Health Committee - Minutes of EvidenceHC 171

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Oral Evidence

Taken before the Health Committee

on Tuesday 4 June 2013

Members present:

Mr Stephen Dorrell (Chair)

Rosie Cooper

Andrew George

Barbara Keeley

Grahame M. Morris

Andrew Percy

Mr Virendra Sharma

David Tredinnick

Valerie Vaz

Dr Sarah Wollaston


Examination of Witnesses

Witnesses: Anthony Marsh, Chair, Association of Ambulance Chief Executives and Chief Executive, West Midlands Ambulance Service NHS Foundation Trust, and Mark Docherty, Chair, National Ambulance Commissioners Group, gave evidence.

Q96 Chair: Good morning. Thank you for coming this morning. Can I ask you to begin the session by briefly introducing yourselves and your posts?

Anthony Marsh: Good morning. I am Anthony Marsh. I am the chairman of the Association of Ambulance Chief Executives and the chief executive of the West Midlands Ambulance Service NHS Foundation Trust.

Mark Docherty: Good morning. I am Mark Docherty. I am chairperson of the National Ambulance Commissioners Group.

Q97 Chair: Thank you very much. I would like to begin by focusing specifically on the question of commissioning. The question is focused particularly on Mr Docherty, but I am interested in both witnesses’ points of view on this. In this session, we are interested primarily in ambulances but only, in truth, in ambulances as part of the ability of the NHS as a whole to respond to needs for urgent and emergency care. This morning, we have press stories about further problems in A and E departments. We have stories with a later witness, Clare Gerada from the Royal College of GPs. Everyone agrees that there needs to be a more integrated capacity for the system to respond to the need for urgent and emergency care.

I would like to open the session by asking how the commissioning system is developing to deliver not an ambulance service, an A and E service and a primary care service-different bits that are unrelated-but an integrated, joined-up service. In particular, how is the organisation for commissioning of ambulance services intended to relate to the new idea of urgent care boards? Can you tell us how we will get an integrated service from what looks like a disintegrated commissioning system? That is, I guess, my question.

Mark Docherty: The point to start with is that responsibility for commissioning ambulance services rests with the new clinical commissioning groups. That is really important, because that is where the urgent care system starts. The clinical commissioning groups will design pathways of care for patients who have urgent or emergency care needs. However, the important thing to remember is that an ambulance service does not exist on such a small footprint. Most ambulance services in this country cover fairly large geographical areas and will, therefore, have a number of clinical commissioning groups within them, so it is important that there is collaboration in the commissioning of ambulance services. The group that I represent exists for that very purpose. Our reason for being is to encourage collaboration in the commissioning of ambulance services, so that patients-

Q98 Chair: I am sorry to interrupt you, but is it fair to conclude from that that the intention is to have one commissioning process per ambulance trust-that there will be a system to ensure that commissioners speak with one voice to their ambulance trust?

Mark Docherty: That would be an ideal, but what we have described in previous work we have undertaken is different levels of commissioning. Commissioning ambulance services for emergency preparedness-terror attacks and things like that-needs to happen on a very large scale, we believe, probably on an England-wide scale, whereas commissioning ambulance services to take patients to alternative pathways of care has to happen on a very local basis, because that can be designed only around very local health care systems. The collaboration has to happen on different scales, depending on the type of ambulance response we are talking about.

Anthony Marsh: You mentioned the urgent care boards. What Mark has just said is absolutely right. You have the core 999 emergency service being commissioned in most parts by a consortium arrangement of clinical commissioning groups across the geographical footprint of the ambulance service, but then, more locally, through the urgent care boards. In most places around the country, those arrangements have existed to a lesser or greater extent-although they may have been called something different-to pull together some more local CCGs to ensure that the service is commissioned locally for their people. In addition to that, sometimes further local arrangements are put in place by clinical commissioning groups for their local population. Obviously, it is early days-clinical commissioning groups have not been in existence for very long-but we welcome wider clinical engagement. I think that will help and support ambulance services to shift to becoming more clinically focused providers of services and ensure that the services are delivered to meet the needs of local populations, because of course those do vary-one size does not fit all.

Q99 Chair: But when we are told-as we have already been told in this inquiry and are regularly told-that the key to effective response to urgent care needs is a joined-up service, who is responsible for delivering that?

Anthony Marsh: Commissioners are responsible for commissioning it and the providers with whom they commission are responsible for delivering it. You are absolutely right. We welcome the integration of ambulance services and the 999 service, out of hours, NHS 111 and other-

Q100 Chair: We all welcome the words. Can we focus on any evidence that anything is happening actually to join up these different silos-including, incidentally, social care?

Anthony Marsh: In some parts of the country-I am not aware of every particular part-there are single commissioners with responsibility for the out-of-hours service, the 999 ambulance service and NHS 111. That is a good start; at least the same individual or teams of individuals within a CCG are working on behalf of the other CCGs within a geographical footprint. In my patch, all 22 across the west midlands together commission NHS 111 and the 999 service. The arrangements are in place to make that happen, but clearly there is an opportunity to strengthen that and really to make sure that it is mainstreamed through the commissioning arrangements.

Q101 Chair: How does that link with the commissioning boards’ responsibility for commissioning primary care?

Mark Docherty: The important thing is that we make sure that all of these commissioning arrangements are joined up. Primary care is clearly an important part of the system that prevents people from accessing urgent and emergency care. For many patients, primary care would be the first port of call.

Q102 Chair: According to the Royal College of Physicians, it would be if the light were on.

Mark Docherty: Yes. The important thing for the ambulance service is that for many patients that will be their first port of access to the health care system. Increasingly, we are finding that some younger patients are choosing to access emergency or urgent services as opposed to primary care. The important thing is that it should not matter how patients access-it is the response we give to that request for access that is important. Increasingly, the ambulance service will send an alternative response or signpost a patient to an alternative, more appropriate service. Anthony’s service in the west midlands would convey a 999 response to about two thirds of the patients it gets; the other third would be directed to places such as primary care, GP out-of-hours services, walk-in centres or community services. The important thing is that we have access to that range of services, irrespective of how the patient has accessed, and what they think is an appropriate way of accessing, the service.

Chair: Okay. We could spend all morning discussing this, but perhaps we should not.

Q103 David Tredinnick: An increasing number of ambulance trusts are failing to meet the Red1 eight-minute response target. In the short term, what do you think can be done to improve that situation?

Anthony Marsh: The Red1 target is a new target; it has only been in existence for just over a year. Most ambulance services are achieving it, and those services that are not are continuing to make improvements. There is a lot of benchworking going on among the director groups to establish best practice and how we can respond even more quickly to those patients with serious and life-threatening emergencies. From speaking to colleagues, I am confident that they have an action plan in place that will enable them to improve on that target, particularly the Red1 target for life-threatening emergencies.

Q104 David Tredinnick: We are getting a lot of media coverage about the increased pressure on ambulance services. Do you think there is any evidence that patient outcomes are worsening as a result of this?

Anthony Marsh: Certainly the ambulance quality indicators and the clinical indicators for ambulance services show an improvement. We have been able to improve in relation to patients suffering from cardiac emergency, stroke and, more recently, trauma, as a consequence of the introduction of trauma networks. Patients are benefiting from those new arrangements and, of course, from the increase in the number of paramedics who are being trained and the additional paramedics who have been recruited to work in ambulance services. You are right, there are occasions when ambulance services are under pressure-the CQC’s recent reports on some ambulance services are evidence of that-but be assured that ambulance staff on the front line and their supporting organisations are doing everything they can to deal with the increase in 999 calls. On average, over the last 10 years, there has been an increase year on year of about 4.5%.

Q105 David Tredinnick: You just mentioned the trauma networks that have been formed. How effective are those? How do you think they are going?

Anthony Marsh: Where they have been and are fully implemented-I am aware that in some parts of the country full implementation may still be being put in place-we have seen substantial numbers of additional lives being saved. The latest evidence that I saw was an improvement of an additional 5% of lives being saved as a consequence of those new arrangements, which enable advanced-trained paramedics to bypass existing emergency departments to take those patients who are most critically injured to a regional trauma centre so that they can get the very best care.

Q106 David Tredinnick: So it is another example of better targeting of resources. Is that right?

Anthony Marsh: Absolutely right-and ambulance staff are well placed to be able to provide those services.

Q107 David Tredinnick: Moving on from that, do you think that the splitting of the category A calls into Red1 and Red2 has achieved the Government’s aim of reducing the number of inappropriate and, possibly, mischievous calls and the multiple dispatch of ambulances?

Anthony Marsh: I am not sure that it has reduced the number of calls-I am not sure that that was one of our objectives-but being able to target the finite resources that ambulance services have and to prioritise those calls more effectively to ensure that we are able to get to the Red1 patients even more quickly is helping patients and, undoubtedly, saving more lives.

Q108 David Tredinnick: Finally, in your long experience in this service, do you think that generally we make sufficient and effective use of computers in allocating resources? Do you think that the information technology is up to the task, or have you identified problems there?

Anthony Marsh: I have no doubt that the extent to which we use computer technology in our control rooms is world class. Could it be better? Yes, it could-I am absolutely sure that there are areas where we can make further improvements-but the progress that has been made is really first class. I do think that the use of technology in ambulance services in the broader sense could be improved. The extent to which we can use electronic patient report forms, rather than having to fill out paper documents for assessing and treating patients, is an area where we could make further improvements. It would also be enormously helpful for front-line paramedics-both those in the control room and responding paramedics-to have access to the national spine, which would enable them to pull down useful and critical information about a particular patient, rather than looking at patients with very limited information, as is very often the case.

Q109 David Tredinnick: So you very much support the Health Secretary Jeremy Hunt’s idea of getting all the medical records on to a computer?

Anthony Marsh: I certainly support access for paramedics to critical information. I am not saying that paramedics need access to all health records for a particular patient, but they certainly need the most critical information in order to make better-informed clinical decisions and clinical assessment for those emergency patients.

Q110 Mr Sharma: My question is on indicators. What clinical outcome indicators could be included in ambulance services performance measurement to provide a better picture of overall service performance?

Anthony Marsh: Good progress has certainly been made on shifting towards a greater emphasis on clinical performance and clinical outcomes, rather than just the speed of response, although that is really important and we should not lose sight of it. Good progress has been made in relation to the key indicators that we put in place for ambulance services a couple of years ago-in relation to patients suffering from heart attacks, stroke, asthma, hypoglycaemia and other indicators-but I think we can place even greater emphasis on those clinical indicators to improve performance, to reduce variation and to provide better training and reflective practice for our paramedics, so that they become even more confident and competent and can provide even better services for patients.

Mark Docherty: The important thing in measuring clinical outcomes is that we look at the clinical outcome of the pathway of care and not just the individual sections of the care. We know there are services where one part of the system can produce very good clinical outcomes, but, if a different part of the system is not also producing good clinical outcomes, the net result for the patient is not a good outcome. We need to become more sophisticated at that-for example, by measuring the patient’s unique NHS number as they go through the care pathway. At the moment, we measure the pathway outcome for people who have a cardiac arrest, so we know the patients who leave hospital alive and the ones who are alive up to a month later. We can become more sophisticated at measuring those pathway outcomes.

Q111 Grahame M. Morris: This issue has been very much in the news-and again today, with the King’s Fund report on the growing pressures on A and Es. In the evidence you have submitted, you indicate that greater use can be made of skilled paramedics who can exercise clinical judgment and that that can have an impact not just in the conveyance of patients to hospital. If that is an appropriate avenue to go down, why is it not standard? Is that an issue for commissioners? Is there a particular reason why that is not the norm?

