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Those improvements have been recognised internationally. Last November, the Commonwealth Fund survey of primary care services ranked the UK first in almost
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every area. There has been a transformation in the NHS, which has moved from being pretty poor to being good, although it must still go further before it is great. If we want a great health service, we must continue to invest in it and ensure that we deliver improved care beyond that which we are delivering now.

As the hon. Gentleman said, the time of rapidly increasing budgets is coming to an end. The stimulus package that we and Governments around the world have put in place has avoided a second depression, but the cost of that will mean tighter budgets in years to come. I do not for a moment accept the argument that a crisis is coming, and neither do I believe that a great storm is coming. There is, however, a demand for good management and efficiency, and a need to ensure a clear focus on the priorities.

Should any manager happen to overhear the debate-saying something in the Commons is almost like trying to smuggle a message out-the message that came out in the Mid-Staffordshire inquiry and in the problems with out-of-hours doctors and a range of issues is this: the first priority for any manager in the health service is patient safety and the quality of care for patients. Managers must be aware of issues to do with finance and targets, but the priority must be to ensure patient safety and patient care.

Bob Spink: Does the Minister accept that there could be a crisis if decisions were wrongly taken to slash and cut public services such as the health service in a devastating way? We should certainly avoid that policy. One way in which we could move forward is by addressing the amount of funding that is spent on NHS management.

Mr. O'Brien: I do not want to get sidetracked into a discussion about what is or is not management. A lot of figures are bandied about, which I sometimes worry about. Sometimes they refer not to managers but to staff who are necessary to ensure that a patient knows when their appointment is and can get there, and that the health service is properly administered. More than ever in the coming years, we need good-quality management and sometimes we have not had that in the past in the NHS, which is why we are mounting a programme to improve the quality of management in the health service.

Mr. Andrew Pelling (Croydon, Central) (Ind) Will the Minister give way?

Mr. O'Brien: I shall give way once more and then I must make some progress.

Mr. Pelling: As this is the season for giving way, I will intervene at this stage. I apologise, Mr. Jones, for not being here for the first 10 minutes of the debate. I am mortified that I was not here for my leader's speech. The Government are to be congratulated on the amount of money that they have provided to the NHS and on the transformation that the Minister has spoken about, but will he acknowledge that there is a danger in being over-ambitious and trying to create rather remote hospitals as centres of excellence and in being too ambitious about how much we can move patients away from hospitals to polyclinics? When it comes to planning
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appropriate savings and improvements in health provision, managers and, indeed, Health Ministers should not be too ambitious about how such changes to management can be provided. That is a great controversy, as the Minister knows, in London and in south London as well.

Mr. O'Brien: Polyclinics in London-GP-led health centres in other parts of the country are a slightly different type of NHS institution-are providing a great opening for people. They offer extended hours and deliver the services that patients want. We have to accept that the NHS will not be frozen just as it is now. What we have to see, particularly in the years to come, is a resolute focus on quality and improving patient care within reasonable budgets. We need to ensure that managers in the health service are focused on that, which means innovation and change. Change will come to the health service, and the changes that we want to see will improve the quality of patient care.

We want to ensure that managers know that there is not a crisis. My right hon. Friend the Member for Oxford, East (Mr. Smith) is right: sending the wrong message at this stage would be very dangerous. The NHS budgets are increasing this year by 5.5 per cent. and next year by 5.5 per cent., if the Government remain in power at least. We have said in the pre-Budget report that we are committed to protecting front-line NHS spending for the following two years, growing it in line with inflation.

However, the demand for health care from an ageing population, new technology and ever higher patient expectations mean growing pressures on the NHS budget. That is clear, so along with commitments on spending, we have set out the quality and productivity challenge that the NHS faces. In four years' time, the NHS needs to be making efficiency savings of between £15 billion and £20 billion a year. Importantly, those are not cuts. Let me make that clear. The money will not be taken out of the NHS by the Treasury. After all, we are not Thatcherites. Importantly, those funds will be kept within NHS budgets. Our aim is that every penny of those savings will remain within the budgets, allowing us to realise our vision of continuing to improve the quality of care for all. Essentially, we envisage no cuts in NHS front-line funding.

