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The hon. Member for Wyre Forest also spoke about a very sad case of a young boy who died in his constituency. I am sure that all our thoughts and prayers are with the family. It is so difficult when that sort of things happens in our constituencies, as it does every now and again.
People needed the help of the NHS; sadly, they were let down. We look forward to seeing the results of the inquiry.
My hon. Friend the Member for Mid-Bedfordshire (Mrs. Dorries) never ceases to amaze me with her depth of knowledge. She worked in this sector and took a huge interest in health issues while she was there. Many of us may have worked in different areas of different industries over the years, but we have not absorbed to the same extent as her an understanding of where the problems lie. My thoughts were with her as she talked so powerfully about the loss in her family.
I bring my own experience to the subject of what used to be called road traffic accidentswe have changed the language over the years, but I will continue to call them RTAs. When I first joined the fire service, I came in with a paramedic qualification from the armed forces. I was asked to take a first aid course. That is where we were. I sat so often at road traffic accidents and saw how the medicsthere were no paramedics in those daysdid their very best to keep going the vital signs of people whom we were trying to extricate from vehicles. Very often, people died. I had the most appalling experience with a young lady who had a stoved-in chest and was drowning internally; no one had the ability to drain her or keep her airways open. That, thank goodness, has changed.
Although I understand my hon. Friends concerns about single responders, I have been present at RTAs that it has been physically impossible for an ambulance to reachlet alone an air ambulance, if one was available. Bikes do get through, however. She is right to say that they are not a replacement for a two-crewed ambulance, and it is vital that ambulances are dispatched at exactly the same time. I also understand her point about all the different techniques such crews need to have, and that it is better to have six hands than four or even two. Two is better than none, however; I have been at RTAs where there have been none, and it is better to have someone there. I agree that we must make sure that we do have not only single responders, but I do not think that is the situation; I have not met an ambulance trust chief executive who has told me that they have only single responders to RTAs, and I have asked every time. If that were ever brought in, it would be fundamentally wrong, and I am sure the Secretary of State would object to that, too.
However, there is a crisis in the ambulance service involving the difference between paramedics and technicians and what has been described as the wonderful new skilled roadside role of the emergency care assistant. I had in the past understood that in no situation would an ambulance go out without a paramedic or technician on board, but it is now my understanding that, at present, ambulances with under-qualified staff on board are responding to emergencies and they are invariably called emergency care assistants. That is very worrying. Over the years, we have built up the skills of paramedics. They have increased, not least because of the extra skills they pick up on operations with the military and then take back into the domestic sector. We cannot go the other way, and allow decreased skills. At present, we have paramedics on the one hand and emergency care assistants on the other hand, and something is falling through the middle: the skill base that we would all want.
Let me say a few words about queues outside hospitals. Ambulances queue up and hospitals will not take patients in because they are worried about the four-hour limit. This is no criticism of the West Midlands trust, but let me explain a situation I learned of while visiting Birmingham recently. Seventeen of the trusts ambulances were queued up outside a hospital, and the only way that they could be freed up was by putting one of the senior ambulance officers into the porch area of the accident and emergency department so that the ambulance crews handed over patients to her but not to the hospital. If that is what happens in a modern hospital service in the 21st century, something is seriously going wrong. I understand that happens around the country. It is one of the ways that ambulance trusts manage to free up their vehicles and get them back out on the road again; they have to avoid getting their patients into the hospital accident and emergency department because there is concern about the four-hour target.
My new colleague, my hon. Friend the Member for Crewe and Nantwich (Mr. Timpson), raised an important point about how communities feel about responders. Although they are unpaid, I have to emphasise to him that they all need to learn their skills. They need to come out of their basic training; 18 weeks is a short period but it is long enough to get their basic skills together. The key is that skill base as we take them forward. If we just left them with 18 weeks of training, and they went back in the community and never had any further training, that would not be useful. In terms of my hon. Friends comments, what particularly worried me is that the critical care which responders give is key, so excluding them from category Ain other words, saving lives at critical pointsis the opposite of what we should be doing. In many respects, their job is to save lives, not just to patch up a fracture or tend to a sprained ankle. It is crucial that we use them with such necessary skills, rather than pushing them off to less important roles. I will take that issue up in my shadow role.