Mark Docherty: If you take the traditional ambulance model from 20 or so years ago, it was predominantly a transport system to get sick people into hospital. That is the background the ambulance service has come from. In recent years, we have seen the development of paramedics, enhanced care practitioners or consultant paramedics, in some parts of the country, so the skill mix in ambulance services is growing at a fairly rapid pace, against a backdrop of increasing demand. It is taking time for skill mixes to increase, but in some parts of the country, we are getting close to a 70% paramedic skill mix. The significance of the 70% paramedic skill mix is that with that skill mix you can ensure that every vehicle has a paramedic on board, so that whichever vehicle responds to the patient the first response that gets to the patient will include a paramedic. Up to now, that has not been possible. With a less than 70% skill mix, that will always be a challenge, but most ambulance services are increasing their skill mix fairly rapidly.

Anthony Marsh: That is absolutely right. As a consequence of that, we have seen conveyance rates of patients fall from about 70% or more in some parts of the country five years ago to just over 50% now. That number is continuing to reduce, despite increases in 999 calls.

Mark Docherty: It is not just about having paramedics. Paramedics are very well trained in saving lives. We are finding that the clinical need of patients is urgent primary care, so enhancing the skills of the paramedic beyond trauma and life-saving care into the field of urgent primary care is a development that we are starting to see happen more.

Q112 Grahame M. Morris: Is using the clinical skills of the trained paramedic now the norm, or is it just a trend? Is it part of the solution, not just to relieve the pressure on A and E but to ensure better outcomes, because patients are referred to the appropriate service, which may be primary care? A and E may not necessarily be the best place for them.

Mark Docherty: Some of these patients have really complex needs. It is a difficult environment for clinicians to work in. Even some of the most experienced clinicians will struggle to make decisions in a pre-hospital environment, where your access to diagnostics and a whole range of other things is fairly limited. We have to build the skill of those paramedics so that they have the knowledge, the experience and the expertise. For example, an elderly person with a chest infection may have some quite serious underlying issues; experience may be needed to get to the bottom of those.

Anthony Marsh: You asked about the solution. Paramedics and advanced-trained paramedics are absolutely part of the solution. Paramedics in the ambulance service enjoy high rates of public confidence and are very well placed to be able to expand what is already taking place in many parts of our country.

Q113 Andrew Percy: Following on from Grahame’s point, while the conveying rates and the alternative pathways are important, on Friday I met the chief exec of one of my two ambulance trusts, who explained to me that, perversely, there is a disincentive financially to the trust to reduce call rates. Obviously you have regular offenders, if you want to call them that-nursing homes and care homes, in particular, are very big users of the service, sometimes unnecessarily-but, if the trust were to work to reduce those calls, it would, of course, see a drop in income. Do we need to change the way in which this whole model is commissioned to pay trusts by results on how well they do in reducing call demand as well, through other work in the community?

Anthony Marsh: I am sure every ambulance service does everything it can to provide the best service. I am aware that, almost without exception, every ambulance service is doing some kind of prevention work-nursing homes are a really good example of that-to make sure as best we can that the people who dial 999 for an ambulance service response, although not necessarily an ambulance, are those people who really need an emergency response.

Q114 Andrew Percy: But the trust then loses money, doesn’t it?

Mark Docherty: The answer is that that depends. There is no central edict that determines how the ambulance service is paid. To some extent, that depends on how skilled your local commissioners are and how sophisticated they can make the commissioning process. For example, in the west midlands, the West Midlands Ambulance Service NHS Foundation Trust gets paid for advising a patient over the telephone and signposting them to the right service. The amount of payment is the same as if the patient were taken to hospital. Arguably, there is an incentive not to take the patient to hospital, because the job cycle time for signposting a patient can be much quicker. The answer is that it can work and be sophisticated, but that depends on the arrangement that the local commissioners have.

Anthony Marsh: However, the point that you are making is right. What Mark has described is right for those calls that you receive, but if you reduce the overall number-which is your point-you will receive less income overall, regardless of how much you get for what you do with the patient who does contact you. However, it is absolutely about doing the right thing. As I said, year on year for the last 10 years, the increase in 999 calls has been 4.5%. Ambulance services generally are not looking for more activity.

Mark Docherty: That is the point. There is not an ambulance service in the country yet that has actually reduced activity in any one year. Even though we may have schemes that give alternatives for people to call, in total the ambulance activity is going up year on year-and has done for 20-odd years.

Q115 Chair: If a particular patient’s needs are best met by the primary care service, the social care service or the community health team, are the commissioners able to reward that in the way you have just said they can reward activity by the ambulance service?

Mark Docherty: The word "reward" is often a difficult one.

Q116 Chair: Let us not get into that. Are they able to pay for it?

Mark Docherty: In a sense, the health care system for urgent care should be set up so that the ideal is that the patient gets to the right point of care first time. That is the goal of most of the systems that are in place, although they may have differing effectiveness in terms of whether they achieve that. In terms of the money following the patient, ambulance services have, in differing forms, what we call a payment-by-results system, so if the work goes to an ambulance service, generally the money will go with the patient. Whether that works effectively or not-

Anthony Marsh: That is right, but there is also the quality income. Commissioners can set quality indicators alongside the main contract and commissioning arrangements. There are other quality indicators for which commissioners can provide additional funding. Some of those contracts include reducing re-contact rates, particularly from nursing homes; that is a really good example. You can actually attract additional funding by reducing the number of regular callers to 999.

Q117 Barbara Keeley: You may have answered the question that I was going to ask, which was about the mix of paramedics to technicians. We had some evidence to suggest that it was going the other way to what you have suggested. You are saying to us that, in that ratio, the number of paramedics is definitely increasing.

Anthony Marsh: Overall, the numbers are increasing across England.

Mark Docherty: That may be something on which we could respond to you following this. We have data on the percentage of paramedics in each of the ambulance services. We could give you that information after this Committee meeting.

Q118 Barbara Keeley: That is fine. I want to follow up on the points that you have just been making. We have more questions about NHS 111 in a little while, but I have been gathering evidence locally on what is happening. Are you getting evidence that more people are being taken by ambulance to hospital specifically because early triage from a clinician is now missing and we have computer scripts and non-clinicians at the early stage? There are really a number of things. One is that you do not get the right triage at the early stage or you just get nursing homes phoning up, as we have heard. The other possibility is that there are some services missing. Is there evidence that either or both of those are happening and that that is part of the mix that is causing, we have heard, more elderly and frail people to be taken to hospital than was the case and was expected?

Anthony Marsh: Rather unhelpfully, it is all of the above, because we are working in a really complex system. The first thing to say is that, although some of the triage systems are quite risk-averse, even if a call is placed on the ambulance service to provide a response-whether it is an ambulance response or a paramedic in a rapid response car-that does not automatically mean that the patient will be taken to the emergency department. In some cases, they will, but that is a different matter. Very often, the paramedic may be with the patient. They know they do not need an emergency department and recognise that the patient needs some other form of ongoing assessment or care, but either that facility is not available or they are not entirely sure how to access that particular part of the health care system in that very local area, so the default position is to take them to the emergency department. Increasingly, paramedics are able to address that as part of the network. It comes back to one of the earlier points about the ambulance service being part of an integrated system, working alongside primary care, out of hours, mental health and, indeed, social care-being part of that integrated solution. That, as well as the additional training for paramedics, is why we are seeing the overall conveyance rates fall.

Q119 Barbara Keeley: I see. That is quite an important point. The evidence I have seen locally seems to suggest the point you have just made-that there are some conveyances to hospital now because a service is missing. Some of the examples I was given were of people who are really on an end-of-life care pathway and should be being treated in the community, but, if there is a crisis there and that service is missing, they are just taken to hospital. Effectively, people are coming into A and E to die.

Mark Docherty: It is a valid point that there needs to be consistency of alternative services. For example, if they close on a weekend, that is not helpful sometimes. I will mention one of the areas where I think there may be scope for us to do more. We find that a lot of the calls from elderly patients, in particular, are falls-related. This is where clinical commissioning groups really come to the fore. For example, Dudley CCG has commissioned a falls car from you, hasn’t it?

Anthony Marsh: Yes.

Mark Docherty: Its role is to be able to respond rapidly to an elderly person who has had a fall, for whatever reason, to go out to assess them and either to treat them on the scene and sort them out or to take them onward, if that is needed. That has shown a massive decrease in the number of people with falls who are taken to hospital. Falls can account for up to 17% of an ambulance service emergency work load. It is a significant amount.

Anthony Marsh: It is also about linking that to prevention. If they have fallen today and do not need to go to hospital, we can sort them out and then put in place other arrangements to prevent further falls.

Q120 Valerie Vaz: You mentioned earlier paramedics talking to patients on the phone. Is that with a view to keeping them out of A and E or to taking them to A and E?

Anthony Marsh: To keeping them out. We provide appropriate advice over the telephone that may be able to deal with the patient or signpost them to another part of the system.

Q121 Valerie Vaz: Do you feel that there is currently sufficient training among paramedics to enable them to make that sort of decision?

Anthony Marsh: Yes, but more could be done. Paramedics are very well trained-and always have been-to deal with very seriously ill and critically injured patients. We are seeing more of that with the networks I referred to earlier. However, working alongside the clinical commissioning groups, in particular, and other parts of the system, we need to accelerate nationally to ensure that more paramedics receive that additional training. It is not instead of the critical end-of course, we still need paramedics to deal with that as well-but we need paramedics to be trained at a faster rate so that they are able to become more confident and competent in dealing with the primary care types of difficulty that patients have, rather than having to take them to an emergency department.

Q122 Valerie Vaz: Could you be a bit more specific about the additional training?

Anthony Marsh: One example is the extent to which they are able to undertake greater patient assessment and diagnostics, so that they can better understand exactly what is going on for that patient. Going back to a point that I made earlier, access to the national spine that enabled them to have some critical information about a patient would help that decision making. Assessment and diagnostics are really important. Paramedics are now able to administer antibiotics and a wider range of other drugs, which will help to keep people out of hospital. Another issue is the extent to which we are able to treat, glue, suture and appropriately dress wounds to keep people out of hospital, to use other diagnostics such as urine testing and to assess patients by ear examination.

Q123 Valerie Vaz: Is dressing wounds something for you or something for a district nurse? Would you ever need to be called in for something like dressing a wound?

Anthony Marsh: For ongoing care, certainly, the paramedic could make an appropriate referral to a district nurse in primary care services. Initially, when there is an emergency, the patient, the relative or the carer will dial 999. Sometimes, it is easy to make an informed clinical assessment over the telephone, but in most emergency situations it is very difficult to do that. Sometimes, therefore, we will send a paramedic promptly so that they can respond to the patient and make an informed clinical assessment. At that point, in the example that you are framing, if the wound needs gluing, suturing and appropriately dressing, the paramedic can deal with that and then provide a referral to the district nurse, who can pop in to see the patient in the next day or so.

Q124 Valerie Vaz: You talked about an integrated service. Do you think that will work with multiple providers?

Anthony Marsh: There is no reason why it should not. There is good evidence where it does work well with multiple providers. Clearly, the more providers you have, the more complex-

Q125 Valerie Vaz: Could you give us that evidence?

Anthony Marsh: Certainly. We can share that with you.

Q126 Valerie Vaz: Do you want to tell me now?

Anthony Marsh: Of course. Where we have 111 providers, with GP services locally in hours and a different set of arrangements out of hours, the issue is the extent to which those are well connected with paramedics locally and paramedics in the control room. A directory of services draws upon the services that are available in a particular local community, so paramedics working in the control room can connect with the paramedic making an assessment in the patient’s home and provide advice on the services that are in place. There are really good examples of paramedics working alongside GPs and district nurses in local communities and of mental health paramedics working alongside mental health specialists. The difficulty is that that is not standardised. There is not exactly the same practice right across the whole of the west midlands, let alone the whole of England.