In previous times of financial challenge, patients have borne the brunt through longer waiting times, reduced availability of drugs and treatments and, ultimately, poor-quality care. Managers lacking in imagination made slash-and-burn cuts. That approach is indefensible when the scope for improving quality and productivity in the system today is still great. Patients should not pay the price of poor managers who are unable to handle budgets. The Mid-Staffordshire lesson is a lesson for every manager in the system.

We need imaginative managers who will focus on the quality of care. I make no bones about it-I will name and shame managers who are making slash-and-burn cuts across the health service. Just in the last couple of weeks, I saw a press release from Gloucester hospital that deeply concerned me. I wrote to the managers at Gloucester hospital, expressing concern. They have said that the economic situation means that they have to slash a load of beds-a couple of hundred beds. That is nonsense. Thankfully, they have now decided that that sort of slash-and-burn announcement is unnecessary
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and needs to be looked at with care. It is a product of a lack of imagination by managers, and managers need to be very careful when they go down that route.

Mr. Pelling: Will the Minister give way one more time?

Mr. O'Brien: No, I will not, if the hon. Gentleman will forgive me. I have only a few minutes left.

The vision of high-quality care for all is one of local clinical leadership, of empowered patients shaping their own health care, of prevention being as important as treatment, as the hon. Member for Wyre Forest said, and of unstinting demand for higher-quality care. We must not for one second consider stepping away from that. Improving quality can also reduce costs. Our record on reducing health care-associated infections demonstrates that. We have made great strides, reducing MRSA by 74 per cent. and clostridium difficile by 37 per cent. That has not only improved care and saved lives, but saved the NHS £240 million.

There are many areas with the potential to improve quality and increase productivity. In the time allowed, I shall give a few examples. Enabling all hospitals to meet the staff productivity currently delivered by the best could deliver annual savings of up to £3.5 billion. The hon. Gentleman talked about the productive ward programme. As a result of that, nurses in London were able to spend an extra 500,000 hours-500,000 hours-with patients, because they themselves have worked out ways in which they can improve the quality of what they do in productive wards to give that time to patients. We are talking about the equivalent of an extra 255 full-time nurses, costing about £7.5 million. So far, the productive ward has been introduced for only 12 per cent. of London's wards, but the ideas that underpin the productive ward programme have also been applied in mental health wards and operating theatres and in the delivery of community services.

Pilots of productive community services have already produced promising results and suggest potential reductions of time spent: on travel by more than one fifth; on administration of referrals by more than 80 per cent.; on finding stock and supplies by two thirds; and on dealing with interruptions by more than half. That has led to an increase in time spent on direct patient care and, not surprisingly, staff morale has gone up by more than 90 per cent. That is the type of measure that can change the quality of care and save money. Reformed community services and transforming the care of those with long-term conditions, delivering integrated, efficient and people-centred care, has the potential to improve the quality of millions of people's lives and to save up to £2.7 billion in the process.

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The next area of our focus is improving health as well as treating sickness. That has the potential to save the NHS further billions of pounds. For example, screening by pulse palpation to improve detection of atrial fibrillation improves the quality of care by reducing the risk of stroke, and it avoids the costs associated with stroke and its complications, particularly through emergency hospital admissions.

The Government have made clear their intention to drive down the costs of management, back-office support and procurement across the public services. The NHS wants to find ways in which that can be done sensibly, rewarding good-quality management but also ensuring that innovation in management and administration is acknowledged in the health service and rewarded, too. All too often, managers who are innovative in how they run things and who deliver higher-quality care for patients are forgotten, because that is just the administrative side, not the flashy, operating theatre, medical style of care, but they too are contributing to the quality of health care. We need to acknowledge where good management has reduced costs and improved the quality of care through administrative changes, rather than just medical changes.

All this cannot be administered from Whitehall. Instead, we need to empower clinicians and their patients. It is through innovation, through looking for new ways to do things, assessing them and, most importantly, spreading them throughout the health service-the NHS is great at innovation, but it does not spread it-that we can ensure that we unlock productivity gains. To support that, we have published the best examples of quality and productivity improvement on the NHS Evidence website. That has already been seen by more than 10,000 visitors to the site.