When making notes for winding up this debate, I knew that I particularly wanted to talk about the ambulance issue because I knew that my hon. Friend the Member for South Cambridgeshire was going to talk in his opening remarks about the accident and emergency issue. I did not want to talk only about emergency care assistants or the emergency response times. I do not think that the Government intended to happen what is happening when they moved to regional ambulance trusts, but it is happening; if the ambulance trusts were smaller, it would be more difficult for the figures to become skewed between rural and urban.
I covered the way in which the performance targets workthat is a major issue and I hope that the Minister will examine it. The crucial thing when examining the performance of a trust is that we examine the outcomes. He is disagreeing with most things that I am saying, but if he thinks that the accident and emergency facility at Chase Farm should be closed, as is proposed, and that the accident and emergency closures that affect the Welwyn Hatfield area should proceed, or if he wants to continue with the mad closure programmes for the Hemel Hempstead general hospital, he should call an electionhe should go to his boss and say, Let the people decide. The Secretary of State says that he wants local democracy, so let us have an election and let the people decide.
The Minister of State, Department of Health (Mr. Ben Bradshaw): I assure the hon. Member for Hemel Hempstead (Mike Penning) that I was shaking my head not because I disagreed with all of what he saidI think that there is a great deal of consensus on these issuesbut because he took 20 minutes to say it. The debate has generally been good and positive, and we have heard many interesting and constructive contributions from across the House. We could have had an even broader debate, given that the title of the debate covers a range of issues, including not only the ones that we have discussed, but walk-in centres, general practitioners, out-of-hours services and NHS Direct. Urgent and emergency care is a broad canvas indeed.
I shall concentrate on the specific points that have been made, but if I do not have time to respond to all of them, I shall endeavour to write to hon. Members.
Mr. Bradshaw: I shall give way to the hon. Gentleman, particularly as his former colleague, the hon. Member for Hemel Hempstead, would not.
Bob Spink: That is very kind of the Minister. On specialist trauma units, does he agree that getting people with strokes and other such conditions straight to the right place, rather than to any old accident and emergency facilityonly for them to have to be transferred lateris crucial in preventing deaths and disability? And does he therefore accept that the Tory motion is, at best, very poorly drafted, because choice is not the relevant factor for trauma patients, but speed and specialist centre provision are?
Mr. Bradshaw: Absolutely. The hon. Gentleman has pointed to the inherent contradiction in the Conservatives policy: they say that they recognise the need for reorganisation, including the creation of trauma centresthe need for which he has describedyet they oppose every single reorganisation when one is actually proposed.
I need to correct the figures, or the impression, given by the hon. Member for South Cambridgeshire (Mr. Lansley) about the increase in accident and emergency attendances. A small increase in the number of such attendances took place between 1997 and 2003, but between 2002-03 and 2007 the figures for the average annual increase in accident and emergency attendances were as follows: the figure for major accident and emergency departments was 2.2 per cent.; that for single specialty accident and emergency was 4.9 per cent.; that for other types of accident and emergency department, including minor injury units, was 4.6 per cent., and that for walk-in centres was 15.7 per cent. Hon. Members can see that the biggest single proportion of the increase in accident and emergency attendances arose because of walk-in centres, which did not even exist under the previous Government, and that the smallest increase was for major accident and emergency departments. [Interruption.] The figure is not going up; the hon. Gentleman is wrong about that, too. The 2007-08 figures for major accident and emergency departmentsthe latest onesshow that there was a reduction of 1.5 per cent. compared with the previous year.
