In the same paper, the trust recognises the importance of rotating staff between the A and E department, the urgent care centre and the minor injuries unit. That is absolutely vital in any network so that staff work in all the different departments and know each other. That means that the lesser unit will not be held in lower esteem because it will have the same staff. Moreover, if a patient going to the lesser unit needs to transfer to the major unit, the history taking and investigations are done only once in the lesser unit, sparing the scanning
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department and the X-ray department in the larger unit. That is absolutely contrary to my experience of years ago. I trained about half a mile from here at the old Westminster hospital, which sadly no longer exists. In those days, we used to get a lot of patients coming from out of London. We did not trust the work that had been done in perfectly reputable hospitals outside London, so we repeated all the investigations, which was entirely wrong. That would not happen in really close working networks with shared staff.

The report to the trust board about the pilot in my area goes on to say that the trial has demonstrated only modest clinical demand. That is not surprising, because for various reasons the doctor has been put there from 9 to 5 on Mondays to Fridays only. That is when people do not much need the service, because with most sorts of moderate to mild emergencies they can go to their GP. It is vital that it is extended to seven days a week, perhaps from 9 am to 9 pm, to cover the out-of-hours periods that are most important to people. I am pressing for that and pointing out that a doctor on site in the minor injuries unit would ease the problems for the out-of-hours service, because if a doctor were there all the time, the few GPs on call might have to cope only with visits.

That brings me to my third suggestion. It is very difficult to get people to the right place. No amount of telling will be recalled by patients or families in an emergency situation, who will just dial 999—that may well be appropriate; if it is life-saving, it obviously is—or take themselves to the nearest hospital regardless of what it is able to provide. I strongly believe that what is needed is a single phone number dedicated to patients and services within each network area of emergency care. The Minister will remember that in a Westminster Hall debate of mine some time ago, to which he responded, I listed the confusing variety of places and phone numbers that patients have the option of calling when they do not know what to do. They can phone NHS Direct or the out-of-hours service, or they can go to a minor injuries unit, a walk-in centre or an A and E department—the list is immense.

I advocated, and still advocate, a single number to a triage system such as NHS pathways, which would advise and direct to the appropriate local service for that particular area and that particular patient. Trials of NHS pathways have been under way, and I hope that the Minister will be able to tell the House something about them, as they were due to report last autumn. A single number for specific direction to the appropriate unit would be ideal and would prevent people from going unnecessarily to the A and E department.

My fourth suggestion is really a query. Delayed discharges keep beds occupied for the wrong reasons and make admissions to an A and E department more difficult. The Health Committee did a report on this matter during the 2001-02 Session. We went through the reasons and the cures, and the Government said in their response:

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My question for the Minister is whether that has actually been achieved. What is the situation for delayed discharges now?

My fifth point, which was drawn to my attention by staff working in A and E departments, is the potential conflict between the 18-week target for elective admissions and the four-hour target for admission from A and E departments. One wonders whether some hospitals favour the 18-week target and use beds for elective patients, rather than attempt to maintain a reasonable bed occupancy rate so that there is slack for emergency admissions through A and E departments. Hospitals running with occupancy rates above 90 per cent. are likely to be in trouble. We come back to my main point that solving the problem involves limiting the number of people who turn up at A and E to those who really need to do so.

Finally, I shall outline an extremely unacceptable use of an A and E department, which was just reported to me by a patient’s family. It is so crazy and unbelievable that I have not waited for the trust’s response to the family’s complaint or my letter. An elderly lady was transferred from an acute ward to a less acute ward in the same hospital—probably quite appropriately. In that ward, sadly, she deteriorated, and a doctor’s opinion was sought. Her son-in-law—my constituent—wrote to tell me that because no doctor was available in the unit to deal with her condition, she was transferred by ambulance to the A and E department of the same hospital, where she spent much of the night on a trolley before being transferred to a bed in an acute ward the next morning.