Q127 Valerie Vaz: I am going to put you on the spot slightly; I am sorry, it is a personal thing. I suppose I am trying to go down the road of avoiding the situation that happened at Walsall Manor hospital, when a man was stepped over by paramedics and then died. How can we prevent that?

Anthony Marsh: That was a very unfortunate incident. It was a very isolated incident. We undertook a thorough investigation, which demonstrated that, and both the ambulance service and the hospital dealt with it. We should not confuse an isolated incident, as serious as it was-and we have dealt with it-with the overwhelmingly excellent care that paramedics and ambulance staff provide every single day of the week right across our country. Treating people with care, dignity and respect and responding to them promptly are at the heart of what the ambulance service does. We are absolutely determined to continue to provide high-quality care consistently.

Q128 Valerie Vaz: I accept what you say and that you all do a great job, but clearly something was missing there in terms of training, perhaps.

Anthony Marsh: Something was missing there.

Q129 Valerie Vaz: Perhaps it was because he had an alcohol-related problem that people are not picking up.

Anthony Marsh: We have taken steps to prevent a recurrence of that. We have reinforced the values of the ambulance service both locally and more widely. I am confident that it was an isolated incident, as sad as it was, and we have taken measures to prevent a recurrence.

Q130 Valerie Vaz: How helpful is the eight-minute response time?

Anthony Marsh: For some patients, it is absolutely critical.

Q131 Valerie Vaz: I mean for you, in terms of your response locally.

Anthony Marsh: As I said, for some patients it is critical. It does focus the mind. Sometimes we have a substantial number of 999 calls coming into the control room, and it helps us to prioritise those that are in real need. However, I think that some patient groups we are currently trying to get to in eight minutes do not necessarily need an eight-minute response. The difficulty can be that, if there are too many priorities, the patients who are really sick and seriously injured get lost in among some other patients who need a prompt response-maybe 10 minutes-but do not necessarily need a response within eight minutes.

Q132 Valerie Vaz: In the west midlands, you must cover some lovely rural areas as well. How does that response time help in a rural setting?

Anthony Marsh: You are absolutely right that one size does not fit all. That is why we tailor the way in which we deliver the services. Almost without exception, every one of the 10 ambulance services has very urbanised areas and very rural parts of its service. The way in which we deliver services varies depending on whether you are in a major city centre or in a very rural county. We use community paramedics who are embedded, working alongside primary care GPs, the out-of-hours service, mental health and the like. Community first responders also do a great job working alongside ambulance services. They are able to provide an immediate response while the paramedics are en route in a response car or ambulance. In urban areas, of course, they use motorbikes and pushbikes as well.

Q133 Valerie Vaz: Not to carry patients, I hope.

Anthony Marsh: No, to provide an immediate response.

Chair: I have a long list of members who want to come in. Virendra wants to come in briefly.

Q134 Mr Sharma: It is on the training aspect. When you recruit staff, they have a basic understanding and basic qualifications, but then extra training is given. Is a system in place to enable staff to get training from an outside agency or is it training on the job, under the supervision of senior staff?

Anthony Marsh: It is both. We now recruit predominantly from graduate paramedics. As with other professions, these are individuals who have left school, have gone to university, have trained to be paramedics and have then been recruited into ambulance services. Those individuals go to university, but they also have substantial clinical placements within ambulance services to gain their experience, confidence and competence, so that when they graduate from university they are part of an integrated work force within ambulance services. They then go on to do advanced training in trauma, for example, and in the primary care examples we spoke about earlier.

The other route by which staff become paramedics is by being recruited directly into the ambulance service, generally by the student paramedic route. They undertake basic training, core training, emergency driver training and so on. They have a year or so of consolidation before they go back to university to conduct their paramedic training. About two and half years later, they graduate. So there is a mixture of training working alongside other paramedics, training working alongside clinical practice mentors and classroom training in universities. There is also work in hospitals-work in emergency departments alongside nurses, doctors and other clinical staff, and work in theatre, so that they get experience and practice in intubating, cannulating and patient management, as well as in other parts of the system.

Mark Docherty: I want to emphasise the training of a paramedic. At the point of registration, a paramedic may have done just a two-year foundation degree. What we are asking of them in their practice is quite a big ask. We are asking them to make diagnoses, to choose whether to leave patients at home and to choose which patients go to which hospital, so the importance of post-registration training and development is critical if we are to develop a work force that will be fit for the future in terms of what the system will demand of them.

Q135 Mr Sharma: Are we talking about a four-year period?

Mark Docherty: We should not treat it as one-off training. The ongoing development of these professional staff delivering highly sophisticated urgent and emergency pre-hospital care is absolutely critical to the system working effectively.

Q136 Rosie Cooper: Before I ask the question I intended to ask, I want to say that this all sounds wonderful-it sounds really good and as if you have it under control. Why, then, will the public watching this session be sitting there thinking, "It’s not working for me. I am stuck in an ambulance"-perhaps outside an A and E-"and not having people arrive at the right time"? I think the stories are fantastic. You talk about referring people to district nurses, but they are disappearing faster than snow in the summer. You can refer all you like, but it actually has to join up. You are telling us a wonderful story, but the experience of people out there is not the same. What is going wrong?

Anthony Marsh: There are a number of things. The first thing I would say is that the overwhelming experience of patients with the ambulance service is outstanding; the evidence from patient surveys and the like supports that. The point you are making, with which I would agree, is that there needs to be greater integration and more joined-up service across those aspects. In some parts of the country, it works really well and in others it works less well. Our challenge is to ensure that it works the best it can everywhere, while recognising that one size does not necessarily fit all.

While there are undoubtedly patients who do not need to attend an emergency department because their needs can be dealt with better elsewhere or they do not need to be taken to an emergency department, we need to be mindful that whatever alternatives are put in place must be effective, well utilised and cost-effective, otherwise we could end up with a plethora of alternatives that are very good but have a very low utilisation rate in certain communities and therefore do not represent value for money. There is a mixture, which is about the population that you are attempting to serve and the geographical location. I know you understand all of those complexities. What I am trying to describe is a system that we know can work well, because the evidence exists and it happens in many parts of the country, and the extent to which we can level up that variation to standardise those improvements for everybody.

You mentioned handover delays. You are absolutely right that those represent a risk, but the substantial risk is not necessarily for those patients who are waiting in corridors or ambulances.

Q137 Rosie Cooper: It is for the ones waiting to come.

Anthony Marsh: It is for the patients we cannot respond to promptly-which was your second point-because ambulances are tied up and are not able to respond effectively. The good news on that-I am not saying that it is perfect and is all resolved, by any means-is that there have been improvements this year. That has largely been about refocusing and emphasising the importance of prompt clinical handover. There is real, joined-up, integrated working between ambulance services and the acute sector to streamline and to speed up that handover. Also, in the national contract this year, penalties have been applied by commissioners that have undoubtedly helped to reinforce the importance of prompt clinical handover of patients, for the benefit of those patients but, more widely, of the patients who need a prompt response by ambulances.

Q138 Rosie Cooper: Okay. I will go to the question I was going to ask and come back to this in a different way. Ambulance trusts and the Department of Health say that ambulance services are well placed to deliver the efficiencies that are required across the whole emergency care system. You have described a year-on-year increase of 4.5% to 5%. Did you get additional money to deal with that increase? I have heard you describe how you are changing services, but not uniformly, how best practice is not necessarily being used everywhere and how commissioning is doing what it can. You talk about urgent primary care. What does that mean? How can these targets be met continually without additional resources? Understanding that you are changing the mix all the time, there is still that incredible pressure on you and the service around you that is also having to deal with efficiencies and real pressures-district nurses who are not there and things like that. I sit and listen, and the answer is joined-up services; the problem is that they are not. As money comes out of one part of it, pressures increase somewhere else. You can say, "We will make referrals, stop nursing homes making inappropriate referrals and do x, y and z"-yeah, yeah, yeah-but what is happening?

Anthony Marsh: The first thing to say is that, generally speaking, ambulance services have received some additional funding but not at the rate of the increase in activity, so a lot of the continued improvements that ambulance services have been able to achieve over the last period have largely been about internal efficiencies, the extent to which we can streamline, using technology in the control rooms that we discussed earlier, and the extent to which we have been able to provide additional training for paramedics to enable them to treat and refer or, increasingly, to treat and leave patients at home. I do not want to give you a false impression that more than 40% of the emergencies that we attend are referred elsewhere, because they are not-a tiny proportion of patients are referred to district nursing and others. The bulk of the patients-nearly half-whom we do not convey to a hospital have been treated and discharged by paramedics in the patients’ own homes. We are not reliant on a plethora of other systems. Of course, referrals are made, but they are only a tiny percentage.

If you stand back from all of this, the substantial efficiency savings for the ambulance services are the extent to which we can reduce conveyance rates to the emergency department. That is the overwhelming opportunity for the contribution of ambulance services to the £20 billion Nicholson challenge efficiency target, because we know that when patients get into emergency departments they are often admitted-for a whole range of very good reasons, but sometimes when perhaps that was not absolutely necessary. Being able to keep those patients in their homes, treated and discharged by a highly trained advanced paramedic is absolutely the right thing for the overall system. That is why I am confident and genuinely believe that the experience of patients who have come into contact with the ambulance service is overwhelmingly a good one.

Q139 Rosie Cooper: You mentioned referrals into or interface with "urgent primary care". Can you describe what you are thinking of there? For example, this week I arrived home at lunchtime for my father to tell me that he had not been able to get out of bed that morning. Eventually he was able to get out, but I did not find out about it until lunchtime. I phoned the GP at 2 o’clock and tried to organise an appointment, perhaps for the following morning. The receptionist, who was very helpful, said, "We have an emergency appointment at the end of surgery. I will ring you back." She phoned me at 4 o’clock, and the response was "There are no emergency appointments. Either come to the open-access wait in the morning or go to a walk-in centre," which is code for A and E. This is a GP in the afternoon-not an emergency. If that is where we are operating, we’ve got big trouble.

Anthony Marsh: I am sure that in some parts of the country that does happen, but equally-I am not here to speak on behalf of the particular part of the system you are referring to-we know that there are other parts of the country where access is better than that. It goes back to the point I made earlier about trying to level up to where we know it already works. We know it can be delivered, so how do we level up?

Q140 Rosie Cooper: So how do you see urgent primary care? It really makes a big impact on your job.

Anthony Marsh: It does.

Q141 Rosie Cooper: So what do you mean?

Anthony Marsh: For us, it is the ability of the paramedic-whether it is the paramedic in the control room or, increasingly, the paramedic with the patient, very often in their own home-being able to have a clinician-to-clinician conversation with the doctor in the surgery or with the out-of-hours service. One thing we have really been pushing for, both locally and nationally, is for ambulance paramedics to have access both to the doctor in hours and to out-of-hours providers, so that you can have that clinical conversation.

Q142 Chair: It sounds pretty basic.

Anthony Marsh: It is.

Q143 Chair: Who says no? What is the obstacle?

Mark Docherty: I think the issue is that primary care-

Q144 Rosie Cooper: No-can you answer that question? That is the core of it. If I were looking after cats and dogs, I would want to speak to whomever. These are human beings. Why doesn’t it just happen? I do not get it.

Mark Docherty: I was attempting to answer the question. The issue is that primary care is very busy itself. One of the solutions I have seen in one area is that GPs collectively pool some of their emergency work. Sometimes the peaks and troughs of the work create an inability to respond at a particular time.