On the general issue of accident and emergency provision, a number of hon. Members have fairly recognised that the latest independent health watchdog report by the Healthcare Commission not only reports an improving picture88 per cent. of the public rate their experience of accident and emergency as excellent, very good or good, which is an increase from 85 per cent. in 2003-04but makes a number of criticisms, including some associated with pain relief and discharge, which the Government take very seriously and expect the NHS to address.
The hon. Member for South Cambridgeshire gave the reply that I was going to give in response to the hon. Member for West Chelmsford (Mr. Burns) on the gap between the findings of the Healthcare Commissions survey and the official figures. That occurs because some people may, for clinical reasons, need to be to moved into an assessment unit or a side ward if the consultant who has seen them is not in a position at that stage to make a decision on their care. Such people may still feel as if they are in accident and emergency, whereas in fact they are not. That four-hour target, which the Conservative party would scrap, has been incredibly important in driving up performance. I do not know any serious manager in the health service who thinks that it would be a good idea to abandon it. That would be a recipe for returning to the terrible days of patients having to wait hours, and even days, on trolleys, and the closure of accident and emergency departments.
It is important to put on the record what the College of Emergency Medicine report said about emergency medicine. It has been widely, but selectively, quoted by the Opposition, including in an early-day motion, but they omitted to mention that the report states on page 8:
There is no single solution to the reorganisation of emergency care. In urban areas where
are close together (less than ten km apart) there may be advantages to amalgamating some services.
It goes on to argue that that could result in a more coherent service for local residents.
The colleges report states that, throughout the country, many patients who attend A and E but do not need the full services of an acute hospital could be dealt with in an urgent care centre on a hospital site or in a community setting. The recent independent Healthcare Commission report on urgent and emergency care found that, in a typical urgent care centre, care starts within an hour for 93 per cent. of patients.
There is evidence of highly effective urgent care centres that are properly integrated, and have good collaborative working relationships with A and E colleagues. The key issue is that services should be integrated and staffed by people with the right skills and competencies to deal with the population using the service. Whether an urgent care centre is appropriate in a particular area, and how services are best structured, will depend on local circumstances. The Opposition motion suggests that to achieve that may mean concentrating expertise in a smaller number of centres of excellence that bring together specialists in different subjects to work together as a single team.
Many people who walk through the doors of accident and emergency departments do not need such a high level of care, and for them the most effective treatment will come from a nurse or GP. We can trade figures, and other reports have been quoted, but I am advised that
the most conservative estimate is that 50 per cent. of those who present in accident and emergency departments in fact require primary care. That is a huge proportion.
Of course, when any reorganisation takes place it can be, and often is, controversial. But as my right hon. Friend the Secretary of State made clear in his opening remarks, the changes must be locally led and, clinically driven and, in contrast with what the hon. Member for Mid-Bedfordshire (Mrs. Dorries) suggested, they require full public consultation. If democratically elected local councillors disagree with recommendations made by their local primary care trusts, they can object through the overview and scrutiny committee and refer those proposals to the independent reconfiguration panel. Some hon. Members have said that the panel is just a front, but in the past six months it has comprehensively rejected two major reorganisations, one in Oxfordshire and one in Sussex. It bases its decisions on the clinical case, and it was absolutely right for my right hon. Friend to take the politics out of the matter and set up a process that is transparent, independent, and based on clinical need and what is best for the patient.
My right hon. Friend the Member for Enfield, North (Joan Ryan) has championed Chase Farm hospital with great effect during her years in the House. I am sorry that she was not in the Chamber for the contribution by the hon. Member for Hemel Hempstead, but she may like to read the Hansard record, because he grossly misrepresented the position on Chase Farm and what she has done to ensure that the proposals affecting Enfield are much better than they were at the outset.