That is not just inappropriate use of A and E, but scandalous, inadequate care. No doctor was available to go to her, so in her frail state, at the age of 89, she had to go to A and E. That is totally unacceptable, and points to a basic failure of organisation and a failure to provide adequate numbers of medical staff on call. I hope that it is a unique example, but misuse of A and E departments is rife. I hope that I have given the Minister food for thought, and action, to improve the situation.

7.13 pm

The Minister of State, Department of Health (Mr. Ben Bradshaw): I congratulate the hon. Member for Wyre Forest (Dr. Taylor) on securing this debate, and I welcome the fact that he has taken up the two cases that he raised. I would like to be kept informed of the progress that he or his constituents make in pursuing those complaints; he said that he had made one about the second case he outlined, but it was not quite clear whether he had about the first. Even so, I would be interested to hear from him, because it sounds as if they are cases that have not been handled well, to say the least.

Before I move on to some of the hon. Gentleman’s key points, I would like to reflect on the huge national transformation we have seen in recent years in accident and emergency departments. In 2003, almost a quarter of patients waited for more than four hours in accident and emergency departments in England. In 2006-07, more than 98 per cent. of patients in England were seen, diagnosed and treated within four hours of their arrival. There has been a revolution in patient care. We should
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no longer allow patients to spend many hours—or even days, as some used to do—in A and E. That transformation has been achieved thanks to the hard work and professionalism of thousands of front-line NHS staff—not only doctors, but nurses and the full range of NHS staff.

In addition, our drive to eliminate long waits in A and E has made the whole health and social care system work together in new and better ways, resulting in faster access to treatment for patients. When patients are surveyed, they tell us that A and E is better than ever. In the latest independent Healthcare Commission survey, which was published in 2005, eight patients out of 10 said that they had had a good experience in A and E departments.

However, as the hon. Gentleman rightly highlighted, A and E departments are busy. In 2006-07 there were some 18.9 million attendances at all types of A and E, and 3 million emergency admissions via major A and E departments. They are one of the few NHS services that have their doors open 24 hours a day, 365 days a year, dealing with a multitude of different conditions and issues. However, against that backdrop, A and E services continue to provide responsive, high-quality and timely care to patients. That is partly thanks to the increase in medical staff working in A and E. The last NHS work force census on 30 September 2006 shows that there were 4,714 medical staff working in A and E, including consultants—an increase of 61.8 per cent. since 1997. Health service spending by commissioners on A and E has increased by 125 per cent. since 1997, from almost £750 million in 1997-98 to nearly £1.7 billion in 2006-07.

We recognise that there will be fluctuations in demand for A and E services. However, the NHS routinely plans for such changes and it is for services locally to decide what arrangements to put in place to deal with any changes in attendances to ensure that patients can regularly access high-quality, timely care. It is also worth noting that the rate of growth in attendances at A and E is now slowing. The annual growth rate in 2006-07 was less than 1 per cent.

However, as the hon. Gentleman said, one of the key considerations is to view A and E activity in the context of other aspects of NHS patient contact and other services that deal with urgent and emergency needs. As he pointed out, people have several options if they need to access care: they can call an ambulance, or visit A and E, a minor injuries unit or a walk-in centre. They can also make a same-day appointment with their GP, or call NHS Direct or their local out-of-hours primary care service. Community services such as pharmacists, community mental health teams and community social services can also play a role.

Those other services provide a lot of care. For example, although there were more than 18 million attendances at all types of A and E services during 2006-07, and more than 13 million were at type 1—major—A and E departments, there are nearly 900,000 general practice consultations a day, equating to around 290 million GP practice-based appointments a year. Many of those services provide crucial care to patients to help them manage their condition without having to resort to urgent or emergency care later. Indeed, as the hon. Gentleman said, some people have a range of complex
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health and social care needs, and simple problems can cause their condition to deteriorate rapidly, putting them at risk of needing to attend A and E, and possible emergency hospital admission.

Case management, which I believe is a modern way to describe the sort of multi-agency response teams that the hon. Gentleman mentioned, can provide improved preventive and tailored packages of care to people at risk of unnecessary attendance at A and E or admission to hospital. That is a fundamental element of the Government’s overall strategy for improving care and outcomes for people, especially those with long-term conditions, along with the target to reduce emergency bed days by 5 per cent. by 2008, through better primary care and community settings.

