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As well as improving pay for staff on the lowest pay grades, “Agenda for Change”, which was introduced in October 2004, has significantly improved the pay and conditions for ambulance staff in particular. They are
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no longer expected to work nights, weekends and public holidays for the same rates of pay as normal hours. Their pay has increased, as has the training and the professional development that they receive.

The hon. Member for South Cambridgeshire is right to say that winter pressures place additional strain on urgent and emergency care. As hon. Members will know, last month was the coldest December for 30 years. Increases in accidents, flu cases and other health problems associated with cold weather put the NHS under great pressure. In some hospitals that I visited, it was miraculous that the staff were keeping the service going at such high level of quality. At one hospital that I visited in Yorkshire, the amount of ice on the roads meant that it had to treat 200 fractures over four days. However, better planning, more staff and improved organisation have given the NHS the capacity to cope with such pressure without a return to the dreadful scenes of the early 1990s, when many A and E departments had to close because they could not cope with patient demand.

I agree that we should support further improvements of acute hospitals and develop more specialist centres. I would also like to point out that the abolition of long waits and greater investment in specialist centres for conditions such as stroke over the past 12 years has radically transformed patient care in our hospitals. I, too, welcome the report by the College of Emergency Medicine, but I take issue with the claim that the vital reconfigurations of urgent and emergency care services are motivated by financial constraints or that they are clinically unproven. Every reconfiguration of urgent and emergency care is clinically reviewed by the national clinical director for urgent and emergency care and his team. All decisions are taken on the basis that they will improve patient safety and improve the quality of care and that they balance these concerns against improving patient access.

Mr. Paul Truswell (Pudsey) (Lab): A few moments ago my right hon. Friend mentioned stroke, which the hon. Member for Westbury (Dr. Murrison) raised earlier. Will he describe in a little more detail what the Government intend to do to raise professional and public awareness of stroke symptoms, improve access to scanning, ensure that acute stroke units are brought up to the standard of the best and look into the development of hyper-acute stroke units?

Alan Johnson: I recently had occasion to visit the health service in my hon. Friend’s constituency. Stroke care is crucial. The stroke strategy that was adopted in December 2007, with the involvement of all the charities and experts, is being taken forward. The fast test, for a quick assessment of whether someone is suffering from a stroke, is now widely spread, in all GP surgeries. However, we are talking about a continuing programme, and my hon. Friend is right to raise the importance of stroke care in the NHS.

Dr. Murrison: Does the Secretary of State agree that although stroke has emerged from the shadows as a true emergency because of the advent of imaging and thrombolysis, the United Kingdom has some of the worst outcomes in the western world? Will he also comment on the Stroke Association’s assertion that

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Alan Johnson: We all accepted when we came into power in 1997 that the three major killers—cancer, heart disease and stroke—needed to be tackled. They could not all be tackled at the same time and with the same intensity. However, it is fair to say that although we saw early improvements in cardiovascular disease and cancer in particular, stroke care came a little later. The hon. Gentleman is right to say that. I do not know when the Stroke Association said the words that he quoted, but it has worked closely with us to improve services. Neither we nor the Stroke Association believe that we have a perfect stroke care service. However, in relation to the very issues that we are discussing today, we do believe that as specialist centres are introduced more widely and as we put in more resources and implement the stroke strategy, outcomes will improve accordingly.

I was talking about how we deal with reconfigurations and what the Conservative motion says about the importance of concentrating services where appropriate. As part of his review last year, albeit that it was separated from the final publication by a couple of months, my noble Friend Lord Darzi set out clearly the rules that will govern the changes. I would be very surprised if there were any differences, given the importance that we all attach to moving with the times and implementing more specialist care. Lord Darzi said that change must

and that it must always be “clinically driven”. Change must not come from a Richmond House edict, but must always be

and recognising that

Change must always involve patients, the public and local staff. If proposals are adopted and change is to occur, the local population has to see the benefits in place first, before the changes occur. That means some quite expensive but very necessary double running to ensure that things work. That seems to be the perfect model in a world where no one is suggesting—I presume that that includes those on the Opposition Front Bench—that there must be no change and no so-called reconfigurations whatever.

Professionals estimate that between 50 and 70 per cent. of people who turn up at A and E would be better treated elsewhere. The majority would be better treated in primary care—that is why primary capacity is so important, as my hon. Friends have rightly pointed out—or in minor injuries units or urgent care centres. Our urgent and emergency care services see patients with a huge range of conditions, from a major trauma to a broken finger. It is nonsense to suggest that a patient who has twisted an ankle is always best accommodated alongside a patient who has had a heart attack or been seriously injured in a road accident. To deal with major trauma or severe injury successfully, A and E departments need the right concentration of expert staff to assess critically ill patients quickly. In many areas, there will be two A and E departments in relatively close proximity to each other, trying to do that as well as deal with many less serious complaints. That is why many SHAs are taking decisions to concentrate expert A and E staff in one hospital and equip the other to deal with more minor complaints. That is what has
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happened successfully in areas right across the country. The suggestion that these decisions are being taken because of the European working time directive is, frankly, laughable.