My right hon. Friend took the trouble to highlight the fact that many of the improvements in the NHS in her constituency, including GP-led health centres and the planned new polyclinics, represent developments that the Conservative party opposeher local Conservative party is completely silent on that subject. We have had many such debates, and the national director for emergency access referred to the proposals from the local primary care trustnot the Governmenton the reduction from three to two accident and emergency departments. He said:
Put starkly, it is evident that safe, high quality modern care cannot be provided for all specialties in all three acute hospitals in the area...Care of the standard that members of the public have a right to expect will require the centralisation of some specialties on two of the three hospital sites. Immediate care around the clock by experienced clinicians cannot be guaranteed whilst efforts are made to maintain all three sites.
My right hon. Friend will also be aware that there is an outstanding judicial review application by the local authorities concerned, but the challenge from the local authorities to the Independent Reconfiguration Panel was not successful.
The hon. Member for Romsey (Sandra Gidley) raised in some depth the issue of ambulances, but she did not mention that we are achieving the best ever response times. The ambulance service is the most popular in the NHS, as it scores the highest level of patient satisfaction of any servicesome 97 per cent., according to the independent Healthcare Commission. Investment in ambulance services has increased by 135 per cent. since 1997.
The hon. Lady raised the specific issue of ambulance services in rural areas, and how the new larger ambulance services are expected to perform. The Department issued directions to each ambulance trust following the
reorganisation of services in 2006 to set out the requirement that each trust must be able to demonstrate that it has regard to the reasonable needs of everyone in their area, and has arrangements in place to meet the national response times. The way in which each trust does that will depend on the local geography and fleet mix, and is a matter for local decision. However, since the reorganisation, ambulance services have improved their performance and displayed the highest response ever on category A calls, with 77.1 per cent. in the latest figures.
The hon. Ladyand the hon. Members for Mid-Bedfordshire and for Hemel Hempsteadalso raised the issue of delayed handover of patients at accident and emergency departments. Let me make it clear againas my right hon. Friend the Secretary of State has done on many occasionsthat it is totally unacceptable for A and E departments not to accept patients, or for ambulances to have to wait outside for whatever reason. Hon. Members will be aware that the accident and emergency clock starts when the handover occurs or 15 minutes after the ambulance arrives, whichever is earlier. So if hon. Members wish to make specific allegations about such problems occurring at a hospital, they should let us know and we will come down on that hospital like a ton of bricks.
The hon. Member for Wyre Forest (Dr. Taylor), and others, raised the issue of the three-digit number. I am sorry to have to say that they will have to be patient for a little longer. As the hon. Gentleman acknowledged, it is a complex issue, as several different models could be implemented. As he knows, we were clear about our commitment in the next stage review, and it is important to consult on the different models with all the different organisations involved, in the public interest.
The hon. Member for South Cambridgeshire rightly raised the concern about the pressure on accident and emergency departments caused by alcohol and drugs. He will, I am sure, be aware of the cross-government strategy on alcohol and drugs, which aims to address the three problem drinker groups, and therefore take the pressure off accident and emergency departments.
The hon. Member for Mid-Bedfordshire also raised concerns about solo response teams, and I will write to her in more detail. What I can say is that if, according to the best knowledge and decision making of the trust, a traditional double-crewed ambulance is required, one should always be sentbut it is important to provide a fast response as quickly as possible, with back-up if necessary.
We do not have to cast our minds back too farjust to the mid-1990sto remember the horror stories of people waiting for days to see a doctor, waiting in corridors on trolleys in accident and emergency departments. They were waiting with neither privacy nor dignity at a time when they were at their most vulnerable. Over the past decade, this Government have transformed peoples experience of urgent and emergency care. Ambulance services and accident and emergency departments are scoring record performances with a huge expansion in alternatives to urgent care for people for whom accident and emergency treatment is not appropriate. That is an enormous tribute to NHS staff, and I commend our amendment to the House.
Question put (Standing Order No. 31(2)), That the original words stand part of the Question.
The House proceeded to a Division.
Mr. Deputy Speaker: I ask the Serjeant at Arms to investigate the delay in the No Lobby.
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