Case management, led by a community matron or a case manager, should provide intensive, ongoing, personalised care with a focus on prevention and integrated working between health and social care professionals. The community matron or case manager should take the lead in co-ordinating services, which are provided as far as possible in the community setting, supporting people to live in their own homes and communities. For the service to be most effective, the community matron must integrate with other parts of the health and social care system by working alongside GPs and others in the primary health care team, as well as the local acute trust, mental health care providers and social services.

NHS and social care organisations have already made a major impact, by reducing emergency bed days in 2006-07 by 10.1 per cent. over the baseline year of 2003-04, meaning that the reduction target has been significantly exceeded. Continued efforts and reform are crucial to maintain those improvements in care in all parts of the country and to sustain bed day reductions in future.

One of the Government’s commitments is that by this year we expect all PCTs and local authorities to establish joint health and social care networks and teams to support those with long-term conditions who have the most complex needs. We will issue guidance later this spring to embed integrated working and standardise it across the country. Integrated team working will benefit a range of individuals, not just those with long-term conditions, and there are a range of other services and teams across the NHS and social care that provide valuable support.

I recently visited a good model of that kind of care, at the Calne health centre in Wiltshire—a rural county, like the hon. Gentleman’s—where I met the neighbourhood nursing team. It was providing an excellent service, so patients did not have to make long unnecessary journeys to hospital, and emergency admissions were not delayed. Instead, patients received excellent care from those teams of nurses in their own homes.

We need to ensure that all parts of the urgent and emergency care system provide the most timely and appropriate care for patients, and that there is integrated provision that makes sense to patients. As the hon. Gentleman said, we also need to ensure that wherever patients access care, they get a robust and consistent assessment of the urgency of their need. As the hon. Gentleman reminded us, he has shown interest in the work under way to pilot a potential assessment
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tool, NHS pathways. We hope to have the outcome of that evaluation in the first half of this year—not, to correct him, last autumn.

Although much has been done, the NHS Next Stage review will ensure that things are driven even further forward. As hon. Members will know, last year the Prime Minister invited Lord Darzi to conduct a review of the next stages in the development of the NHS. At the local level, each strategic health authority has set up working groups of local clinicians and other NHS staff to develop their vision of world-class services in their area. That will include a vision for acute services and for a number of other pathways that can have an impact on A and E, such as long-term conditions. Those visions will be developed with clinicians, based on their own experience and combined with the best clinical evidence available.

It is also clear that local health commissioners and providers need to continue working together to ensure that patients can navigate their way through the system of urgent and emergency care services. It is important for people both to have straightforward information, clearly communicated, about what to do in an urgent or emergency situation, and to be aware of the options available.

In connection with that, we want to simplify access to urgent care services. We are, as the hon. Gentleman requested, exploring the possibility of introducing a three-digit number to sit alongside the emergency services
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number, 999. That number would need to be memorable for the public. Users would need to be confident that they would get a rapid and safe assessment of their needs and an appropriate response to meet them. As stated in my noble Friend Lord Darzi’s interim report, the Department has been pressing ahead with preliminary feasibility discussions with Ofcom, the telecoms regulator. A number of technical issues concerning the provision of a three-digit number still need to be addressed. Ofcom will also need to consult formally on any proposals to introduce such a number, but we are making good progress in our discussions with Ofcom, and I feel confident that that can be achieved.

In conclusion, I am sure that the hon. Gentleman will join me in congratulating the staff who work in A and E departments up and down the country to ensure that patients are seen and treated in a timely way, on their hard work and continued dedication, and in welcoming the huge contribution that a range of other services and staff make in supporting people to live at home and be cared for in the community. I very much regret the examples that he raised this evening, and I would be grateful if he could keep me informed on the progress of his complaints. I share with him a wish to see an integrated and seamless service that does not let people down, and which patients want. That is the service that we are determined to provide for them.

Question put and agreed to.

Adjourned accordingly at twenty-four minutes past Seven o’clock.

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