Q145 Rosie Cooper: Okay. I must remember not to have my heart attack at an inappropriate time. This is ridiculous.

Mark Docherty: No. What I am saying is that in some areas I am seeing primary care looking at innovative solutions to enable it to respond to peaks and troughs.

Q146 Rosie Cooper: Out-of-hours doctors-should we have more of them then?

Mark Docherty: The issue is about the system being able to respond to the patient need.

Q147 Rosie Cooper: Okay. You talk about the system responding, but it is not. You are sitting there and my life is in your hands-what is happening?

Mark Docherty: I am sorry. What I am trying to explain is that many GP surgeries work on their own, so when all of their emergency appointments are taken, there is an inability to respond to the patient need. Some areas are working across GP surgery boundaries. Obviously, we have not come prepared to talk about the issues in primary care-

Q148 Rosie Cooper: I appreciate that, but you do not live in isolation. You are a commissioner-what are you doing? Do you not see where it joins up? I have heard lots of lovely warm words, and I love the ambulance service-it is not the problem. The problem I have is that I hear these warm words. You talked about your patient satisfaction. If I went to a hospital, they would give me the same loads of numbers and the same tosh-everybody loves us; nothing is wrong.

Anthony Marsh: I am not saying that nothing is wrong. I think the point you are making is that the cohorts of patients who are seriously ill-you gave the example of your having a heart attack-are well catered for.

Q149 Rosie Cooper: Absolutely. That was a flippant remark in response to what was being said. You cannot have a system that is not able to respond at the bottom as well as at the top. If you are looking for a GP but cannot phone and speak to one, that is just nonsense.

Anthony Marsh: I agree. Your frustration is often shared by paramedics, who are frustrated that they may not be able to get hold of a GP in hours or out of hours either to get some advice-

Q150 Rosie Cooper: So what have you done about it?

Anthony Marsh: We have been very clear, certainly in the west midlands-I have also spoken to colleagues about this-about working with commissioners and, in particular, out-of-hours providers to ensure that paramedics have real-time access to doctors to enable them either to get advice or to make sure that there is a home visit, if a doctor really needs to see that patient and the patient cannot be dealt with appropriately by a paramedic. Those conversations are absolutely going on, and at the highest levels.

Q151 Rosie Cooper: But all I am hearing is "will", not "is".

Anthony Marsh: No, it is happening.

Mark Docherty: We can give you examples where the ambulance service does a scheme called "GP in a car". It works in Tower Hamlets and in Dudley. The issue is that we need to avoid more patients ringing the ambulance service for their immediate primary care urgent need. That is the risk with those schemes, as they are very responsive and very reactive to patient need. Actually, they deliver a really good service.

Q152 Rosie Cooper: So should we put all GPs in cars and send them out?

Mark Docherty: No.

Rosie Cooper: Thank you.

Chair: I think we have covered it. We are running out of time. We have a GP on the Committee who wants to come in.

Q153 Dr Wollaston: I am not going to speak on behalf of GPs, because I know we will hear evidence from the Royal College of General Practitioners later. Just to reflect, when I was in practice, I would sometimes take calls from the ambulance service, so there is nothing to stop the ambulance service calling GPs. Are there some areas where that is particularly difficult? You mentioned single-handed practitioners. In your experience, is that generally the situation in which it is most difficult to get hold of people?

Anthony Marsh: Yes. It has been difficult with some out-of-hours providers as well for the paramedic to have a paramedic-to-doctor conversation about a particular patient. We have made improvements in relation to having that access. I am sure that more could be done to make that mainstream, but it goes back to the point I made earlier. If the paramedic had access to some information from the underlying history for that patient through the national spine and from electronic patient records, it would negate the need for some of those conversations with the doctor. However, sometimes it is appropriate for the paramedic to have a conversation with the doctor. That is in part why we now have GPs working in our control rooms alongside paramedics and other staff either to deal with the patient over the telephone initially or to provide advice to paramedics responding with the patient.

As Mark just mentioned, in many parts of the country we now also have GPs working alongside a paramedic in a car, responding to appropriate calls-not the big emergency heart attack and road accident-type patients but primary care-type patient care difficulties that they can treat appropriately face to face-and taking calls from paramedics dealing with other patients. That is an additional facility that we are putting in place to work alongside paramedics.

Q154 Dr Wollaston: Can I take you back to a comment that you made earlier, Anthony Marsh, about the issue of avoiding unnecessary admissions? Undoubtedly, this Committee would share your enthusiasm for trying to avoid unnecessary admissions, but the flipside to that-and the side that always makes headlines-is when a patient who did need to be admitted is not admitted. Alongside avoiding unnecessary admissions, are you seeing increasing complaints about patients being left at home who should not have been?

Anthony Marsh: No, not at all. That is largely because of the additional training that we have put in place for paramedics to enable them to make that informed clinical assessment, but also because of the back-up arrangements that we have put in place so that they can talk to a GP in a car who is dealing with another case or in the control room. Sometimes, patients’ expectations are not necessarily met by a paramedic or an ambulance responding to them and a paramedic or GP deals with their case over the telephone. Some patients would prefer to have a face-to-face consultation, rather than a telephone consultation, so we have seen a slight increase in complaints of that nature, but certainly not relating to face-to-face consultation.

Mark Docherty: When there has been a high-profile case, as in London recently, we do see conveyance rates to hospital go up quite significantly, because paramedics feel personally very vulnerable if they make a decision that turns out in hindsight not to have been the right decision.

Q155 Dr Wollaston: So you see a spike in the immediate aftermath.

Mark Docherty: Absolutely.

Q156 Dr Wollaston: How long does that tend to last?

Mark Docherty: It is difficult to say, because we have not necessarily done detailed work on that. Some of this stuff-building the data on non-conveyance, for example-is fairly new. In the particular case that I mentioned, which was in outer London, it happened fairly quickly; from memory, the case was from two years ago. I cannot answer on how long it lasts, but we could look for some information on that.

Anthony Marsh: Fortunately, it does not happen very often, so it would be very difficult to gather any evidence, but we can certainly have a look.

Chair: Valerie wants to come in, followed by Barbara. We then need to move on to the second panel.

Q157 Valerie Vaz: I want to take you back to the handover at the hospital. I would like you to take us through it-as briefly as possible, because obviously we have to hear other evidence. There is some indication that the delay in handover is because the clinicians do not trust the paramedics’ judgment. Could you elaborate a bit on that?

Anthony Marsh: I am not sure that it is about the clinicians not trusting the paramedics’ judgment. Very often, the paramedics will attend the patient when they have had their sudden emergency, whatever that is. Of course, by the time the paramedics have dealt with that, saved their life and taken them to hospital, in most cases the patient’s condition has improved, so sometimes you are describing to hospital staff a patient you saw 30 minutes ago-or, in a rural community, where the journey time is longer, maybe an hour ago-when they were quite sick, and who has improved quite substantially. Obviously, you need continually to take your baseline assessment to ensure that you provide a full picture, from the patient’s initial emergency, when the 999 call was made, to the arrival of the paramedic, with the treatment that they have provided-hopefully, in most cases, the patient will have made a substantial improvement-and then how that patient is being presented to clinical staff at the hospital at that particular time.

Q158 Valerie Vaz: So you are saying that there is not an issue with delay at handover.

Anthony Marsh: There are sometimes issues in the handover, but it is not generally because the nursing staff or the hospital staff do not believe or trust what the paramedic is saying to them. Very often, it is simply that the emergency department is full and there is no space to take that patient, unless they are critically ill or injured, in which case they are taken through to the resuscitation room. Certainly, there are occasions, albeit at a reducing frequency, when front-line ambulance staff have continued delays in handing over patients promptly.

Q159 Barbara Keeley: There is an increasing emphasis on the role of community services, particularly volunteer first responders to support ambulance services. Obviously that is important in rural areas, but I know of volunteer first responders who are very heavily used. I was surprised when talking to a volunteer first responder by how much they are used. In some ways, that is disturbing, because it feels that we are subcontracting out an important part of our emergency services to people who are volunteers and are not in any way trained. We are not talking about GPs; you are talking about not using GPs in those situations. Can you comment on that, because it seems to be an increasing emphasis?

Anthony Marsh: The first thing to say is that community first responders have now been in place for a good number of years-10 or 15 years-and do a fantastic job, predominantly in rural communities.

Q160 Barbara Keeley: Clearly, but I am talking about an urban area-urban Salford, where one volunteer I know is very heavily used, particularly at weekends.

Anthony Marsh: Yes. They do a great job in being able to respond to predominantly life-threatening emergencies in their local community, whether it is a rural or, in some cases, a more urbanised area. That is the first thing. The second thing to say is that they are not instead of-they are as well as. When an emergency call comes in in that geographical area, the control room deploys the community volunteer first responder in that local area, as well as the paramedic in the response car and/or an air ambulance and/or a land ambulance. We welcome the continued support of community first responders, who do a great job. We know that very often, particularly if the patient is unconscious, fitting or, even worse, in cardiac arrest, the ability of those volunteers who arrive in the very first few minutes to start basic life support and early defibrillation is a life saver while paramedics are en route. However, they are as well as, not instead of, the front-line paramedic ambulance service.

Q161 Barbara Keeley: As I said, the thing that disturbed me when talking to one of them was how heavily that person is used-and I mean heavily.

Anthony Marsh: I understand that. In part, that reflects how busy our ambulance service is. Ambulance services in England deal with more than 25,000 999 calls every single day of the year.

Q162 Barbara Keeley: But it is a paid job for professionals. Why are we contracting out-at the most serious end of it, it seems?

Anthony Marsh: We are not contracting out anything. They are volunteers, trained in the main by ambulance service staff and equipped to be able to respond to those patients where the first few minutes are vital. If you are unconscious, are not breathing and need early defibrillation, those first few minutes while the paramedics are on their way are absolutely vital. The international evidence demonstrates that the more quickly you arrive at those patients, the greater the chance of their survival while the paramedics and the ambulance are en route.

Chair: We have a first responder on the Committee who would like to ask a question.

Q163 Andrew Percy: It is sort of on Barbara’s point. As you said, it is not contracting out-it is simply that we can get there more quickly. When you are in cardiac arrest, you are pleased with whoever turns up-or the family are. That is true, isn’t it?

My point was not so much about that as about co-responding. We have seen a huge spike in demand for ambulance services over recent years, but we have seen a big fall-off-about 40%-in demand for fire services in the last 40 years. There seems to be quite a lot of opposition in my own area. Volunteer, retained firefighters are prepared to co-respond, but full-time firefighters are not or are prevented from doing so because of their union’s view on this.

This was brought home to me on the first cardiac arrest I went to. I drove past a fire station on the way there and thought to myself, "This is barking mad." Here I was trotting out, but no one was being sent out from a fire station fully crewed with people who were being called out probably once a day-don’t get me wrong; they do an incredibly important job-with this training and a defibrillator in the building. In that case, the gentleman sadly died. Isn’t it time that we tried to crack this, really got to the bottom of co-responding and said, "We have an emergency service here that is being used less and less. It does an incredibly important job, so we do not want to stop it and take it off the run, but there are trained people here who are being paid by taxpayers and we have to start really pushing co-responding nationally"? What is your view on that?

Anthony Marsh: The first thing to say is that ambulance services and fire services work together incredibly closely on a whole range of emergencies. Co-responding does exist in some parts of our country. Where those co-responding schemes are required, they should be encouraged. One size does not necessarily fit all, so there will be competing priorities for ambulance services and, indeed, other emergency services. Where patients would benefit from closer working, that should be encouraged, but be assured that ambulance and fire services already work very closely on a day-to-day basis on responding to emergencies, training and, indeed, exercising.