The hon. Member for Wyre Forest highlighted the debate that we had the other day on self-care. That is an important debate and one that we need to take further, but we also need to give people more access to information about the care of their own health, both through the internet and through interactive television, which presents a great opportunity. Let us say that someone has a problem such as asthma. Interactive television can be useful for someone who is not perhaps as technology-literate as younger people often are.

We face a great challenge, but we can overcome it by improving the quality of care, reducing the costs at the same time and delivering within NHS budgets, while recognising that the highest priority of the NHS must always be patient safety and ensuring that we improve the quality of patient care.

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Peripheral Arterial Disease

1.30 pm

Dr. Brian Iddon (Bolton, South-East) (Lab): It is a great pleasure to serve under your chairmanship, Mr. Jones, for what I think is the first time. It is also a great pleasure to see the Minister here to respond to the debate. I will try to persuade her that we can avoid lower-limb amputations if the national health service works more holistically.

Amputations are in the mind of the general public for the tragic reason that many of our troops are returning home from war theatres-particularly Afghanistan-having undergone not only lower-limb amputations, but amputations of parts of their arms. However, the vast majority of amputations undertaken in the national health service are caused by peripheral arterial disease, diabetes or, quite often, a combination of both. Losing a limb is a tragedy for any patient, and their quality of life afterwards, particularly if they are elderly, can be extremely poor. Only half the patients who undergo a major lower-limb amputation as a result of such diseases live more than another two years. The number of major lower-limb amputations is still rising-there were well over 25,000 major amputations between 2003 and 2008. There is an urgent need to reduce amputation rates and to save more legs. The good news is that that can be done.

Peripheral arterial disease is a form of arterial sclerosis and is closely associated with stroke and coronary heart disease. The condition is caused by a narrowing of the arteries, usually in the legs. A symptom of the disease is intermittent claudication, which is a cramping pain felt in the calf, thigh or buttock during walking or other exercise. It is caused by poor blood flow and affects up to 870,000 people, or 5 per cent. of the population. Without proper blood flow, wounds cannot heal, which leads to infections, ulcerations and, tragically, to amputation in some cases.

Bob Spink (Castle Point) (Ind): I congratulate the hon. Gentleman on bringing this matter to the House. He is going through the disease processes, but does he acknowledge that one of the greatest risk factors after genetics is smoking? Will he therefore welcome no-smoking day on 10 March, which will be run in community halls, schools and shopping centres across the country? Will he try to get the NHS to get more people to stop smoking?

Dr. Iddon: I have been a great advocate of stopping people smoking, including people in my family, and I will refer a little later to smoking as a causative factor of narrowing arteries.

Diabetes is a major cause of peripheral arterial disease. Diabetics have an increased risk of developing the disease and account for up to 70 per cent. of non-traumatic amputations. The relative risk of amputation is 40 times greater for diabetics. Anther pretty stark statistic for right hon. and hon. Members to digest is that a diabetic who smokes runs an approximately 30 per cent. risk of amputation within five years-the point made by the hon. Gentleman.

We all know how the prevalence of diabetes is increasing to worrying proportions as a result of lifestyle and obesity. There are an estimated 3 million people with
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diabetes in the UK, and large increases in amputation rates are a possible unfortunate consequence of the growing number of diabetics. However, the good news is that, according to the International Diabetes Federation, 85 per cent. of amputations in patients with diabetes can be avoided, and that is the main point of today's debate.

The impact of amputation on patients is stark and evident. Amputations also cost the country and the NHS large amounts of money. The amputation rate is between 5 and 6 people per 100,000, but the figures range broadly between strategic health authorities. I have just received the latest statistics on the numbers of amputations in England, which are broken down into the different kinds of amputations. The numbers are still rising.

Each surgical procedure costs between £10,000 and £15,000, which means an annual bill to the NHS of between £50 million and £75 million. However, that does not take into account the substantial costs of rehabilitation, the provision of prostheses and social care, and the social and economic impact on society. The wider cost of patients in employment with moderate-to-severe peripheral arterial disease can be measured in terms of working days lost through illness and disability. We should also consider the loss of taxation revenue to the Exchequer and the cost of benefit payments to ill and disabled people, which are likely to amount to hundreds of millions of pounds on the taxation bill.