Mr. Lansley: Does the Secretary of State agree or disagree with the College of Emergency Medicine when it argues that, for a proportion of patients, distance to an emergency department is a significant risk factor in overall outcomes? Its document published just a month ago says:

Does the Secretary of State agree or disagree with that principle?

Alan Johnson: I would broadly agree with it; there is a strong argument for that, but it has to be decided locally. That college does not say that a hard and fast rule should be set in all circumstances. The major thrust of the report, representing as it does A and E consultants, is that we should double the number of such consultants—having doubled them already! When I was leader of the Communication Workers Union, not a single report it issued failed to suggest that more of my members were needed somewhere in British Telecom or the Post Office, so I am not surprised by that report. It also says, however, that there is no single solution to the reorganisation of emergency care. It makes the point that in urban areas where emergency departments are close together—the very point I just made—there may be advantages to amalgamating some services. On the whole, it is a bit sceptical and it makes the point about long distances, but I do not think there is anything between us if we are guided by the five principles set out by my noble Friend Lord Darzi, who knows more about the health service than all of us put together—more even than the hon. Member for South Cambridgeshire. Let us say rather that he has forgotten more than we ever knew and put it that way round! The key issue is how we deal with the problem.

Conservative Members say that the European working time directive is the issue, but they have always been a bit confused about it on the Opposition Benches—perhaps it is the word “European” that explains their opposition to it. When they were in government under an employment Minister called Mr. Portillo, they got confused and thought that it was part of the social contract—

Mike Penning: The social chapter.

Alan Johnson: The social chapter—the hon. Gentleman is right to correct me, as the social contract is something completely different, which I well remember from the early 1970s. Let us be clear: the Tories got confused about the social chapter and the British taxpayer— [Interruption.] I am asked what this has got to do with it, but the European working time directive is mentioned in the motion. They got confused and spent thousands of millions of taxpayers’ money, fighting a case in the European courts, which they lost because it is a health and safety measure and does not come under the social chapter or the social contract.

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I was also asked in an earlier intervention about the opt-out, which the British Government intend to maintain. In co-decision with the European Parliament, we will maintain the opt-out as we have done for 12 years. The fact is that that argument—Opposition Members should understand this—will make not the slightest difference to the NHS. There is a separate agreement for junior doctors. We have decided—I would be surprised if anyone took a different view—that the national health service will have a 48-hour working week with no opt-out. The reason for that is that with the rotas and flexibility necessary in the NHS, the system cannot be run effectively if we are constantly depending on who opts in or out. Whereas individual doctors can, we are implementing this by having a 48-hour week, which will come about on 1 August 2009.

That is not to say that we do not recognise the argument about doctors flogging themselves to death. The hon. Member for Banbury (Tony Baldry), who is no longer in his place, raised this issue and said that he is kept awake at night worrying about the working time directive. The point of that directive was to stop clinicians staying awake all night because they were obliged to be at work for horrendously long hours, which adversely affected the quality of care provided.

Mr. Lansley: The Secretary of State lectures us about the working time directive, but ignores the point that really matters. There was an agreement in the Council of Ministers to change the definition of “resident on call” so that it related to time spent actually working at night rather than all the time when one is resident but asleep. That is a critical issue, so will the Secretary of State explain why Labour Members of the European Parliament voted against the Council of Ministers’ compromise, the purpose of which was to enable us to interpret “resident on call” in a way that worked for the national health service?

Alan Johnson: I am raising this because I was asked about the opt-out in an earlier intervention, but the opt-out is not the issue. What the hon. Gentleman mentions is, of course, an issue. It is a crucial issue in order to ensure that the agreement we struck with the Commission, after a long period of virtually hand-to-hand fighting, was maintained. [Interruption.] It is a co-decision. I am not sure how Conservative MEPs voted on the issue, but it is a co-decision, as I said. The decision is taken based on decisions in Parliament, but it has to be agreed with the Commission and with Ministers.

The working time directive was first introduced in 1998, the NHS has made excellent progress in meeting its terms and the majority of NHS services—the vast majority of them—already meet the 48-hour requirement, which will come into force in August 2009. There will always be parts of the service where this is particularly challenging, and we will work with the British Medical Association and the Royal Colleges to address those areas over the next few months. [Interruption.] Incidentally, the BMA is fierce in protecting the safeguard of the 48-hour week and would not appreciate any— [Interruption.] That is a relief— [Interruption.]

Madam Deputy Speaker (Sylvia Heal): Order. If hon. Members wish to make a point, I think that they know the parliamentary procedures for them to do so.