Q164 Andrew Percy: Do you think it should be expanded, as one way of helping to ease the pressure on your service?

Anthony Marsh: I think it depends on the local circumstances. One size does not necessarily fit all. In some parts of the country it would and does work very well. That is not necessarily true in every part of the country. I think it needs to be looked at on an individual basis.

Andrew Percy: So that I do not get accused of wanting to destroy the fire service, I should say that I support that because I think it is actually a way of protecting a publicly funded fire service, by having it expand into other areas

Chair: I was going to say that I admired Anthony Marsh’s optimistic outlook. Rosie has one very quick question.

Q165 Rosie Cooper: There is an assumption that volunteers will get there first; that is their raison d’être. I am sure that in a rural area that is great. However, further to Barbara’s point, if a volunteer is used so heavily and gets there first, doesn’t that say that the ambulance service itself is so stretched that it cannot manage and needs more resources?

Anthony Marsh: The important point is that there will always be occasions, whether it is in an urbanised area or in a rural area, when someone may have their heart attack at the point at which the local ambulance or the local paramedic is dealing with another emergency. Community volunteer first responders are trained and equipped to deal with those patients with really life-threatening conditions and have more availability than directly provided paramedic resources of the ambulance service. Because of their immediate availability to respond within the first few minutes to provide basic life support and early defibrillation, they really are life savers. We would want to continue to encourage community first responder schemes across our country.

Chair: We cannot have competition for the last word. Thank you very much for your evidence. You have given us plenty to think about.

Examination of Witnesses

Witnesses: Dr Clare Gerada, Chair, Royal College of General Practitioners, and Andrew Webster, Associate Director Integrated Care, Local Government Association, gave evidence.

Q166 Chair: Good morning. Thank you very much for coming. I am sorry that we are running a little bit late. Could you introduce yourselves very briefly?

Andrew Webster: I am Andrew Webster. I am the associate director for integrated care at the Local Government Association.

Dr Gerada: I am Clare Gerada. I am the chairman of the Royal College of General Practitioners and a GP.

Q167 Chair: As we did with the previous panel, I would like to begin by asking about your experience so far and your views on the future development of commissioning for integrated emergency and urgent care. I know that you were present for at least some of the previous session. Some of the frustrations that were expressed by members of the Committee and, to some degree, by witnesses as well were about the failure of the system to deliver a joined-up service. Do you believe that the commissioning process, through commissioning for ambulance services, the urgent care groups and the different forms of commissioning that now exist in the health service, is fit for purpose to deliver joined-up response to a demand for emergency care? We will start with Mr Webster.

Andrew Webster: That is exactly the point we would like to address. I think there is an opportunity to change it to make it more fit for purpose. I will say something about three broad areas, the third of which will focus on your question.

The first is access-are people getting access to the care they need to deal with emergencies? The evidence from the local government and social care world is that, broadly, they are, because eligibility has remained broadly the same. Reablement, to get people back on their feet, back home and back out of hospital, has been extended; 82% of people benefit from that, and it is well liked. Many people focus on the issue of whether people are getting stuck in hospitals-what are described as delayed discharges. Those are actually going down, and those that are attributable to social care are going down faster than those that are attributable to things in the health system. So access has held up.

Resources are clearly very tight. Social care spending in local government has gone down by 20% over the last three years and will go down further as a result of continued austerity. We have been able to sustain that access by some transfer of money from the NHS-about £900 million in the last year-by great improvements in efficiency and by some increases in charges to people who are eligible to pay. That will continue. I do not need to tell you that demand for the services is also growing and the pressure is increasing; that is evident in the figures and the issues you are looking at.

Our belief is that response to that has to be local, because the reasons for the pressure on emergency care are different in different places. A national prescription will not work. It has to be whole system, because at the moment the work with hospitals is not as closely connected to the planning for services in the community and social care as it should be. The system has to bring how our hospitals are organised, supported and remunerated into scope. We believe that the new health and wellbeing boards, where local government has a lead role in public health and where the leaders of the CCG and the leaders of the local political system are all gathered, are the right places to bring a real focus on planning for integrated care, but that will require them to step up from where they are now into a much stronger and more ambitious lead role.

Q168 Chair: Before asking Dr Gerada to comment, can I ask you to cover in your reference to health and wellbeing boards the relationship between the world you have just described and the urgent care boards that are being developed by NHS England?

Andrew Webster: I think there is good complementarity and that they can work together well.

Q169 Chair: Do you need both of them?

Andrew Webster: Were the health and wellbeing board doing the job that I have just described, I think it would become part of the machinery that the health and wellbeing board used, but I do not think it is unhelpful to prompt people to do that. In so far as it engages the public, local leaders and the hospitals in resolving those bigger system issues, it is a helpful contribution.

Q170 Chair: I turn to Dr Gerada.

Dr Gerada: First, can I apologise for the late submission of our written evidence? I am afraid that, probably like the rest of the health and social care system, we are inundated with work, with all the demands on my team.

With respect to the question you have just asked, of course the answer must be yes. We must make sure that we commission an integrated approach to urgent care. The document that I have here, which is called "Guidance for commissioning integrated urgent and emergency care: A ‘whole-system’ approach", was published in August 2011, had more than 50 stakeholders, is signed off by a number of the major relevant royal colleges and gives an action plan around exactly what you are saying-delivering an integrated approach. I might differ slightly from Mr Webster in that I think that a whole-system approach has to be more than just local. Once we start to look at capacity of some parts of the system to deliver emergency care, as opposed to urgent and unscheduled and routine care, just dealing with local may be too small; of course, it depends on what "local" is.

So the answer to your question is fundamentally yes. The evidence you heard from the ambulance service shows that, if you squeeze one bit of the system, all you are doing is squeezing that problem to another part of the system. With all the debate that has been going on about emergency departments, I could just as easily put the words "general practice" into there. We are under similar pressures. If one thinks that the floodgates to the NHS, the gates that stop it breaking down, are primary care-I put GP and community care into that bracket-and emergency departments, and those two bits of the system are under serious pressure, it is not surprising that the rest of the system is under serious pressure.

I cannot remember who said that for walk-in clinics we should read emergency departments-I think it was Rosie-but they are not. Again, that is a real misconception. Walk-in clinics are predominantly GP-led services, with a much lower tariff. They have to have GPs there, have primary care nurses and other staff and were set up in order to ease the problems on emergency departments. They are not a proxy for emergency departments. They, too, are heaving.

Q171 Rosie Cooper: It was a GP who said that.

Dr Gerada: Who said that it was an emergency department?

Q172 Rosie Cooper: No, who told me either to wait until the next morning or to go with my father to a walk-in clinic. I took that to mean, "If it’s serious, go to A and E; if not, hang about."

Dr Gerada: I am very sorry that that is what is happening and that general practice cannot deliver the sort of care that I was trained to deliver. Again, let us get some facts out. We have seen an approximately 100% increase in our work load over the last decade. We are seeing more and more long-term chronic disease. What I do now is what a physician did 10 years ago. What I do now is what a psychiatrist did 10 years ago. GPs still see the majority of urgent care. We do not see emergencies; I think we need to start dissociating that. We do not see fractured limbs, although walk-in clinics and urgent care centres see ambulance cases. But GPs are also the ones who, in hours, over an increasingly long day, pick up the vast majority of the care that presents to the system. The focus on dealing with just one bit of it will push the system to breaking point-which it already is, in all honesty, down the other end of the system.

Q173 Chair: Before I invite colleagues to come in, could I ask you to focus? The danger on these occasions is that we all say, "Wouldn’t it be nice if the system were more joined up?" and everybody can sit round and agree that it needs to be more joined up. Can you demonstrate evidence of levers being pulled, contracts being written and services being developed on the ground that are breaking down the differences between the ambulance service, the communities and so on?

Dr Gerada: Can I put on my other hat, which is my conflict of interests hat? I am a GP at a practice that is one of the largest providers of services in London, including a number of walk-in clinics, which are integrated. Some are at the front end of emergency departments, where there are links to the ambulance service; as I said, we take ambulance cases. We are not unique. Across the country, GP-led walk-in clinics are working very closely with their foundation trusts-or non-foundation trusts, if they are not in a foundation trust-to develop an integrated approach. For example, you might have a front end of urgent and emergency care-let us call it that-that is manned by the same admin staff. At the next stage, where you get triage, they triage to the different parts of the service-left, emergency; right, GP walk-in clinic-with integration between the two, if it is wrong. This is happening across the NHS. I am afraid that I am not an expert on how often it is happening, but it is certainly happening in London and I suspect that it is happening across the country.

Q174 Chair: The thing the Committee needs to focus on is the extent to which it is happening-I guess everyone can agree that it is not happening enough-and, perhaps even more importantly, what it is in the system that is inhibiting these developments and what can be done to encourage them.

Dr Gerada: Dare I say constant change? Dare I say that no sooner does one form relationships with the commissioners and the providers across the system than the faces change? That imposes huge organisational difficulties. The burn of developing these sorts of services can sometimes be a year or 18 months to two years. If you have an ever-changing landscape, it becomes very difficult. I know it is a flippant answer. I think the will is there; there are certainly examples across the country. The will to join up care across a whole system is there-absolutely-but it is hard work to join up, especially now, when you have differences in commissioning arrangements and, as you know, phenomenal differences in tariffs. The lowest tariff for an emergency department attendance, which is just for a urine test, is higher than the highest tariff at a walk-in clinic, so you have these discrepancies in tariffs. Clearly there are all sorts of issues that go on there.

Andrew Webster: I concur with the point about change. Stability of leadership and commitment to doing it are very important locally. There are some good practical examples of rapid-response services, where the service goes to the patient’s home rather than the patient coming to the hospital; of virtual wards, where doctors, nurses and social workers work together on people, supporting them at home rather than taking them into hospital; and of services that get people back home and sustain them at home-80% of the people who go through reablement do not need a service 90 days later. So there are clear success stories.

There are some practical things that get in the way. Money is certainly one. There are some ways of rewarding people for supporting people over a long time, rather than running the register every time something happens. The year of care model would help with that. There are other ways of capitating budgets, so that the whole system knows how much money it has to support someone to keep them independent. Another issue is the ability to share data in real time. GPs often do not know that their patients have been admitted to hospital, because it takes a while for the information to get back. Social care services often do not know what has happened to people to whom they are providing services, because the information does not come to them. So there are some very practical things about sharing information, incentivising people and paying for what we want, rather than what we do not want, that could make a significant difference.

Q175 David Tredinnick: It seems to me that you have identified a problem we need to look at closely-the tariff issue, where you have different tariffs. That is something I shall raise later. Dr Gerada, before I get on to the question I wanted to ask, which has partly been answered, you seemed to suggest that one of the problems is the process of change itself. We have just had the Health and Social Care Act, which is a massive change. Surely that is inevitable. We just have to work with the change. There will be difficulties in co-ordination to begin with, but when you have this kind of change it has to be taken through and is not really an excuse for a situation being unsatisfactory. I put that to you.

Dr Gerada: Dare I disagree with you?

David Tredinnick: Please do.

Dr Gerada: Come to my surgery and see what is going on, where we do not know who is responsible for certain issues. Come and see what is happening with the issues that do not make the headlines, such as our patients with chronic diabetes, who have had community services pulled, which means that we have to absorb that work. In answer to the question about appointment times, I am getting e-mails from colleagues across the country to say that their surgeries are now fully booked by 8.30 in the morning, which is disgraceful. How can we run an NHS where, unless it is an emergency-and by that I mean a dire emergency-you cannot get an appointment with your GP on the day and appointments are fully booked by 8.30? This is not because GPs are going to play golf in the afternoon; it is because they are trying to respond by working 15-hour days. With the best will in the world, change produces confusion. Change means that you have to rebuild relationships. Change means that you also find that bits that were running well stop running well.

