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Recruiting into emergency medicine is also becoming difficult and application rates into training schemes involving general medicine are also in decline. According to the RCP, there is an increasing reliance on locums and unfilled consultant posts. That will have a negative effect on emergency care, which is vital to all. There is also an increasing recognition that services such as emergency surgery might be unsafe out of hours, and the provision of those services needs to be concentrated in fewer centres that are better able to provide senior medical cover.

Improving the quality of care often entails making available senior medical cover in some services on a 24/7 basis. That in turn means reducing the number of hospitals providing those services, to enable consultant medical staff to operate effective rotas in the evenings and at weekends. That would also reduce mortality rates, as most deaths happen on poorly staffed wards at weekends. The most contentious issues concern changes in the provision of accident and emergency and maternity services because of the importance attached to those services by patients and the public. Many of the changes derive from work force shortages, for example among consultants and midwives, making the current model of care unsustainable. That is leading to increasing differentiation in how services are provided. For example, some hospitals provide midwife-led maternity care and others no longer provide accident and emergency services at night.

I will now move on to cost. The merger of particular services, such as intensive care, A and E services and cardiac surgery, could improve quality and save money. NHS London, for example, has demonstrated that the recent reconfiguration of stroke services has achieved an improvement in quality as well as significant cost savings. The Department of Health estimates that in the last quarter of 2011-12, 10 out of 72 NHS acute and ambulance trusts were rated as “underperforming” or “challenged” on their financial performance. Of 143 foundation trusts, Monitor reports that 10 had a financial risk rating of 1 or 2—on a scale of 1 to 5, 1 being high—and that 11 were in breach of the terms of their authorisation on financial grounds. Twenty trusts have declared themselves unviable in their current form, including Heatherwood and Wexham Park Hospitals NHS Foundation Trust, which serves part of my constituency.

One of the most comprehensive reviews for clinical and financial evidence was Lord Darzi’s review of the NHS. He argues that future technological advances will result in an expanding number of diagnostic tests and therapies that could be provided more cost-effectively in a smaller number of regional specialist centres, such as the one I have suggested for junction 8/9 on the M4, rather than a large number of low-volume district general hospitals, which is currently the pattern in large parts of the country. For example, the Audit Commission has identified 25 operations or admissions and estimated that 75% of surgeries should be carried out as day cases. It estimates that if all trusts achieved an average 75% day case rate across these procedures, at least 390,000 bed days could be freed up. That would save £78 million, based on £200 per elective patient bed day.

Lord Darzi further explains that minimally invasive techniques will continue to improve. In the next 10 years, endoluminal surgery—entering the body through its

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natural holes, such as the throat—will become the standard method for treating many complex cases. Better diagnostics will also help most surgery to become non-invasive. Minimally invasive surgery means smaller scars and less risk of post-operative infection, which means patients will also recover more rapidly.

Furthermore, there is an argument for reducing the number of administrative staff required, which will be more cost-effective and save money that could be better spent on the quality of care. Hence, reconfiguration can deliver improvements in quality and safety without significant additional cost.

There are strong political and policy pressures to sustain, and where possible increase, local access to services, particularly those needed in an emergency such as A and E and maternity care. We have an ageing population, and the majority of hospital users will rely on public transport to take them to hospital. Transport systems will have to be put in place so that people can access the central hub hospitals.

How do we achieve the utopia I am seeking in the location and structure of national health service hospitals? I fear that we will need something that we do not currently have: some central direction. This project will take many years to achieve, and we need a cross-party committee to draw up a plan that applies to the whole of England and Wales, so that we can decide where the hospitals, including the community hospitals, are required. If we do that, I am convinced that we will be in a position to deliver the best care in the western world to all our constituents.

2.49 pm

The Parliamentary Under-Secretary of State for Health (Dr Daniel Poulter): I congratulate my hon. Friend the Member for Bracknell (Dr Lee) on securing this debate and on making such an eloquent speech about the importance of modernising the NHS so that it can continue to deliver high-quality care. That often goes hand in hand with both improving efficiencies in care delivery to patients and reducing the cost of delivering care.

My hon. Friend outlined how the NHS crisis management system focuses on the acute sector. If we were designing the NHS today, it would look very different. My hon. Friend explained the importance of community-delivered care and pointed out that we need to keep people living well and healthily in their communities, rather than picking up the pieces in the hospital setting after they become unwell. He rightly made the point that the length of time of hospital stays for surgical operations has fallen. It has fallen from about nine or 10 days over the past decade or 15 years to an average of about five or six days. Increasing use of keyhole surgery and other minimally invasive procedures have also increased the quality of care we can provide, reduced the cost and, importantly, ensured that patients are treated in a more effective way. These developments also take account of the fact that people are much better off at home than in hospital, or when being treated as day cases rather than long-term admissions.