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Alan Johnson: I apologise for encouraging them, Madam Deputy Speaker.

The hon. Member for South Cambridgeshire is wrong to say that we are not prioritising the improvement of trauma care. We believe trauma care needs to be recognised as a specialist form of medicine. Patients who are severely and critically injured need the expertise of many specialist professionals—from critical care doctors to neuro-surgeons. Just as we have improved specialist care for conditions such as stroke, so we will also improve trauma care. That is why, as part of my noble Friend Lord Darzi’s review of the NHS, every strategic health authority set out how they would improve the provision of trauma care—most by setting up specialist centres in trauma care.

The hon. Member for South Cambridgeshire asked in his speech and his motion what happened to the report and why there was nothing in the Darzi review, save for the three-digit number, about urgent care. What he fails to recognise is that the Darzi report incorporated all nine SHAs’ visions for the future in their regions, which were worked out with their clinicians, their patient groups and the public. The final report published in July last year was an implementing document or an overview so that all of that could be put in place.

Sandra Gidley (Romsey) (LD): It was a useful idea to have all these workstreams at each SHA level, but I am somewhat confused by the acute care pathway reports for the South Central SHA, as the chair is a consultant in the care of the elderly. Many would have had more faith in the process if it had been chaired by somebody with expertise in trauma care. How can the public and people working in the sector who are trying to drive change have full confidence in the process if the team is not as appropriate as it should be?

Alan Johnson: I do not think that the process should be judged by the profession of the person chairing it. Someone has to chair these groups and in this case it was necessary to look at clinical services right across the patch. The point is that trauma was a priority in every SHA report. They made it a priority in the regions. People cannot accuse us of being top-down and top-heavy and tell us we should have local involvement, and then complain when the Darzi review is implemented in that very way—I am not saying the hon. Member for Romsey (Sandra Gidley) was complaining, but Conservative Members were.

The report on trauma care was published two years ago just as the Darzi review was being formulated, and the idea now is to carry forward those visions in each strategic health authority. We need someone to oversee this, however, and I can today announce that I am appointing Professor Keith Willett, chair of the British Orthopaedic Association’s trauma committee and a leading international expert on fractures and trauma, to be the first national clinical director for trauma. The hon. Member for Banbury, who is not in his place, will probably know him very well because he is a leading clinician at John Radcliffe, Oxford.

I agree that the public should be given a say in how urgent and emergency care services are configured. Indeed, the next stage review sought the views of more than 40,000 people, and asked them specifically what improvements they wanted to see in urgent and emergency
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care. Clinicians used the views expressed by patients to make their recommendations for what should happen in each region.

I join the hon. Member for South Cambridgeshire in his praise for the contribution made by community first responders. They play a vital role in improving responses to 999 calls in many parts of the country and in supporting ambulance services. They are not, however, a substitute for an emergency ambulance response. I am delighted that the Opposition are favourably disposed to potential plans to bring in a new, single digit number to access urgent and emergency care services. As my noble Friend Lord Darzi has pointed out, this would provide a quick, convenient way for people to find out about local urgent care services, particularly out of hours or away from home, and we will be consulting on this proposal in due course.

Mr. Graham Stuart (Beverley and Holderness) (Con): Yorkshire ambulance service, with which the Secretary of State will be familiar, provides data by local authority area at present; it does not do so on a ward-by-ward basis. Given that there is concern in rural communities about differences in performance between wards, will the Secretary of State encourage ambulance trusts around the country to provide data down to ward level so that we have a clearer picture?

Alan Johnson: That point is worth looking into, and I will do so. We currently have the best performance ever from our NHS ambulance service, and we should include it in our congratulations.

The hon. Member for South Cambridgeshire asked us to publish the urgent care strategy, and I dealt with that in mentioning the strategic health authorities. [Interruption.] I accept that my responses to the points that have been raised are of varying quality. It is sensible that SHAs should carry forward their vision, and we should help them and fund them to do that.

Over the past 12 years, there have been real—indeed, dramatic—improvements in patient care. Patients no longer have to wait years for treatment after referral; at most they have to wait 18 weeks, and the average wait is about eight weeks. The vast majority of patients wait for less than four hours in accident and emergency. Let me put in perspective what this means for patients. A doctor I spoke to recently told me about the accident and emergency department in which he worked in 1995, where waits of 12 hours or more were so frequent that patients were asked for two meal choices when they arrived. Sheets were taped across the corridor to create makeshift wards. He now works in a hospital in the same area where accident and emergency patients are treated on average in just over an hour.

The measures we have taken over the past 12 years have dramatically improved the quality of urgent and emergency care, as the Opposition motion recognises. The abolition of long waits for treatment is one of the NHS’s finest achievements. Greater investment, more staff, better planning and strong leadership have transformed urgent and emergency care services for patients, and I commend the amendment to the House.

1.44 pm

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