I am not using it-I think there are opportunities with the Health and Social Care Act. For the first time, with CCGs now being responsible for commissioning all of out of hours, they can actually start to join up with our fantastic ambulance services, our paramedic services and our social care services and to look at how we can deliver and develop, but you have to give these GPs time. You have to say that this is something that will take time and that an amount of expertise will probably have to be brought in from some of the people who were running these sorts of services before. So I am afraid that I disagree with you.

Q176 David Tredinnick: Thank you for saying that. At the risk of raising blood pressures, I wanted to ask you what GPs and other primary care services can do to help alleviate the pressure A and E departments are currently working under.

Dr Gerada: I would turn it round. What can you do to help maintain the floodgate-the barrier that stops the rest of the NHS disintegrating? The GP is the barometer of the NHS. We now see outside our practice queues going down the road, which I have not seen since the flu epidemic two or three years ago. We need to have a whole-system approach and to start looking at the underinvestment in primary care. I have a conflict of interest; I am head of the college. We have 9% of the resources for 90% of the activity. We have problems with social care, which means that we cannot move patients out of hospital. So I would turn it round. If we get the delivery of primary care right, that will reduce the pressure on the rest of the NHS. Then we may well start to free up some of the beds in hospital, meaning that I can start delivering care in and out of hospital in and out of hours, which is what I want to do again. I cannot do it-and nor can my colleagues-with the current work force and work load issues that we are facing.

Q177 Dr Wollaston: Can I follow up on that point about work load? There is a real crisis in GP recruitment and a retirement bulge coming up. How far do you think part of the solution will lie in increasing the skills of those who support primary care? We heard from the ambulance service about increasing the percentage of paramedics. How far do you think that needs to be the answer in primary care?

Dr Gerada: It is a very good question. The answer has to be yes, of course, but you know, as a GP, the skill involves dealing with uncertainty-dealing with risk. We heard from the ambulance service the very telling comment, which should not be missed, that by the time the ambulance crew gets the patient to hospital, in essence, many patients are better. However, there is the fear when you are with the patient, as you do not know how things are going to end. The same applies to general practice. The skill of not sending everybody to hospital is an immense skill that comes with a lot of training. Nevertheless, we must invest in health care assistants, physicians’ assistants and nurse practitioners. Pharmacists have an enormous role to play. However, these people are not twiddling their thumbs; they, too, have their work force and work load crisis.

Q178 Dr Wollaston: So how are we going to get more doctors to go into primary care?

Dr Gerada: The Royal College of GPs is just about to publish a document called the 2022 vision, which lays out the evidence around the efficacy of primary care and community care. It then says what we need to do in order to continue to deliver and to deliver 21st-century health care, including better-integrated care in and out of hours, better use of telecare and better use of shared decision making. Included in this document is an action plan for how we will engage doctors to become GPs, retain them and then train them throughout their professional lives. We will need your help. Already Mr Hunt has announced in the mandate a wish for 50% of medical students to become GPs. When I qualified, it was 70%; it is now probably about 30%.

Andrew Webster: At the risk of intervening in a GP conversation, it is important from the local government point of view to state that a wider team delivers the care that is planned and organised in the community to keep people at home. Obviously we need more and more skilled general practitioners, but increasingly social care professionals and public health professionals are working alongside those people in teams for the same groups of patients, managing the same risks. There are real opportunities to get more resources and capability into primary care to deliver some of the things that will reduce pressure on our hospitals.

Q179 Chair: Can I come in there? I would be interested in Dr Gerada’s response to that. Is part of the response to the pressure of increasing demand for urgent care-in primary care, but on the system as a whole-a redefinition of the respective roles within the primary, community and social care teams?

Dr Gerada: Yes. We have to be careful, because over the last decade and a bit we have had more and more bits of general practice taken away from us and put into other individuals who are sometimes quite disparate, away from what I would say would be the medical home of the patient-to the point where we now have district nurses employed by foundation trusts, where they should not be employed. What happens then is that you increase fragmentation, because you increase the number of contacts that you have to have before you get a direct contact with a very good social worker, social care in the community and so on. I think it is the answer-of course you do fantastic work-but it is about bringing it back into primary care and making that the medical home.

The second point is around integrated care, which is where I think you are going. Integrated care-shared working across professional boundaries-is difficult. We use this term as if somehow we will all get together like one big happy family when we do not have similar values, as we have come from different professional groups, we do not have similar budgets-some are means-tested and some are not-and we do not have a similar record. Some have confidentiality issues, which means that one bit of the system cannot look at the other bit of the system. Integrated care will work, but it needs time and stability and to be led by GPs. Again, that will need resources. In our 2022 vision, we talk about integrated care-GP-led, multidisciplinary teams with communication that goes beyond the simple exchange of letters-and starting to risk-stratify our high-risk patients, probably from the 5% to 10% group that we know is responsible for about 70% of all health service costs. I think we were nearly there in 2008 and that we can get back there, with a lot of work through CCGs and local government.

Andrew Webster: I broadly concur with that. I think that having a planned service in the community, using the point of access that most of the public think is the natural one-their general practitioner-is the right approach. However, becoming proactive and focusing on the 10% or 15% of the population who use all the service and drive all the costs is a big change from where we are in most places now, where the system is, as you have seen, reacting to things as they occur rather than planning for them not to occur. It would require a change in all parts of the system-in local government and social care, in primary care, in the hospitals and in the community services that are currently run by community foundation trusts. If you do not change all of them at once, one of them will become the blocker to the other three.

Chair: You put it in the conditional, implying that there is a choice, which is perhaps a subject for debate-but anyway.

Q180 Barbara Keeley: I want to clarify an issue that has cropped up for me locally. A GP told me that she had an awful lot of extra work pressures from DWP, effectively, and from other changes. My constituency is very hard hit by the bedroom tax, which is apparently requiring an awful lot of certification of medical needs from GPs. I even had a job centre that had sanctioned a constituent with an urgent medical need insist on having a letter to say that he had had a GP appointment on that day. It was interesting that my own experience of this came together with a GP telling me that she had a lot of extra work load from this sort of thing. Clearly, when 2,600 people are suddenly told that they will have to pay more for a spare bedroom that they may have medical reasons for using, it will put quite a strain on the GPs in that locality. I wondered whether that was the case in areas other than mine.

Dr Gerada: Yes. The new disability forms themselves are pretty complex, let alone the appeal forms. I am well used to the medico-legal world, but it is difficult even for me to fill in some of these forms, where I am asked for my opinion and am not sure that I am competent to give an opinion on issues related to people’s capacity to work. The bedroom tax and some other changes in the benefit system have also meant that patients are more likely to come to us, as their GP, to ask us to write letters. Again, from discussing this with colleagues and with my sister organisation, the General Practitioners Committee, I know that they are getting an increased number of calls from their members saying that this is becoming a problem.

Absolutely rightly, the backstop for most patients is their GP. Again, I am so sorry that we cannot respond. I see people saying that their GP says that they cannot write appeal letters or housing letters. Isn’t it terrible that we have had to stop activity that is really our bread-and-butter activity?

Q181 Andrew George: To a certain extent, Dr Gerada, you have covered the issue of the way in which-according to the King’s Fund, at least-primary care services might actually generate more demand for A and E services. It seems that the King’s Fund is arguing that having more accessible primary care services-walk-in services and so on-has resulted in more demand for A and E, emergency departments and MIU services. To what extent do you concur that this seems to be driving patients towards A and E services, rather than actually dealing with them in primary care?

Dr Gerada: I am sorry, but I think I have misunderstood. You are saying that the King’s Fund is saying that walk-in clinics are creating demand.

Andrew George: Yes, that is what it is saying.

Dr Gerada: And that if walk-in clinics did not exist, that activity would go-

Andrew George: It is simply saying that one of the consequences of the walk-in clinics is that there has been an overall increase in demand for A and E services.

Dr Gerada: In that case, I think it has probably not looked at some of the stats. I have some stats for our organisation. We saw 160,000 walk-ins at one of our sites. We surveyed them and asked, "If we did not exist, where would you go?" Nearly 40% said they would go to the local A and E department; 6% said they would go to NHS Direct; 9% said they would go to the GP co-op; and 20% said they would go to their own GP-so it is clearly reducing the demand on their own GP. We then have "other". In essence, what we are picking up-we know this anecdotally, as we ask them where they would go-is that they would go to their emergency department. On the whole, when we are frightened-that is to say, when we are ill-we default to what we know. We do not go through a complex algorithm: should I go to 999, 111, walk-in, urgent care or the pharmacist-blah, blah, blah? You tend to remember three things: 999, the local accident and emergency and your GP. Increasingly, the GP is being replaced by the walk-in clinic. Rather than saying that we are creating demand, what we must do is simplify the system. So I do not agree with the King’s Fund.

Q182 Andrew George: I am simply reporting-it does not necessarily follow logically to me. I just wanted to know what your response was.

Dr Gerada: What the King’s Fund has not done, which is very sad-I did ask it to do it-is start to collect primary care activity data. We should not imagine that the world begins and ends in a hospital emergency department. If we started to collect activity data accurately across primary care, including walk-in clinics, urgent care centres and minor injuries units, we might start to see what we know already-that that is absorbing vast amounts of activity at a much cheaper rate.

Andrew Webster: What we know from the places that have looked at the data in an integrated way is that the people who generate the demand in all parts of the system are the same people. The same people are using lots of social care, visiting their GP a lot, going to the hospital a lot and having lots of support go into their house. The King’s Fund is on to a point when it says that, if that were done in a different way, you might be able to reduce the pressure across the whole system. However, I do not think you could argue that the need is created by the service being there, because those were all people who were eligible for higher levels of service.

Q183 Andrew George: Is it that we are becoming a more calamitous, accident-prone nation, that there are larger numbers of worried well or simply that, because of the age of the population, inevitably you get higher levels of illness?

Dr Gerada: It is multiple, isn’t it? The King’s Fund report showed that the patients who turn up at the emergency department are iller and older and tend to be admitted for longer-it is a cohort. If you look at the patients who turn up at walk-in clinics, they are younger. They are not the sort of patients who turn up at emergency departments-they tend to be younger, with acute illness. Those who turn up at general practice services are a mix of both, but predominantly patients with long-term conditions or urgent problems. Again, we need to start unpicking these data and looking at them. If you design a service that is only for those long-term elderly patients, you will still have this massive group of people who will, for one reason or another, fall ill, stub their toe, cut their finger, have a rash, get worried, have a cough and need to see a doctor. Those are now increasingly being seen by GPs. Regardless of the newspaper coverage that says we are all twiddling our thumbs, that sort of activity is being seen by GPs now and will continue to be.

Q184 Andrew George: Following that pattern of provision and subsequent demand argument, if the King’s Fund is right, with fewer A and Es-because more A and Es have been closed or downgraded over the last 10 years-one would assume that, because they are less accessible, there would be fewer patients going to them. Of course, that is clearly not the case.

Dr Gerada: There are fewer patients going. Again, let us look at the facts. It is slightly outside my expertise, but if we take away urgent care and look at the number of emergencies-the tariff one-there has been an increase of about 1.7% per year over the last decade. The population has risen by just about the same amount; in other words, it has flatlined. If you look at London, it has actually decreased. As the King’s Fund report says, we have had a blip recently, probably since August but most certainly in the last quarter. As I flippantly said on Twitter this morning, that could be because of the publicity provided by that BBC film on a day in the life of an emergency department. It could be something as simple as that-we do not know. It may be because we had a long winter and a nasty flu virus was going around-I do not know.