My hon. Friend rightly highlighted that there is a big challenge facing our health service in the decade ahead: we have many people with long-term medical conditions who need to be treated and we have many older people.

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People with diabetes, heart disease and dementia are also living longer. The way we should look after them is not to wait for them to get unwell and then pick up the pieces when they arrive at A and E, but to prevent them from getting unwell in the first place. We must deliver more care in the community and, where we can, focus on prevention rather than cure. We need to do more to ensure that proper rehabilitation is available for people after a stroke or an operation. That needs to be delivered, as much as possible, in the community and people’s homes, as it produces much better care.

We already see good examples of where that is working. In Wigan there has been a cost-saving to the NHS of £700,000 through a new service that makes sure people who have suffered a stroke spend no longer than 50 days in hospital. They are in hospital for a much shorter period and they get the vital rehabilitation and care they need to improve their outcome and improve their recovery. That care is now delivered in the community, rather than the hospital setting. That is cheaper for the NHS and better for patients. It is a good model of care that we can take elsewhere.

As my hon. Friend said, it is important that politicians are brave in how we talk about these matters. He should be commended for the way in which he has approached the issues and been very honest about the fact that medical care will need to look different in future. Sometimes the politician is the worst enemy of the physician. We are both medical doctors—we both still practise medicine—and we understand that good care will look different in the years ahead. It is important to make the case in our roles both as physicians and as politicians that what matters is delivering high-quality patient care, which will have to look different if we want more care at home and more preventive care.

My hon. Friend talked about the need for service reconfigurations that provide specialist centres and more focused centres of care. Among the many examples that he outlined, he said that the reconfiguration of stroke services in London was massively to the benefit of patients and that having fewer centres for stroke care has been saving many hundreds of lives every year; indeed, there are good clinical data to support that. Yesterday I visited hospitals in Manchester, where I saw another good example of where service reconfiguration has worked well after a case was made for reconfiguration of maternity care and neo-natal care. Having fewer obstetric-led maternity units and more midwifery-led units is saving the NHS money but also saving 30 babies’ lives every year in the Manchester area. Mike Farrar, the former head of the strategic health authority, delivered that change very effectively.

Although I take on board what my hon. Friend said about nationally led service reconfiguration, a key thing that we can derive from the changes to services in Manchester and London is that they were driven at a local level by good clinical leadership and effective engagement of local communities. There are many good

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examples of strong clinical leadership at a local level delivering improved patient care as well as saving money which is being ploughed back into the NHS to improve care for other patients.

Let me turn to service reconfiguration in Bracknell, my hon. Friend’s part of the world. As he is aware, this Government, like previous Governments, have set a number of tests for service reconfiguration. There are four key tests. First, while it is important that local health care services should be designed around local needs, the Government are clear that the NHS should develop and implement plans for service change in a consistent way that gives confidence to local communities. The four tests clearly outline that there should be strong local clinical leadership and ownership of how services are redesigned, as well as strong community engagement. As in the example of Manchester, where community engagement was achieved and people are buying into the change because it is saving 30 babies’ lives every year, we can not only deliver better-quality care for patients but bring the community with us in doing so.

Under the third test, the change, as well as being clinically led, should encourage choice and availability. In more rural parts of the country, focusing on bigger and better centres will often reduce choice, because due to their rural nature such areas need more service providers—more hospitals. People may therefore have to travel long distances to receive their care.

Finally, even if the proposed change involves cost savings to the NHS, the key focus should be on its ability to deliver better-quality patient care. Where all four tests for local reconfigurations can be met, we should all welcome it. My hon. Friend mentioned that the new arrangements are already working well in London, Manchester and elsewhere.

I am happy to meet my hon. Friend to talk through the service reconfigurations that he is advocating in his part of the country, if he wishes to do so. I know that he is already working with his primary care trust and strategic health authority, and with fellow MPs whose constituents and hospitals will be affected by the proposals, and I urge him to continue to engage at local level with the PCT and the SHA, and with colleagues. If he continues to advocate the case that he has outlined today, he will bring people with him.

It is important to stress, however, that the decisions will be taken at local level. As PCTs turn into local clinical commissioning groups, it will be a matter for those groups to work together to decide what health care services will look like at local level. I am sure that my hon. Friend and other parliamentary colleagues will want to continue to engage with them and to make a strong case for proposals such as these. Given the eloquence with which my hon. Friend has put forward his proposals today, I am sure that he will have some success.

Question put and agreed to.

2.56 pm

House adjourned.