Some 85 per cent. of amputations are preceded by a foot ulcer. The estimated cost of foot complications alone to the NHS is £256 million per annum. The past 20 years have seen major developments in the healing of foot and/or leg tissue loss, which have been driven by innovations in assessment and treatment, the development of modern wound-care dressing materials and the development of surgical and other, less invasive interventional treatments by vascular specialists. Despite that, the numbers of lower-limb amputations are still high.

At this point, I pay tribute to the work of the Circulation Foundation, the Vascular Society and the British Society of Interventional Radiology, whose members have done, and are still engaged in, excellent work highlighting the need to save people's legs. Indeed, I recently hosted a parliamentary reception to highlight the subject. Groups such as the Lindsay Leg Club Foundation also do excellent work helping patients with leg and foot tissue loss through direct support and care.

Clinicians are only too well aware of the challenge of rising amputation rates. Put simply, patients are being seen by vascular specialists far too late, when amputation is the only option available. When a patient first goes to their general practitioner with mild symptoms of intermittent claudication, they are correctly advised to change their lifestyle and particularly to cease smoking and undertake some exercise. Medication with aspirin or statins can reduce clot formation and cholesterol levels and can help to limit disease progression. Other cardiovascular risks to which the patient is likely to be subject can be addressed at the same time.

Unfortunately, treatment by a vascular specialist is often seen as a last resort. However, revascularisation through an open surgical procedure or angioplasty, with or without a stent, can bypass or unblock arteries, improving blood flow in the lower extremities. Revascularisation can significantly add to the benefits
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of lifestyle change. Britain has one of the lowest revascularisation rates for legs in Europe and some of the highest amputation rates, which tells us a lot. If patients were referred to vascular specialists a lot earlier, they could get the appropriate treatment, and we could save a hell of a lot of legs.

We must increase awareness of peripheral arterial disease among health professionals and particularly among GPs. That is what I am trying to do today. A clear referral pathway from primary care to secondary care would help vascular specialists to see patients sooner. Peripheral arterial disease is not, however, a condition that involves just one discipline, which is why I mentioned an holistic approach at the beginning of my speech. A diabetic patient with foot ulcers and advanced intermittent claudication should be seen by a wound care specialist, as well as by a diabetologist and a vascular specialist-either a vascular surgeon or interventional radiologist.

Peripheral arterial disease requires a multidisciplinary approach. There are some great examples here in the UK where that approach is seen to be working and is already saving legs. An 11-year survey of diabetic amputation rates, conducted between 1995 and 2005 at Ipswich hospital, showed a significant decrease in lower-leg amputation rates following the introduction of a multidisciplinary foot team. Over the survey period, the incidence of all amputations fell by a staggering 40 per cent., and among people with diabetes by a more staggering 70 per cent. Similar outcomes have been achieved in Middlesbrough and Southampton, and there are probably other examples of best practice in this country of which I am unaware.

Although I have painted a generally bleak picture, I hope that I have shown hon. Members, and particularly my hon. Friend the Minister, that we can achieve great improvements through a co-ordinated effort and bringing services together. In the end, the improvements in care I suggest would lead to a higher quality of life for many patients and could be cost-effective overall, too. The Government have made great strides in improving survival rates and treatment for patients with coronary heart disease, and we know that the NHS, with a clear strategy, can achieve great things-there have been many examples of that in the past 10 years. Peripheral arterial disease is often seen as a poor relation to stroke and heart disease. I think it is high time that we should focus on peripheral arterial disease as well.

We can save legs and save money, even in an age of austerity. I am confident that, by learning the best practice from our European partners, which do much better than we do, particularly through early referral; by incorporating best practice from the UK; and by bringing into every hospital multidisciplinary collaboration between leading clinicians, we can reduce amputation rates, despite an ageing population and more patients unfortunately being diagnosed with diabetes. That view is shared by many consultants, some of whom I have talked to personally.

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