Q185 Andrew George: Can I move on to the out-of-hours GP service? Dr Gerada, in your evidence you suggested that in fact that seems to be working well or, at least, has worked well. I accept that since the changes in 2003-04, and all the studies show, there was not a significant increase in A and E attendances at that point. However, many out-of-hours GP services have contracted through competitive tendering to become private companies rather than GP co-ops. They have also adopted pathways where telephony systems, algorithms and telephonists make judgments about clinical need. Certainly in the case studies I have been looking at, as a result there has been a significant increase in the number of patients who have been diverted at a very early stage from outofhours GP services to emergency departments. Would you agree that particularly over the last couple of years-the early stages of the 111 service seem to suggest this is going on as well-it is much more risk-averse? Clinicians are not dealing with patients sufficiently early; they are dealt with through algorithms and systems by non-clinically-trained people, and therefore patients are being driven into A and E services. Is that a fair portrayal of the system?

Dr Gerada: Yes, it is. If you put a computer at the front end, it will be risk-averse. Computers have to be risk-averse, don’t they? They cannot ask you searching questions. We need to look at what has gone on. In the old days, I went out in my pyjamas and met my colleague from the practice up the road in his pyjamas along the corridor of a housing estate, which I had taken an hour to find. We would meet and think what on earth we were both doing at the same housing estate and why we did not join resources. Those were the old days. It then moved to GP co-ops, which probably ran reasonably well; they had a sense of ownership. In 2008 it was reasonably okay.

We have gone into the current system, where we have competitive tendering with a whole mix and match, with a drop to the bottom in terms of costs. How many patients can you look after in a total population? Factored into that, we have changed the call-handling system from NHS Direct to 111. Whereas NHS Direct was a clinician and very good nurse able to triage, we have gone to 111, which essentially is someone trained for six weeks and a computer. The computer says, "Go to A and E," and that is what happens. There have been some changes.

Many GPs across the country want to go back to the co-op system, mainly because we get a sense of solidarity and we want to make things better for our patients. Some are being blocked; others are desperate to do it but feel they cannot with the current work force. We will see another exodus of GPs if they are forced to do it. With CCGs commissioning and the plan to get more GPs, hopefully we can start delivering a bespoke solution for the frail and elderly, the in-and-out patients and those at the end of their lives, and then a solution for the others who may need just an advice service. We also have to be careful that we do not over-egg it. Not much activity in the NHS takes place between 11 pm and 7 am, so we must not deliver a service for those hours and ignore the other hours when the vast majority of care happens.

Andrew Webster: Can I link that to the point you made about the changing population? If we have a cohort of people who are increasingly frail and living alone, having lost their partners, with multiple health needs and find the system confusing and complicated, it is natural that they go to the sure place of response, which at the moment is often the hospital. If we were able to plan something that went to them in a more organised way, they would not do that. We know that at small scale we can do that. For people who have breathing problems we can support them so that they stay at home and do not go rushing off to the hospital every time they have an attack or a bit of a crisis. We know that at small scale we can do that. The challenge facing us is that we have got to do it at big scale at a time when we have not got lots of resources. The point I started with, which was about the need to look at this at scale, will deal with those issues, as much as changing the precise organisation of the GP outofhours service.

Q186 Grahame M. Morris: On this theme of disagreeing with the King’s Fund in their rather simplistic analysis of the reasons for increased activity at A and E, for the record, could I have your views on the Secretary of State’s rather simplistic analysis that the reason for the crisis in A and E is the previous Government’s renegotiation of the GPs’ outofhours contract?

Dr Gerada: For the record, I am not disagreeing with the King’s Fund report. I think it is a good place to start, and I laud them for keeping the data because they do not have to. I am being just a little critical of the fact that they do not also keep primary care data alongside it.

With respect to your question, Mr Morris, I am on record as saying that I think it is lazy to blame the 2004 GP contract, which is nearly 10 years’ old, for an issue that has become a problem recently, taking into account that we have seen a more or less flatline increase in emergency department attendances, not admissions. We have seen a big increase in admissions.

GPs have never stopped delivering outofhours care. Who do you think delivers outofhours care today, now, this evening? It is the GP. We deliver 90% of all activity in the NHS in hours and out of hours, but we are not trained to deliver emergency care. You do not want me chopping your leg off in the middle of the night, I promise you. In some countries they do. We are trained to deliver care to patients with complex needs and deal with uncertainty in acute conditions. It is demoralising for my profession to be on the front page of some of the newspapers with our feet up. It is just terrible. I wish we could all work together to sort this out, because we have to for our patients.

Q187 Grahame M. Morris: That is fair, and I fully understand that. I just thought it was important to have it on the record. In respect of some of the targets that have changed-for example, being able to see a GP within 48 hours-has that had a material impact upon people attending A and E, or walk-in centres as an alternative?

Dr Gerada: We had the 48 hours’ advanced access target, which I am sure some of you remember, which sadly skewed things. On the whole, if you see somebody too early in their illness, you are creating demand, which I think was what you were saying. Time is the greatest healer. I am not saying that we should be delaying patients because, in terms of your father and the patients who need to be seen, it is really important, but some of the targets created perversity in the system that meant we were seeing people within 15 to 20 minutes of the first presentation of what would be a minor illness and had to see them again anyway, because time will tell. The Health Select Committee might be wise to look at some of the targets right across the system and see whether some might be creating problems further downstream.

Q188 Grahame M. Morris: I can give you a practical example from last week of something that happened to me in relation to not being able to see a GP within 48 hours. A close family member rang on Thursday. The earliest GP appointment was on Tuesday. The family member went to a walk-in treatment centre, which was unable to do an xray; they went to another centre, with a seven to 10-day wait to see the result; they went to a different centre, and ended up going to the fracture clinic at A and E. They spent all day doing this on the Friday. It just seemed an incredible waste of resource.

Dr Gerada: Isn’t that awful? Using that example, in the days when we had any capacity, what would have happened is that they would have rung up the surgery and spoken to one of the doctors, who would have taken the story. They would have thought, "Is this or isn’t this a fracture?" They would have been seen at the end of the clinic and, if there was a sense that it was a fracture, would probably have been sent up to the local emergency department-probably. What you have now is a mishmash. If you costed out that pathway, it would probably be 10 times greater than the cost the GP gets for the year of care of your friend.

Q189 Grahame M. Morris: It is my mother actually.

Dr Gerada: Your mother-sorry.

Q190 Rosie Cooper: I would like to thank Dr Gerada for her honesty in telling it like it is. I have a brilliant GP, who is really very good, and I wish that was an exemplar for everybody else. If all those patients who inappropriately present at A and E were to access primary care via their GPs, would there be sufficient capacity in the system to accommodate that additional demand?

Dr Gerada: There has to be inappropriate attendance in the emergency department for it to be safe. If 100% of patients turning up in the emergency department need to be there, I am missing at least 15% of cases. I do not know the stats at hand, but I am very happy to try to find them. There have to be some patients who turn up a little bit like the one you heard about from the ambulance man. He did not know that the patient was going to get better. They had got better by the time they got there, so you can classify that as an inappropriate attendance. It was not; it was appropriate at the time they made that decision.

There are some patients who abuse the system; I have no doubt about it. Some patients who are incredibly lonely use the emergency department as their place to meet people. I can give you some examples offline. Equally, if general practice had sufficient capacity, rather like Mr Morris’s mother, they would be able to deal with it more appropriately. A percentage of patients who turn up at emergency departments should not be there, but we should be able to handle them.

There is an issue around new immigrants not understanding how to use the system, especially people from eastern Europe where there is not a tradition of primary care. But, again, when we audited our so-called inappropriate attendances, it was very little. When we looked at it at the time, not retrospectively-it is very easy to look at it retrospectively-there were very few. It usually amounted to one person doing it once. Even if we wanted to target that person and say, "Don’t do it again," they are not going to do it again anyway, because the very fact they have attended once and found they should not have means that they have learned. It is a complex issue.

Q191 Rosie Cooper: Do you know whether in relation to attendances at A and E the big increases are during the day, in the evening or when out of hours are supposedly in operation? Is that any reflection on what is going on?

Andrew Webster: I am quoting somebody else so you should check, but my understanding from NHS England is that it is mostly during the day. To answer your question slightly more broadly, if fewer people were admitted to hospitals, we would not have to spend so much money on the hospitals and we would be able to transfer some of that money into primary and social care to support them better at home. As I said in my opening remarks, we have done that in a fairly crude way by transferring £900 million into social care over the last few years. I think there is an opportunity to do more of that in a more planned way, and therefore end up with a system that is more sustainable and could be managed within what are obviously going to be restricted resources for the foreseeable future. We cannot do that just by transferring cost out of the NHS into local government, where there is even less resource available than in the NHS.

Q192 Dr Wollaston: Dr Gerada, Jeremy Hunt says he wants to make GPs individually responsible for the outofhours care of their patients. Is that going to be incompatible practically with them being able to do so if the service is put out to tender by the CCG and they have no control individually over that tendering process?

Dr Gerada: And factor into that the move, which is not yet happening but may well do so, to remove geographical boundaries. The patient may be registered with me but does not live in the area and therefore will not use my local hospital, so it is going to be more confusing. But I think Mr Hunt is correct in some ways. Given that more GPs are able to spend longer with their patients in communities, it is important that we provide bespoke care to those who need it most. For those patients, especially the frail and elderly who are in hospital, we should find a way-working with integrated teams, not just GPs-of providing a transition service when they leave hospital. It is hard work, but the best of practices do it. If we had more GPs, we would be able to do that in a better way by having micro-teams within large practices, or what we call federations or groups of practices, being able to provide a named person who is responsible for out of hours, not necessarily visiting. If a patient happens to be discharged at 2 am, you can get a call and deal with it, but even in hours you have a named person. We want to do this and make it work. I am asking the Health Select Committee not to focus just on one bit that will increase our workload, which means we are even more unsustainable. I think he is right to flag it up and set it as an aspiration, but we cannot do it at the moment.

Q193 Valerie Vaz: I have some general questions, picking up on what you said earlier. You mentioned attendances and admissions in to A and E. For Joe Public or Josephine Public, could you clarify for someone who is not in the health service bubble what you mean?

Andrew Webster: What is the difference between an attendance and an emergency?

Q194 Valerie Vaz: You measure attendances and admissions differently, don’t you?

Andrew Webster: Yes. An admission is where someone has been admitted by a consultant into the hospital formally, and an attendance is where somebody goes to the hospital and goes home again.

Dr Gerada: It gets blurred. With the four-hour target, there are what we call zero-hour admissions, especially children or the elderly, who are so-called admitted but not really admitted. If you look at the stats and really look at the figures, it is in zero-hour admissions where we have seen a massive increase. We have still seen an increase in elderly care admissions, but when we start to try to unpick the system the question is a very good one. If you start to deal with the wrong problem, you will get the wrong answer. The problem is zero-hour admissions either for observation or because there is not somebody senior enough to make the decision whether or not to discharge. That comes back to the original premise of the College of Emergency Medicine: there are not enough senior doctors in the emergency department to make decisions, hence you are clogging up.

Andrew Webster: I do not think that as a patient or member of the public you are that interested in all of that. You want to know that the thing you needed has been done and you are going to be supported thereafter. However we think of this, we should drive it by what happens to the person rather than what happens to the numbers. At the moment we are counting lots of numbers and not very many people, whereas, if we had a system integrated around people, we could track what was happening to them and the outcomes would be the right ones for them. That would be a much better way of measuring how we do it.

Q195 Valerie Vaz: In my questions I usually ask where the patient is in all of this. The current debate is being formed, and the screaming headlines are about numbers. If people are better informed about them, they would not be so fearful about what is happening and they may be underestimating or exaggerating the difficulties.

Dr Gerada: It is important to say that. If you look at the care of the frail and elderly, the biggest problem with respect to discharge is the wait for social care assessments. It is not that they are being massively admitted. The patients being admitted are predominantly young children and some others. It is important to keep the patient in mind but also to get the stats right so that we sort out the right problem and not the wrong one.

Andrew Webster: Can I just correct that briefly? The problem is not primarily that people are waiting for social care assessments; it is that they are waiting for the thing to get them out of hospital. Sometimes that is a social care assessment; more often, it is something else. Whatever it is, there should be less of it and we should be working together to make sure that those things are done much more quickly. They could be if we were operating the integrated teams with clinical ownership by the primary care team that Dr Gerada is describing. There are ways in which we can tackle that issue.

Q196 Valerie Vaz: In the earlier evidence, the ambulance people said that when your patients-or GPs’ patients-went into accident and emergency the GPs did not know about that. How would you improve the system in that way so that you would know?

Dr Gerada: You do not know immediately, but we get a letter back electronically, which we then code.

Q197 Valerie Vaz: But that is usually when they are discharged, isn’t it?

Dr Gerada: Yes, from the emergency department. I do not know how the emergency department does it. I think they fax them all the next day, or press a button, so we do know. What we do not know, and rightly, is the moment at which they have been admitted or attended. Equally, we do not know that a patient of ours is in hospital, because we know only when they have been discharged. Again, we need to sort this out and get it better.

Q198 Valerie Vaz: You mentioned earlier about GP co-ops being blocked. Could you expand on that?

Dr Gerada: I can give you the example of Hackney GP co-operative, which wants to take over that service. I understand they have been told by the local commissioners that they cannot. They wrote to Mr Hunt a while back, and I understand this is now progressing. There are other examples of that, but it is not my area of expertise; it is just that as chair I hear all these things.

Q199 Valerie Vaz: When we are setting up these outofhours services, where is continuity of care in the whole process?

Dr Gerada: Exhaustingly and hopefully, with the GP, but, if we can deal with the two big issues facing the NHS, which does it better than most other health services-fragmentation of care, as in the case of Mr Morris’s mother, and continuity of care-and put those two bits right at the front and sort the system out around that, we will end up with a better system.

Andrew Webster: We can put in place practical things through local urgent care boards and health and wellbeing boards that will enable people to do that. It would be very useful to the system if the Committee focused on some of the practical and resource issues that at the moment impede people from doing those kinds of things. I agree with Dr Gerada that the will is largely there and encouragement would be important.

Q200 Andrew Percy: I would like to make a correction from earlier, Dr Gerada. The figures show that 111 has not increased the number of people being referred to A and E-in fact it has halved it-but it has doubled the number of people being sent through to GPs and urgent care. We have heard a lot about how resources in local government are under the cosh, and, indeed, GP services are under extreme pressure at the moment. We know that budgets in England will remain flat for the next few years. In Wales, the budget is being cut. We all know what the problem is and that there is this pressure. I am not the brightest button. So I just want to know what are the two or three things we should include in our report that need to be done to try to address the pressure on emergency care services.

Dr Gerada: Can I respond to that?

Chair: Please; make our task easier.

Dr Gerada: The three things are: invest in primary care; invest in community care; and address the social care bed issue. Those are the three things: primary, community care and social care. If you want a fourth-and please forgive me, other royal colleges-you have to examine where the resources have gone over the last 15 years. Predominantly, they have gone in increasing sub-specialisation, which massively increases costs and fragmentation of care, and probably overall decreases quality of care. Please forgive me if you are listening to this, but the solution is to invest in primary care.

Q201 Andrew Percy: But where do we take that money from given that we have not-

Dr Gerada: I have just told you where to take it from.

Q202 Andrew Percy: Yes, but you then apologised for it.

Dr Gerada: 2% of resources from foundation trusts should be earmarked and moved into community and primary care, whether that is real money-i.e. cuts in their services-or people working as generalists across the community: generalist physicians working across the boundaries between primary, secondary and community care. Then you can start to do it. Please don’t cut beds; we haven’t got enough beds, but start to look at step-down beds, such as integrated care beds, which we had moons ago and have all disappeared.

Andrew Webster: The people who are addressing this are doing precisely that. They are looking at how you move the money out of the reactive, expensive hospital end of the system and into the proactive, planned and locally integrated system. There are clearly ways in which that can be done. There are things such as Dr Gerada describes-investing in primary and community services-so you can have that capacity. It can be achieved by-

Q203 Andrew Percy: When we went to Denmark and Sweden we saw how they had invested in this, but it led to closures of hospitals and hospital wards. I am thinking of it from a patient’s perspective. While we may all understand that is perhaps what needs to be done, from a patient’s perspective they will simply see closed wards and services being sent from one hospital to another, and I am not sure that has a great deal of influence in increasing their confidence.

Dr Gerada: We would help you with that. It would not be, "Trust me; I’m a GP." What you cannot have are closures without simultaneous capacity in primary care.

Andrew Webster: It should be the responsibility of the health and wellbeing boards to take the lead so that local government and the NHS work together to get those decisions made in the best possible way.

Q204 Barbara Keeley: I think we have clarified this, but, to make it absolutely clear for the record on social care, ADASS are telling us that £2.6 billion has been taken out of adult social care. I think you said earlier it was almost a fifth. Yet we keep sliding back into talking about integrated working as if that was going to solve the problem. We need to be very clear and straightforward about it. It may be that what Dr Gerada has just said is the answer too. Can we be clear about that? In terms of integrated working, if you have fewer social work staff and fewer people to do assessments, if you just have fewer people in the local authority and fewer care packages, however integrated a system you have of working together, you will not be able to handle the increases in elderly and frail people that we are seeing in A and E.

Andrew Webster: What has happened so far is that the people who get services are continuing to get as much as, if not more than, they did before.

Rosie Cooper: That is absolute rubbish.

Andrew Webster: I was very clear in saying that the main thing to mitigate that impact has been the transfer of £900 million from the NHS spend in social care, and, if you want to mitigate that impact further, you have to do more of that.

Q205 Barbara Keeley: You need to stop in what you have just said, because I, frankly, just do not believe that is true.

Rosie Cooper: That is not what’s happening.

Barbara Keeley: My local authority was meeting moderate eligibility needs. Because of £24 million of cuts this year, they are moving to substantial. There is no way, and I know this from-

Andrew Webster: By and large, it is because they have made other savings.

Q206 Barbara Keeley: Fine, okay, but it is not the case that people are getting the same care packages. I am starting to see it coming in in terms of casework. There were two elderly constituents on Friday who were 24/7 carers. They are halfway through the year and they have had no respite care. It is not true that we are delivering the same as we did before.

Andrew Webster: It is certainly true that three or four councils in the last year have made the change you described.

Q207 Barbara Keeley: But 80% of them were on substantial anyway.

Andrew Webster: I am not saying that everything is exactly the same as it was, because clearly there have been reductions in cost and efficiency changes have been made. I am saying that the figures suggest that there are still quite high levels of service going into the support of a slightly smaller number of people.

Q208 Barbara Keeley: The other question is about community services, which have also been referred to. I am more familiar with my own local area. When our PCT was still in existence it closed two walk-in centres. It ended a pilot of active case management and stopped funding other services locally, which also did active case management. We were in a situation where multiple services reached out to people in the community and checked how they were and dealt with very low-level problems. We were told by the NHS Confederation that, in their view, reductions in the availability of that low-level social care in the community were leading to this increase in A and E admissions. Is that the case, too?

Andrew Webster: We have heard that the things that lead to increases in emergency admissions are many and varied; it is not simply access to low-level social care. For some people that is probably the case.

Q209 Barbara Keeley: They did not say it was solely that; they said it was one factor.

Andrew Webster: Just under 5% of the social care spend is still going into preventive services that do not have any eligibility criteria attached to them. I think the tenor of my remarks was that we want local health and wellbeing boards to be sitting down with their GPs and local hospitals saying, "Should we change the balance of investment here in order to get a better result?" If the system could make that work, it could have the impact of reducing emergency admissions, but a national prescription of that order would not have that impact.

Q210 Barbara Keeley: So you are suggesting that the health and wellbeing boards should go to their local acute services and say, "You should transfer money back into social care because we have cut it."

Andrew Webster: I am saying precisely that, yes; that is exactly what I am saying.

Q211 Rosie Cooper: Do you believe in fairies as well?

Dr Gerada: Fear and loneliness are the causes, though not always, in my experience. I chair an integrated pilot. When it boils down, it is not constipation or breathlessness; it is fear and loneliness. With respect to low-level care, there is an argument for befriending. If you hear evidence from some of the elderly care charities, you will find that staggering numbers of our elders have no face-to-face human contact in a week. It is fear and loneliness. I am not saying it is a simple solution, but let’s turn it on its head and we will help. The public want this sort of high-tech stuff until you translate it. It means that your mother will be admitted and will spend 50 days in a hospital bed if we do not invest in befriending services, community nurses and GPs. I know what they will want. On the whole, they will want a better quality, not quantity, of life. You have a tough job.

Andrew Webster: You are going to be responsible for that.

Dr Gerada: Whatever you want me to do. I leave office in November, so it will be my successor.

Chair: We are drawing to a close, but Rosie has a point to make.

Q212 Rosie Cooper: May I very quickly put on record a couple of things? I am on record as saying that as health and wellbeing boards are constituted they are talking shops. They are all very good. As with everything else, it is fantastic in theory, but unless, for example, the clinical commissioning group turns up at those meetings, gets involved and partakes of it, it is just talk. I do not believe you should be sitting talking to the clinical commissioning group; you should be at the table with a vote. If it is anything other than that, you are not having the influence you think you might have, ergo the difficulty.

To refer to an earlier answer about what goes on in A and Es, the make-up, whether the general public really want to be involved in that and whether it matters, I am talking to you primarily as someone with a history in the health service, but the big thing is that my dad is 88 with strokes and all the rest of it. I hit this system all the time. People do not need to tell me about it; I see it. I hear theory, good wishes and all the rest of it, but it is not reality. What goes on in an A and E does matter; it does matter that the consultant in charge of an A and E over a weekend is a specialist in diabetes and is looking after stroke patients; it does matter; it does impact on the care they get.

Dr Gerada, I had a conversation with a resident in Liverpool. She was not my constituent but she came to ask me a question. She related a conversation with a doctor in Liverpool. She rang up and said, "Can I have an appointment with the doctor?" The receptionist said, "Is it an emergency?" She said, "No. I need a fit note to return to work." The receptionist said, "I can do that." She replied, "No. I need to see the doctor; I need a phased return to work." She was told by the receptionist, "That’s okay; I can do that." That is a receptionist. That is the level to which we are sinking. Let’s take the theory and abstract rubbish out of it and talk about what is going on at the front line.

Dr Gerada: I agree with you. For the record, a receptionist cannot sign a fit note.

Q213 Rosie Cooper: No, no; Clare, I totally appreciate that point.

Dr Gerada: You are right-

Chair: Order; order.

Rosie Cooper: The resident did not get to see the doctor.

Dr Gerada: No, you are right.

Chair: Thank you very much indeed.

Prepared 23rd July 2013